Nexus Pavilion At Belleville
Inspection history, citations, penalties and survey trends for this long-term care facility in Belleville, Illinois.
- Location
- 727 North 17th Street, Belleville, Illinois 62226
- CMS Provider Number
- 145290
- Inspections on file
- 65
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 6 (2 serious)
Citation history
Health deficiencies cited at Nexus Pavilion At Belleville during CMS and state inspections, most recent first.
Surveyors identified inadequate pest control for bed bugs when multiple unoccupied rooms contained live and dead bed bugs on mattresses, baseboards, and glue boards, despite the facility’s routine spraying program. The Maintenance Director and Administrator reported no recent live bed bug sightings in resident rooms and described a schedule of chemical treatments and monitoring with sticky traps, while CNAs and housekeeping acknowledged prior bed bug problems in certain halls. A pest control technician confirmed ongoing bed bug issues and recent targeted treatments in specific rooms, and the facility’s written bed bug policy outlined detailed procedures for room preparation, laundering, room cleaning, and clinical follow-up when bed bugs are found, yet the presence of live bed bugs during the survey demonstrated that pest control services were not adequately preventing or eliminating bed bug activity.
A resident with a history of mental health conditions and identified risk for abuse experienced a physical altercation with a CNA, resulting in visible injuries to her eye and face. Despite care plan instructions to ensure her safety and avoid confrontation, staff engaged in a struggle over a chair, leading to the resident being struck and sustaining injuries. The incident was witnessed and reported by other staff, and the resident consistently stated she was hit by the CNA.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. Surveyors observed that the environment did not meet safety standards and lacked proper oversight.
A resident experienced a significant medication error due to a failure in the medication administration process. The report does not provide further details about the circumstances or the resident's condition.
A resident with paranoid schizophrenia and a history of exit-seeking behaviors was able to leave the facility after an initial attempt was not followed by increased supervision or intervention. Despite a care plan calling for one-on-one supervision and redirection, staff did not implement additional measures after the resident was first observed trying to exit. The resident later eloped during shift change, was found in a cargo container on the property, and was subsequently hospitalized for behavioral disturbances.
The facility did not maintain an effective pest control program, resulting in an ongoing bed bug infestation that led to two residents being displaced from their rooms, belongings being bagged, and staff reporting repeated sightings of bed bugs. Despite daily inspections and spraying by maintenance and contracted pest control services, documentation showed a lack of recent targeted bed bug treatments, and staff described the issue as persistent.
Five residents did not receive their scheduled morning medications on time due to an agency LPN being delayed by a medical emergency with another resident. The affected residents, all cognitively intact and with significant medical conditions, reported not receiving their 8:00 AM medications by late morning, and no nurse was present on the hall to administer them. Facility policy and staff interviews confirmed that these medications were considered late.
On one occasion, a lack of nursing staff coverage on a specific hall resulted in several residents with complex medical needs not receiving their scheduled medications. Medication administration records showed missed doses, and interviews confirmed that no nurse was present to administer medications during the day shift. Staff were aware of the staffing shortage, but instructions to reassign coverage were not followed, leading to the deficiency.
Multiple residents with complex medical needs did not receive their scheduled morning and afternoon medications when no nurse was present on their hall during a day shift. The missed medication passes were confirmed by resident interviews, blank MAR entries, and staff statements, with essential medications such as antiepileptics, anticoagulants, and antipsychotics not administered as ordered.
Several residents requiring assistance with ADLs and incontinence care did not have privacy curtains in their rooms, resulting in personal care being provided without adequate privacy. Residents expressed discomfort and concern about exposure, and staff were observed performing care without privacy barriers. The curtains had been removed due to a bed bug issue, but staff were unclear about the removal process and how to maintain resident dignity in the interim.
A resident with a colostomy and multiple medical conditions was left with a leaking colostomy bag and soiled skin for an extended period, resulting in painful, red excoriation on the abdomen, perineal area, and buttocks. Despite being dependent on staff for care and having a care plan requiring skin care after each incontinence episode, staff failed to provide timely assistance, and the resident remained soiled until a hospice aide intervened. Family members also reported issues with non-functioning call lights and lack of staff response.
A resident with a colostomy developed painful, red excoriation around the stoma and abdomen after staff failed to provide timely and appropriate colostomy care. The colostomy bag was observed leaking liquid stool onto the resident's skin, which was not promptly cleaned, and prescribed skin treatments were not consistently applied. Documentation and interviews revealed gaps in care planning, lack of specific orders for colostomy care, and inadequate staff response, resulting in prolonged exposure of the resident's skin to feces and significant discomfort.
A resident with a colostomy and cognitive impairment experienced ongoing pain and excoriation due to inadequate colostomy care and failure to administer prescribed topical treatments. Staff did not promptly clean the resident or assess and address pain, leaving the resident soiled and in discomfort until a hospice aide intervened. The care plan lacked specific interventions for the resident's pain related to excoriation, and pain assessments were not conducted as required.
Multiple residents with varying medical and cognitive conditions were found to have bed bugs in their rooms and beds, as confirmed by direct observation and staff interviews. Despite previous pest control treatments and mattress replacements, bed bugs continued to be present in several rooms and common areas, and the issue was noted as ongoing in facility records and resident council meetings.
The facility failed to prevent physical abuse among residents, resulting in significant injuries. A resident with cognitive impairments was pushed by another, leading to a subarachnoid hemorrhage and orbital fracture. Other incidents involved residents being struck or pushed due to conflicts over personal space and belongings. These events highlight the facility's inability to manage resident interactions effectively, as outlined in their abuse prevention policy.
A resident with existing pressure ulcers and cognitive impairment developed two new stage 2 pressure injuries due to the facility's failure to adhere to a turning schedule and care plan. Observations showed the resident was left on one side for extended periods, and staff interviews revealed inconsistencies in repositioning practices. The new ulcers were linked to prolonged pressure from a catheter tube and inadequate repositioning.
The facility failed to prevent resident-to-resident abuse, with incidents involving residents with schizophrenia exhibiting aggressive behavior. One resident threw a chair and hit another with a caution sign, while another punched a peer. The facility's response included separating residents and notifying relevant parties, but lacked effective preventive measures and adequate documentation.
A resident with a history of spina bifida and pressure ulcers was readmitted to the facility without a timely skin assessment, leading to the deterioration of a stage 2 pressure ulcer to stage 3. Despite the facility's policy requiring assessments within 24 hours, documentation was lacking, and the resident's care plan interventions were not adequately followed, contributing to the ulcer's progression.
The facility failed to employ a full-time Director of Nursing (DON) to oversee its nursing department, potentially affecting all 126 residents. A Registered Nurse Consultant confirmed the absence of a DON, with the position vacant since February 2024. The facility's policy requires a full-time DON, but the Facility Assessment Tool lacked a designated name.
The facility failed to ensure that garbage in the dumpsters was covered, potentially affecting all 126 residents. Two dumpsters behind the kitchen were observed with one lid missing and the other open, exposing trash to the environment. A dietary aide confirmed the lids should be closed to prevent animal access. The administrator stated the lid was damaged by the garbage truck operator, and the company was contacted for replacement.
A resident's family requested medical records, but the LTC facility failed to process the request in a timely manner. Despite a subpoena sent in December, the facility did not act until late February, after a follow-up letter. The facility's staff and attorney were unaware of the initial request, leading to a delay in providing the records.
A resident with a history of sexually inappropriate behavior, diagnosed with schizophrenia and major depressive disorder, was readmitted to the facility without a proper care plan, leading to the sexual abuse of another resident. Despite staff and residents expressing fear and reporting R3's aggressive behavior, the facility failed to implement effective interventions, resulting in the abuse of a vulnerable resident who is dependent on staff for all activities of daily living.
The facility failed to ensure physician visits every 60 days for four residents, despite their complex medical conditions. Interviews revealed a lack of awareness and adherence to the policy, with residents expressing concerns about infrequent doctor visits.
A resident with severe cognitive impairment and a history of exit-seeking behavior eloped from the facility, resulting in multiple injuries. Despite being at high risk for elopement, the resident was not adequately monitored, and staff failed to prevent his unsupervised departure. The facility's door alarms were reportedly not functioning properly, contributing to the resident's ability to leave unnoticed.
The facility failed to control a bed bug infestation in one unit, with multiple bait stations found with bed bugs and dead bugs on the floor. Residents and staff confirmed the presence of bed bugs, particularly in the 500 hall, with reports of bugs on beds and even on a resident's body. The Maintenance Director acknowledged the issue, and the Administrator confirmed ongoing efforts to address it, although the problem persisted.
A resident with a history of psychological disorders became upset after a CNA allegedly yelled at her for wanting to eat in her room, leading to emotional distress and refusal of medications. Despite the incident being witnessed by staff, it was not reported as abuse, and the CNA continued working without removal from resident contact.
A resident with a history of psychological disorders reported verbal abuse by a staff member, leading to distress and refusal of care. The facility failed to investigate the allegations as required by their abuse prevention policy, treating the incident as a customer service issue instead.
A resident's prescribed Oxycodone was not administered in a timely manner upon her return from the hospital, leading to significant pain. The facility failed to account for 16 tablets of the medication, and discrepancies were found in the documentation, including a forged signature. Staff confirmed the absence of the medication, and the facility's policies on narcotic handling were not followed.
Two residents experienced delays in receiving prescribed pain medications due to the facility's failure to order refills in a timely manner. One resident, with multiple pain-related diagnoses, reported significant pain due to a lag in Tramadol refills. Another resident, readmitted after hospitalization, did not receive Oxycodone for several days due to prescription processing delays. The facility lacked a policy for ordering refills, contributing to these deficiencies.
The facility failed to provide necessary one-on-one supervision for three residents at high risk for elopement and falls. A resident with cognitive impairment left the facility with her boyfriend without staff knowledge, another resident exited the facility leading to a violent incident, and a third resident with a history of falls was left unsupervised due to staff absence. These incidents highlight the facility's failure to maintain continuous supervision for residents requiring enhanced monitoring.
A resident with multiple medical conditions, including an open wound on the right lower leg, did not receive scheduled wound care, resulting in maggots developing in the wound and requiring hospitalization. Despite complaints of discomfort and a saturated dressing, nursing staff failed to assess or change the dressing. The facility's DON acknowledged the lapse in care, which was contrary to the facility's skin management policy.
The facility failed to provide a working call system for residents during ongoing renovations, affecting 14 out of 15 residents reviewed. Observations showed missing call lights in rooms and bathrooms, with disconnected wires at the nurse's station. Residents confirmed the absence of a call system, and staff acknowledged the issue, citing remodeling as a contributing factor.
A resident with cognitive impairments was verbally abused by a CNA, who called him derogatory names during a dispute over an ice scoop. Witnesses, including another resident and a housekeeper, confirmed the CNA's actions. The incident was reported to the CNA Coordinator and the Administrator, leading to the CNA's termination. The facility's abuse prevention policy was not followed, resulting in a failure to protect the resident from verbal abuse.
A resident with altered mental status and schizophrenia ingested bleach due to inadequate supervision and access to hazardous chemicals. The resident was hospitalized for evaluation and treatment. Bleach wipes were found in the resident's bedside table, violating the facility's policy on hazardous chemicals.
The facility failed to protect residents from abuse, resulting in multiple incidents of resident-to-resident altercations and injuries. The facility did not document or investigate these incidents adequately, leading to a lack of protection for the residents.
The facility failed to ensure a resident's coffee was served at a safe temperature, resulting in burns to the resident's thigh and abdomen. Additionally, the facility did not provide adequate supervision to prevent residents from accessing a construction area, where a resident was able to enter without any issues. These deficiencies highlight lapses in safety protocols and supervision.
A resident with multiple diagnoses, including Hemiplegia and Dysphagia, experienced a significant weight loss of 45.5 pounds in less than two months due to the facility's failure to provide appropriate interventions and timely adjustments to the nutritional plan. The Registered Dietician was not notified of the weight loss promptly, resulting in delayed changes to the feeding regimen.
The facility failed to store, prepare, and hold food properly, leading to potential contamination and food-borne illness risks for all 112 residents. Issues included rust and peeling paint in the refrigerator, unlabeled health shakes, improper ice scoop storage, and serving under-temperature pureed food.
The facility failed to identify the causative organisms for infections, hindering their ability to track and prevent further infections. Multiple instances were noted where residents with UTIs were treated without documenting the causative organisms, contrary to the facility's infection control policy. The Director of Nursing acknowledged the importance of this documentation.
The facility failed to ensure that an Infection Preventionist (IP) was working in the building at least part-time, affecting all 112 residents. The IP, V27, was on maternity leave, and the Wound Nurse filling in did not have the necessary certification. The facility lacked a policy on having an IP working in the facility, leading to a significant deficiency in infection prevention and control oversight.
The facility failed to provide proof of continuing education for CNAs, affecting all 112 residents. The Interim Administrator and DON were unable to provide the requested certificates, and the Human Resources person responsible was on vacation. No documentation was available to verify compliance with continuing education requirements.
The facility failed to ensure behavioral health training for all employees, affecting all 112 residents. Documentation showed in-services on various topics, but none on behavioral health. Staff confirmed they only received training on abuse. The facility's assessment indicated a need for training on mental and psychological disorders, non-pharmacological interventions, and substance abuse care, which was not provided.
The facility failed to thoroughly investigate allegations of abuse, neglect, or mistreatment and did not document protective actions taken to ensure resident safety. Incidents involving physical altercations and injuries of unknown origin were not properly investigated, and there was a lack of evidence of staff or resident interviews and protective measures.
The facility failed to ensure a Registered Nurse (RN) was working in the facility seven days a week for 8 consecutive hours, affecting all 112 residents. Staffing schedules and timecards revealed no RN coverage on multiple days, despite the facility's policy requiring sufficient nursing staff to maintain residents' well-being.
The facility failed to locate and replace missing clothing for five residents, leading to unresolved grievances and dissatisfaction. Despite filing grievances and partial recovery of items, the issue persisted, affecting residents' comfort and homelike environment.
The facility failed to ensure that residents were given the correct antibiotics for their UTIs due to the lack of culture and sensitivity (C&S) testing. Four residents received antibiotics without confirmation that the prescribed medication was appropriate for the infection-causing organism. The Infection Surveillance Monthly Reports did not document the causative organisms, and the Director of Nursing acknowledged the need for such documentation.
The facility failed to ensure sufficient qualified nursing staff, resulting in delayed or missed medication administration for five residents. On a specific day, there was no nurse on the 100-hall during the morning shift, leading to residents not receiving their medications or blood glucose monitoring on time. Staff interviews and records confirmed the shortage and the impact on residents' care.
The facility failed to administer medications and perform blood glucose monitoring as ordered for five residents due to staffing shortages and miscommunication. Residents reported not receiving their medications on time, and staff confirmed the absence of a nurse on the 100-Hall during the morning shift, leading to significant delays in medication administration.
A resident with multiple diagnoses, including Type 2 Diabetes and COPD, had an unstageable pressure ulcer on the coccyx. Despite a detailed care plan, an LPN used normal saline instead of the prescribed Dakin's solution for wound care, citing the wound nurse's absence and uncertainty about the correct procedure. This deviation from the physician's order was observed during incontinent care when the ulcer was red and open with significant drainage.
Inadequate Bed Bug Pest Control in Facility Environment
Penalty
Summary
The facility failed to provide adequate pest control services for bed bugs in the physical environment, with the potential to affect all 107 residents in the building. During observations of multiple unoccupied rooms, surveyors noted approximately seven dead bed bugs on a glue board and one live bed bug on a mattress in one room, as well as live bed bugs on a baseboard and mattress sheet in another room, and several dead bed bugs on baseboards in a third room. These findings occurred despite the rooms being designated as not housing any residents at the time of observation. Interviews with facility staff revealed discrepancies between reported bed bug activity and the surveyors’ observations. The Maintenance Director stated that the facility had not had residents with bed bugs for a while, that the facility sprays for bed bugs three times per week, and that only dead bed bugs had been found on sticky traps, with no recent live sightings. The Administrator reported that when she started in November, the facility was finishing bed bug treatment and that she was not aware of any live sightings since then, aside from a dead bed bug found on one hall in December. CNAs and housekeeping staff acknowledged there had been a bed bug problem in the past, with one CNA reporting having seen bed bugs in resident rooms on certain halls, though not recently. The pest control service technician confirmed that the facility has ongoing bed bug issues, though improved from prior levels, and described that recent treatments had been performed in specific rooms due to identified bed bug activity, including dead bed bugs found in one room the prior week. The technician explained that the facility uses chemical spray treatment rather than heat treatment, and outlined the required room preparation and resident removal process for active bed bug treatment. The facility’s written Bed Bug Policy describes procedures for handling bed bugs in resident rooms, including bagging and laundering resident belongings at temperatures greater than 115°F, notifying pest control, vacating and thoroughly cleaning the room, removing or replacing mattresses, vacuuming furnishings and crevices, performing resident body checks, notifying the physician and infection control, and reporting to the state health department when indicated. Despite these policies and reported practices, survey observations documented live and dead bed bugs in multiple rooms, demonstrating inadequate pest control services for bed bugs in the facility environment.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
The facility failed to ensure that a resident was protected from abuse, resulting in a physical altercation between a resident with a history of Schizophrenia, Bipolar Disorder, and Depression, and a Certified Nurse's Assistant (CNA). The resident's care plan identified her as being at risk for abuse or neglect due to self-isolation, use of psychotropic medications, hallucinations, delusions, compulsive behavior, and a history of aggression. The care plan specifically instructed staff to ensure the resident's safety, walk away if she became difficult during care, and allow her time to calm down before reapproaching. Despite these instructions, a conflict arose over a chair, during which the resident threw water at the CNA, and the CNA allegedly struck the resident in the eye, resulting in visible injuries including swelling, scratches, abrasions, and discoloration around the left eye. Multiple staff interviews and progress notes confirmed that the resident reported being hit by the CNA, and that her account of the incident remained consistent. Staff observed the resident on the floor with injuries that did not appear consistent with a simple fall, and another CNA reported hearing sounds of a fight and the resident screaming. The CNA involved denied hitting the resident, stating that the resident fell while she was removing the chair from the room, possibly slipping on water. However, the resident maintained that she was punched in the eye, and staff noted that her injuries were more severe than what would be expected from a fall alone. The facility's abuse policy affirms the right of residents to be free from abuse and outlines the responsibility to prevent abuse, neglect, and mistreatment. Despite this policy, the incident demonstrates a failure to follow the resident's care plan and to protect her from harm. The CNA's actions, including entering the resident's room against her wishes and engaging in a physical struggle over the chair, directly contributed to the resident's injury and emotional distress. The event was reported to the police, and the CNA was suspended pending investigation.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents occurring. Specific actions or inactions leading to this deficiency include the lack of proper oversight and the presence of hazards in the area, as directly observed by surveyors.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident received a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or omissions that led to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Prevent Elopement for Resident with Psychiatric History
Penalty
Summary
A deficiency occurred when the facility failed to ensure adequate supervision and monitoring to prevent elopement for a resident with a known history of exit-seeking behaviors and psychiatric diagnoses, including paranoid schizophrenia. The resident was identified as being at risk for elopement, with a care plan in place that included one-on-one supervision and redirection during exit-seeking episodes. Despite these documented interventions, the resident was observed attempting to exit the facility around 2 AM and was redirected by a CNA, who then notified the nurse on duty. However, no additional interventions were implemented following this incident, and the resident was not placed on increased supervision or monitoring. Later the same morning, during shift change, the resident successfully exited the facility through a door that triggered an alarm. Multiple staff members responded and searched for the resident, who was eventually found hiding in a metal cargo container on the property approximately 15 minutes after leaving the building. Staff interviews revealed that the resident was able to leave the facility unobserved, and there was confusion among staff regarding notification procedures and the implementation of the care plan interventions. Statements from staff indicated that not all required notifications were made, and there was a lack of clarity about who was responsible for monitoring the resident after the initial exit-seeking attempt. The resident was subsequently returned to the facility and sent to the hospital for evaluation, where he was diagnosed with behavioral disturbances related to his psychiatric conditions. Documentation and interviews confirmed that the facility did not implement resident-centered interventions after the initial exit-seeking behavior, nor did they ensure that all staff were aware of and following the care plan. The failure to provide adequate supervision and to act on known risk factors resulted in the resident's elopement and subsequent hospitalization.
Failure to Maintain Effective Bed Bug Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program to eradicate bed bugs, which had the potential to affect all 113 residents. Multiple residents reported being displaced from their rooms after staff discovered bed bugs in their beds. Staff responded by bagging linens and personal items, showering residents, and relocating them to other rooms. One resident stated that the CNAs woke them up to spray the room and remove sheets, while another resident described being moved out of their room overnight and having their belongings bagged. A CNA supervisor confirmed that bed bugs were found during rounds, and a CNA described the issue as ongoing, stating that the facility was infested with bed bugs. The Maintenance Director reported spraying every room and common area upon arrival and stated that daily inspections and spraying of hotspots were conducted. However, review of pest control invoices revealed that the last general pest control service was in April, with the most recent specific bed bug treatment occurring in December of the previous year. The facility's pest control policy required an effective program, but the documentation and staff interviews indicated that the bed bug problem persisted and was not being effectively managed.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to administer medications according to physician orders for five out of seven residents reviewed for medication administration. Multiple residents, all cognitively intact and with various diagnoses such as schizoaffective disorder, major depression, diabetes, hypertension, and blood clotting disorders, reported not receiving their scheduled 8:00 AM medications by late morning. Medication Administration Records confirmed that these residents were prescribed critical medications to be given at 8:00 AM, but interviews conducted between 10:48 AM and 11:24 AM revealed that none had received their morning doses. Observations further confirmed that no nurse was present on the affected hall to administer medications during this period. The delay was attributed to an agency LPN who reported being behind schedule due to managing a resident with a change of condition that required hospital transfer. The LPN acknowledged being late with medication administration and had not yet notified the physician about the delay. The facility's own policy requires medications to be administered as ordered by the physician, and staff interviews indicated that medications given more than an hour after the scheduled time are considered late. The deficiency was directly observed and corroborated by resident statements, staff interviews, and review of medical records.
Failure to Provide Adequate Nursing Staff Resulting in Missed Medication Administration
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of residents, resulting in multiple residents not receiving their scheduled medications. On a specific day, there was no nurse assigned to the 200-hall during the day shift, which led to at least four residents missing their morning and afternoon medications. Medication administration records for these residents showed blank entries for the scheduled times, and interviews confirmed that the residents did not receive their medications as ordered. The affected residents had complex medical histories, including conditions such as spina bifida with hydrocephalus, epilepsy, schizophrenia, and various chronic illnesses requiring consistent medication management. Residents reported not seeing a nurse on the 200-hall during the day and only receiving care from nurses from other halls for personal needs, not medication administration. Staff interviews corroborated that there was a call-in and no nurse coverage for the 200-hall, and instructions to have another nurse cover the hall were not followed. The lack of nurse coverage was not identified or addressed in a timely manner, resulting in missed medication doses for all affected residents. Some residents reported no ill effects, while one resident described feeling moody and tearful due to the missed medications. The facility's staffing policy required adherence to state staffing formulas and adjustment based on resident needs, but this was not met on the day in question. The medication administration policy also required documentation and physician notification when medications were not given, but these procedures were not followed. The facility assessment tool indicated the required number of nursing staff, but the actual staffing did not meet these requirements, directly leading to the deficiency.
Failure to Administer Scheduled Medications Due to Lack of Nursing Staff Coverage
Penalty
Summary
The facility failed to ensure the administration of scheduled morning and afternoon medications for four residents who were reviewed for medication administration. On a specific date, the medication administration records (MARs) for these residents showed blank entries for scheduled doses, indicating that multiple medications were not given as ordered. The residents affected had complex medical histories, including conditions such as spina bifida with hydrocephalus, epilepsy, neurogenic bladder, schizophrenia, and other chronic illnesses, and were dependent on regular medication administration for their health and well-being. Interviews with the residents confirmed that they did not receive their scheduled morning and afternoon medications on the day in question. The residents reported not seeing a nurse on their hall during the day shift, and one resident stated that only a nurse from another floor assisted with personal care but did not administer medications. Another resident reported being told by a CNA that there was no nurse available on the hall that day. The MARs and physician order sheets confirmed that a range of medications, including antiepileptics, anticoagulants, antipsychotics, and other essential drugs, were not administered as scheduled. Staff interviews corroborated that there was no nurse present on the affected hall during the day shift, resulting in the missed medication passes. The facility's policies required medications to be administered according to a standard schedule and for incident reports to be completed immediately after a medication error was discovered. However, the lack of nursing staff coverage led to the omission of medication administration for multiple residents, and the required documentation and follow-up were not completed in a timely manner.
Failure to Provide Privacy Curtains During Personal Care
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical care by not providing privacy curtains in the rooms of four residents. Observations revealed that privacy curtains were missing or not properly installed in the rooms of residents with significant care needs, including those who required assistance with activities of daily living (ADLs), were incontinent, or had cognitive or physical impairments. In one instance, a resident was observed receiving care without the privacy curtain being drawn, and the curtain itself was partially detached and not functional. Other residents reported that their privacy curtains had been missing for extended periods, making them feel uncomfortable and exposed during personal care activities. Interviews with residents confirmed their discomfort and desire for privacy curtains to be restored, as they felt exposed to staff and potentially to people outside their rooms during care. Staff members, including CNAs, were observed providing personal care in rooms without privacy curtains, and several staff interviewed were unaware of the reasons for the missing curtains. One resident specifically mentioned feeling exposed to people passing by the window during dressing changes, while another noted that the lack of a curtain affected both themselves and their roommate during care. The housekeeping and laundry supervisor explained that privacy curtains had been removed from certain rooms due to a bed bug infestation, and that curtains were also removed from adjacent rooms as a precaution. The supervisor stated that the curtains would not be rehung until she was confident the infestation was resolved, and that the curtains were ready to be reinstalled. The DON confirmed that curtain removal was discussed in morning meetings and that cleaning was being done on a schedule, but did not address how resident dignity and privacy were maintained while curtains were absent. Facility policy requires privacy to be provided during hygiene and elimination care, including the use of curtains and closed doors.
Failure to Provide Timely Incontinence and Colostomy Care Resulting in Skin Excoriation
Penalty
Summary
A resident with a history of multiple complex medical conditions, including a colostomy, was observed to have significant issues with timely and appropriate care for activities of daily living, specifically related to incontinence and colostomy management. On observation, the resident was found in bed with a colostomy bag that was three-quarters full and leaking liquid stool onto the abdomen, perineal area, and buttocks. The skin in these areas was red and excoriated, and the resident expressed pain and discomfort. Despite the resident's call light being activated, there were delays in care, with a CNA initially attempting to clean the resident but unable to resolve the leakage, and an RN changing the colostomy bag but leaving the resident partially soiled. The resident remained soiled for over an hour until a hospice aide, not facility staff, completed the cleaning. Interviews and record reviews revealed that the resident was dependent on staff for toileting and daily care, had moderate cognitive impairment, and was at risk for skin complications due to incontinence. The care plan specified the need for skin care after each incontinence episode, and wound care notes documented existing incontinence-associated dermatitis. Family members reported ongoing concerns about the lack of timely care, including an incident where the resident's call light was not functioning and staff failed to check on the resident despite being informed of his condition. The facility's incontinence care policy required keeping residents dry and comfortable to prevent skin breakdown, but this was not followed in the resident's case. Documentation also included a grievance from the resident's family regarding neglect during the night, with findings that staff were educated on the resident's needs. Despite these interventions, observations and interviews confirmed that the resident continued to experience delays in care, resulting in prolonged exposure to feces and worsening skin excoriation. The failure to provide timely and adequate incontinence and colostomy care directly led to the resident's painful skin condition.
Failure to Provide Timely and Appropriate Colostomy Care Resulting in Skin Excoriation
Penalty
Summary
The facility failed to provide appropriate colostomy care for a resident who required such services, resulting in the resident developing painful, red excoriation around the colostomy site, extending to the abdomen and perineal area. Direct observation revealed that the resident's colostomy bag was three-quarters full and leaking liquid stool onto the skin, which was left unaddressed for an extended period. The resident was visibly in pain, expressing discomfort and apprehension during care attempts, and was not promptly or thoroughly cleaned by staff, leaving feces on the skin for over an hour until a hospice aide intervened. Documentation and interviews indicated that the resident had multiple complex medical diagnoses, including autism, chronic kidney disease, and a history of abdominal surgery resulting in a colostomy. The care plan identified the resident as dependent on staff for daily care and at risk for skin complications related to stoma incontinence-associated dermatitis. Despite this, there were no specific physician orders for colostomy care or frequency of bag changes, and the treatment administration record showed that prescribed creams for skin protection were not consistently applied as ordered. Staff interviews revealed inconsistent understanding and implementation of colostomy care, with some staff attributing leaks to the resident's behavior and others acknowledging the need for frequent checks and cleaning. The facility's policy required colostomy/ileostomy bags to be changed at least every five days and as needed, with documentation of care and skin condition. However, there was no documentation of colostomy care or bag changes on the treatment administration record, and the resident's family reported that staff were not changing the colostomy bag or cleaning the resident adequately, particularly during night shifts. The lack of timely and appropriate colostomy care directly led to the resident's skin breakdown and ongoing discomfort.
Failure to Provide Timely Pain Management and Colostomy Care
Penalty
Summary
The facility failed to identify and provide appropriate pain management for a resident with significant excoriation and discomfort around a colostomy site. Observations revealed that the resident was left in bed with a leaking colostomy bag, resulting in liquid stool covering the abdomen, perineal area, and buttocks, causing visible redness and excoriation. The resident expressed pain and discomfort, stating that it hurt and burned, and was visibly shaking and apprehensive during care. Despite these clear signs of pain, staff did not promptly clean the resident or apply prescribed creams, and the resident remained soiled for an extended period until a hospice aide intervened. Record review showed that the resident had multiple complex medical diagnoses, including Autism and moderate cognitive impairment, which may have affected pain communication. The care plan documented an alteration in comfort and included general pain assessment interventions but lacked specific strategies for managing pain related to excoriation or tailored approaches for the resident's cognitive and developmental needs. There was no documentation of pain assessment since several weeks prior, and prescribed topical treatments for excoriation had not been administered as ordered. Interviews with staff and the resident's family confirmed that the resident was not being kept clean, colostomy care was inadequate, and pain management interventions were not consistently implemented. The facility's pain management policy required regular pain assessments and individualized care planning, but these were not followed, resulting in ongoing pain and discomfort for the resident.
Failure to Maintain Pest-Free Environment
Penalty
Summary
The facility failed to maintain a pest-free environment for four out of five residents reviewed for pest control. Multiple residents reported and were observed to have bed bugs in their beds and rooms, with some residents directly showing live bugs on their sheets during interviews. Staff, including CNAs and LPNs, confirmed ongoing sightings of bed bugs in resident rooms and on residents themselves. Observations included soiled and dirty linens with visible bed bugs, and reports from both residents and staff indicated that the issue had been recurring, with bugs found not only in beds but also on curtains and in common areas such as the dining room. Residents affected had various medical conditions, including asthma, diabetes, obesity, schizoaffective disorder, hypertension, bipolar disorder, dementia, and incontinence, with cognitive statuses ranging from intact to severely impaired. The facility's pest control company had previously treated the building and specific rooms, and mattresses with holes and rips had been replaced. Despite these efforts, bed bugs continued to be found in multiple rooms, and the issue was noted in resident council meeting minutes as an ongoing concern. Facility records documented an ongoing pest control program, but the presence of pests persisted at the time of the survey.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent physical abuse among residents, resulting in significant injuries to one resident. Resident R6, who was cognitively intact and diagnosed with bipolar disorder, COPD, and dementia, was involved in an altercation with Resident R7, who also had cognitive impairments. R6 entered a bathroom occupied by R7, leading to R7 pushing R6, causing her to fall and sustain a subarachnoid hemorrhage and a left orbital wall fracture. The incident was not captured on video, and there were conflicting accounts of the event, with R6's daughter expressing doubts about the facility's explanation. Another incident involved Resident R5, who was allegedly struck by Resident R11 in the dining room after taking food from R11's plate. Although no injuries were noted, the incident highlighted a failure to manage resident interactions effectively. R5 and R11 both had cognitive impairments, with R5 diagnosed with paranoid schizophrenia and mild cognitive impairment, and R11 with encephalopathy and hemiplegia. The facility's response included psychosocial follow-up interviews and staff education, but the initial failure to prevent the altercation was evident. A third incident involved Resident R10, who was pushed by Resident R14 after entering R14's room without permission. R10, diagnosed with a traumatic subdural hemorrhage and bipolar disorder, was found on the floor, unable to describe the incident. R14 expressed frustration over repeated intrusions into his room. These incidents collectively demonstrate the facility's failure to protect residents from abuse and neglect, as outlined in their abuse policy and prevention program.
Failure to Prevent New Pressure Ulcers in Resident
Penalty
Summary
The facility failed to prevent the development of additional pressure injuries for a resident, identified as R1, who was already at risk due to existing conditions such as paranoid schizophrenia, a stage 3 pressure ulcer, and atherosclerotic heart disease. R1 was moderately cognitively impaired and required assistance with various activities of daily living, including turning and repositioning in bed. Despite having a care plan in place that included interventions to prevent skin complications and pressure ulcers, R1 developed two new stage 2 pressure injuries. Observations and interviews revealed that R1 was left on his left side for extended periods without being repositioned, contrary to the facility's policy of turning residents every one to two hours. On one occasion, R1 was observed on his left side for nearly three hours, and staff did not offer to turn him during this time. Additionally, R1's new pressure ulcers were attributed to prolonged pressure from a catheter tube and inadequate repositioning, as noted by the wound nurse. The facility's policy emphasized the importance of avoiding positioning residents on medical devices and ensuring regular repositioning to prevent skin breakdown. Interviews with staff indicated a lack of adherence to the turning schedule, with some staff members unaware of the specific requirements for R1. The resident himself reported discomfort when repositioned roughly and stated that he was not offered repositioning on the day the new pressure injuries were discovered. The facility's failure to consistently implement the care plan and turning schedule contributed to the development of new pressure injuries for R1.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent abuse among residents, as evidenced by multiple incidents involving resident-to-resident aggression. Resident R20, diagnosed with schizophrenia, exhibited a history of aggressive behavior, including throwing a chair at another resident and hitting a resident with a caution sign. Despite these incidents, the facility's response was limited to separating the residents and notifying relevant parties, without implementing effective preventive measures. Resident R30, also diagnosed with schizophrenia, was involved in an incident where they punched another resident in the face after a verbal altercation. The facility's documentation lacked a progress note for this incident, indicating a gap in the monitoring and reporting process. The facility's response was to separate the residents, but there was no evidence of further preventive actions to address the underlying behavioral issues. Another incident involved residents R92 and R62, where a physical altercation occurred after one resident sought attention from the other. Both residents were moved to different tables, and behavior tracking was noted to be in place. However, the lack of a progress note for this incident suggests inadequate documentation and follow-up. The facility's abuse prevention program emphasizes the residents' right to be free from abuse, yet the repeated incidents indicate a failure to effectively implement this policy.
Failure to Conduct Timely Skin Assessment on Readmission
Penalty
Summary
The facility failed to conduct a comprehensive skin assessment upon the readmission of a resident, identified as R44, who was at risk for pressure ulcers due to her medical history of spina bifida and existing pressure ulcer. Upon readmission, the resident's hospital discharge paperwork documented a stage 2 pressure ulcer on the sacral region. However, the facility did not perform or document a head-to-toe skin assessment as required by their policy, which mandates such assessments within 24 hours of readmission. This oversight led to a lack of timely intervention and documentation, contributing to the deterioration of the pressure ulcer from stage II to stage III. The resident's care plan included interventions for skin complications, such as regular repositioning and weekly skin assessments, but these were not adequately followed upon her return. The Braden Scale assessment indicated a moderate risk for pressure ulcers, yet the necessary skin assessment was not documented until several days later, when the ulcer had progressed to stage III. The facility's failure to adhere to its own pressure injury policy and to document the necessary assessments and interventions in a timely manner resulted in the worsening of the resident's condition.
Failure to Employ Full-Time Director of Nursing
Penalty
Summary
The facility failed to employ a full-time Director of Nurses (DON) to oversee its nursing department, which has the potential to affect all 126 residents residing in the facility. On March 11, 2025, a Registered Nurse Consultant confirmed that the facility did not have a DON at that time, and the Assistant Director of Nurses (ADON) had just started working at the facility a day prior. The former DON's last day was February 11, 2024, leaving the position vacant for over a year. The Facility Assessment Tool dated March 5, 2025, did not list a name for the DON, and the facility's policy, last reviewed in September 2024, states the intent to comply with registered nurse staffing requirements, including designating a registered nurse as the DON on a full-time basis.
Improper Disposal of Garbage in Facility Dumpster
Penalty
Summary
The facility failed to ensure that garbage in the facility dumpster was covered, which has the potential to affect all 126 residents residing in the facility. During an observation, it was noted that two dumpsters located behind the kitchen were not properly covered. One dumpster lid was missing, and the other was completely open, exposing the garbage bags and other trash to the environment. A dietary aide confirmed the observation, acknowledging that the lids should be closed to prevent animals from accessing the trash. The facility administrator explained that the lid was ripped off by the garbage truck operator, and the company responsible for the dumpsters had been contacted to replace the unit.
Delayed Medical Record Request for Resident
Penalty
Summary
The facility failed to send a medical record request in a timely manner for a resident, identified as R174, whose family had requested access to her medical records. R174 was initially admitted to the facility, and a nurse's progress note documented an incident where she experienced labored breathing, requiring medical intervention and a transfer to the emergency department. Despite the family's request for medical records, the facility did not act promptly to fulfill this request. The issue arose when the facility's medical records staff, V8, stated that she was not aware of any request for R174's medical records until a follow-up subpoena letter was received in late February 2025. The facility's administrator, V1, who started working in February 2025, received the request and forwarded it to the medical records processing center. However, there was a lack of communication and documentation regarding the initial subpoena sent in December 2024, which was reportedly received by the facility but not acted upon. The facility's attorney, V9, claimed not to recall receiving the subpoena and had no documentation of it. The attorney for R174, V10, confirmed sending a certified letter and a check for deposition, which was cashed by the facility, yet no records were provided. The facility's policy required that all medical record requests be processed promptly, but this was not adhered to, resulting in a delay in providing the requested records to R174's family.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident, R2, from sexual abuse by another resident, R3, who had a history of sexually inappropriate behavior. R3, who was diagnosed with schizophrenia and major depressive disorder with psychosis, had been refusing his medication and exhibited aggressive and inappropriate behaviors towards staff and other residents. Despite these behaviors, R3 was readmitted to the facility without a proper plan of care or interventions to ensure the safety of other residents, leading to the sexual abuse of R2. R2, a bed-bound resident who is alert and oriented, was subjected to sexual abuse by R3 in the dining room. R3 exposed himself and forced R2 to touch him, which was witnessed by staff and other residents. R2, who is dependent on staff for all activities of daily living, expressed feeling upset and afraid following the incident. The facility's failure to implement effective interventions and monitor R3's behavior contributed to the occurrence of this abuse. Interviews with staff and residents revealed that R3 had been displaying sexually inappropriate behavior for months prior to the incident. Staff reported feeling fearful of R3 due to his aggressive and threatening behavior. Despite multiple attempts to send R3 to the hospital for evaluation, he was returned to the facility without significant changes in his behavior or medication compliance. The facility's lack of timely and effective interventions to address R3's behavior and protect other residents resulted in the sexual abuse of R2.
Removal Plan
- Administrator/Designee ensured the safety and well-being of the resident.
- Administrator/Designee initiated abuse investigation.
- The resident was assessed by the DON/Designee. The result of the assessments will be documented in the resident's EHR, and the attending physician will be notified.
- Resident was issued an Involuntary Discharge (IVD).
- Police were notified of incident.
- IDT will review and revise R2 care plan, implement interventions to ensure R2's safety.
- Social Service will complete Trauma Assessment on R2 and anyone who experiences abuse.
- Social Service will review behavior tracking sheets daily for all residents with behaviors and if noted, complete a new abuse and neglect risk assessment on them, the resident care plan will be updated by MDS with the intervention of enhanced monitoring initiated until behaviors subside.
- Resident assessments for risk of abuse. The DON and Social Service will complete a facility-wide assessment of residents and review of care plan interventions to ensure no residents are abused.
- Administrator and DON Education. RDO/Designee will provide training to Administrator and DON.
- Staff Education. The Administrator/Designee will provide training to all staff.
- All staff who are not available and/or currently on vacation will also receive the same education upon their return to work.
- Agency staff. The facility will provide similar training to agency staff.
- Interviewable Residents. Residents were interviewed to identify if they felt safe and/or if they have experienced any/all forms of abuse while living in this facility.
- A Regional Consultant Team Member will visit facility to provide oversight, complete audits and provide additional training as needed.
- As part of monitoring, the Administrator/Designee will monitor through facility audit tools five residents daily and then weekly to ensure any allegations of abuse are reported to Abuse Coordinator and investigated and reported to appropriate organizations.
- Administrator and Regional Team reviewed current policies and procedures of Abuse Program. No revision needed.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that physician visits were completed at least every 60 days for four residents, leading to a deficiency in the frequency of physician visits. Resident 2, who has multiple diagnoses including schizoaffective disorder, COPD, and pancreatic cancer, was only seen by her physician twice in the past year. Similarly, Resident 11, with conditions such as kidney calculus and hypertension, was also seen only twice. Resident 12, with a history of heart disease and bipolar disorder, was seen four times, while Resident 13, diagnosed with schizoaffective disorder and hypertension, was seen twice. These findings indicate a failure to adhere to the facility's policy requiring physician visits every 30 days for Medicare clients and every 60 days for other residents. Interviews with staff and residents revealed a lack of awareness and adherence to the required frequency of physician visits. The Administrator acknowledged the absence of MD progress notes and the failure to meet the 60-day visit requirement. The Regional Nurse confirmed the policy of 30-day visits for Medicare and 60-day visits for Medicaid residents. Residents expressed concerns about not seeing their doctors regularly, with one resident mentioning the need to discuss surgery plans. The Director of Nursing was unaware of the 60-day requirement, highlighting a gap in communication and policy enforcement within the facility.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to adequately monitor and supervise a resident, identified as R4, who was at high risk for elopement due to severe cognitive impairment and a history of exit-seeking behavior. On the night of the incident, R4 was last seen inside the facility at 2:00 AM and was found outside on the ground at approximately 3:30 AM. During this time, R4 sustained multiple injuries, including abrasions, a dislocated wrist, and lacerations that required sutures. The facility's records indicated that R4 had been exhibiting agitated and aggressive behavior throughout the evening, and staff had attempted to redirect him multiple times without success. R4's care plan and elopement assessments documented his high risk for elopement, yet the facility did not implement sufficient monitoring measures to prevent his unsupervised departure. Staff statements revealed that R4 was known to be wandering and attempting to leave the facility, but there was a lack of consistent supervision and monitoring. The facility's elopement policy required additional monitoring for residents exhibiting exit-seeking behaviors, but this was not effectively carried out in R4's case. The incident occurred in cold weather conditions, which posed an additional risk to R4's safety. Despite the presence of door alarms, staff reported not hearing any alarms during the time of R4's elopement. The facility's failure to ensure the proper functioning of door alarms and to provide adequate supervision for R4 contributed to the resident's ability to leave the facility unnoticed, resulting in his injuries.
Removal Plan
- R4 placed on Enhanced Monitoring.
- Any Residents with High Elopement Risk Assessment will be placed on Enhanced Monitoring.
- Enhanced monitoring will include but not limited to behavior monitoring every shift and 15 to 30 min location checks on residents that are exhibiting exit seeking behaviors.
- Administrator/Designee to complete Elopement Assessments on All Residents.
- Elopement binders will be updated with any resident that is moderate to high elopement risk and placed at Nurses stations and reception Area.
- Social Services Staff will be responsible for updating binders as needed.
- Maintenance Director to complete 100% Audit on Door alarms to ensure working Properly.
- Q 15 min monitoring of doors until alarms repaired.
- RNC/Designee will provide training to Administrator and DON on Elopement Policy and Procedures, Elopement Drills, and training provided to staff to place resident on enhanced monitoring when exhibiting exit seeking behaviors.
- The Administrator/Designee will provide training to all staff on Elopement Policies and Procedures, Elopement Drill, and training provided to staff to place resident on enhanced monitoring when exhibiting exit seeking behaviors.
- All staff who are not available and/or currently on vacation will also receive the same education upon their return to work.
- The Administrator/Designee will provide the same training.
- The facility will provide similar training to agency staff.
- The Administrator/Designee will provide similar training to an agency staff prior to the start of their shifts.
- A Regional Consultant Team Member will visit facility to provide oversight, complete audits and provide additional training as needed.
- The Administrator/Designee will monitor through facility audit tools to ensure any resident with moderate to high elopement risk assessment are monitored and supervised appropriately.
- New Admit residents will be assessed upon admission and residents exhibiting new onset exit seeking will be reassessed and based on assessment findings will be added to elopement binders and behavior monitoring.
Bed Bug Infestation in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, specifically related to bed bugs, in one of the two units observed. On January 2, 2024, during an inspection of the 500 hall, multiple bait stations were found with bed bugs, and a white powdery substance with dead bed bugs was observed on the floor. Interviews with staff and residents confirmed the presence of bed bugs, with reports of bed bugs being seen on beds and floors, and even on a resident's body. The Maintenance Director acknowledged the ongoing issue and mentioned that they were waiting for bids to conduct a heat treatment. Residents reported seeing bed bugs in their rooms, with one resident stating that the bugs were keeping him awake at night. Another resident mentioned having to kill bed bugs found on his bed. Staff members, including housekeepers and LPNs, confirmed the presence of bed bugs in the facility, particularly in the 500 hall. The facility's pest control policy, dated August 2024, states that the building should be kept free of insects and rodents, indicating a failure to adhere to this policy. The Administrator, who joined the facility in November, confirmed the active bed bug problem and described efforts to remove infested furniture and treat affected areas, although the issue persisted.
Failure to Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident, identified as R2, to the Illinois Department of Public Health. R2, who has a history of major depressive disorder, anxiety disorder, and other psychological conditions, was involved in an incident with a Certified Nurse Assistant (CNA), identified as V4. After returning from an electroconvulsive therapy treatment, R2 requested to eat in her room due to fatigue, which was initially approved by another staff member, V9. However, V4 reportedly yelled at R2, insisting she could not eat in her room, which led to R2 becoming upset, crying, and refusing to eat or take her medications. The incident was witnessed by several staff members, including V5, another CNA, who reported that R2 was visibly upset and crying the following day. R2 expressed feeling unsafe and wanting to leave the facility. Despite these observations, the Director of Nursing (DON), V2, and the Administrator, V1, did not take immediate action to remove V4 from resident contact or report the incident as potential abuse. Instead, the situation was treated as a customer service issue, and V4 continued to work in the facility, performing tasks such as fifteen-minute checks on residents. The facility's abuse prevention policy, last reviewed in 2017, mandates the immediate removal of any employee accused of abuse from resident contact until an investigation is completed. However, this protocol was not followed in the case of R2's allegations against V4. The failure to report the incident as abuse and to remove V4 from resident contact resulted in R2 experiencing significant emotional distress, as evidenced by her refusal to eat and take medications, and her expressed desire to leave the facility.
Failure to Investigate Verbal Abuse Allegations
Penalty
Summary
The facility failed to investigate allegations of verbal abuse involving a resident, R2, who was cognitively intact and had a history of major depressive disorder, anxiety disorder, and other psychological conditions. R2 reported an incident where a staff member, V4, yelled at her for wanting to eat in her room, despite having received permission from another staff member, V9. This confrontation led to R2 becoming upset, crying, and refusing to eat or take medications. R2 expressed feelings of being unsafe and wanted to leave the facility. The incident was reported to the night shift nurse, who assured R2 that the administrator and DON would be informed. Despite the report, the facility did not conduct an abuse investigation as required by their abuse prevention policy. The administrator, V1, who was on vacation at the time, was informed of the incident by V2, the DON, but no further action was taken to investigate the abuse allegations. Instead, the incident was treated as a customer service issue, and an in-service training on meal tray delivery was conducted. The facility's policy mandates that employees accused of abuse be removed from resident contact until an investigation is completed, but this procedure was not followed in this case.
Failure to Secure Resident's Medication
Penalty
Summary
The facility failed to secure a resident's medication, specifically Oxycodone, for a resident who was cognitively intact and had a history of chronic pain due to conditions such as neuropathy and fibromyalgia. Upon the resident's return from the hospital, there was a delay in administering her prescribed Oxycodone, which was not documented as given until several days later. The resident reported significant pain and had to persistently request her medication, indicating a lapse in the facility's responsibility to manage and administer her pain medication promptly. The investigation revealed discrepancies in the documentation and handling of the resident's Oxycodone. The Director of Nursing (DON) acknowledged that 16 tablets of the medication were unaccounted for and that a handwritten Controlled Drug Receipt/Record/Disposition Form was created because the original was removed when the resident was hospitalized. The DON admitted to not knowing the whereabouts of the missing medication or who authored the handwritten form. Additionally, a Registered Nurse (RN) expressed discomfort upon discovering her signature was forged on the form, and other staff members confirmed the absence of the medication upon the resident's return. Further interviews with staff, including a Licensed Practical Nurse (LPN) and the Assistant Director of Nursing (ADON), corroborated the absence of the medication and the resident's complaints of pain. The facility's pharmacy confirmed that a new prescription was filled and delivered shortly after the resident's return, but the medication was still not administered in a timely manner. The facility's policies on narcotic medication handling were not followed, leading to the misappropriation of the resident's medication and a failure to protect her belongings.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to ensure that residents received their prescribed pain medications in a timely manner, resulting in two residents experiencing unnecessary pain. Resident 1, who was admitted with multiple pain-related diagnoses, reported that the facility did not order refills for her Tramadol until she had completely run out, causing her to endure significant pain and difficulty sleeping. The pharmacy representative confirmed a typical lag time of one to three days between the medication running out and obtaining a new prescription. Documentation showed that Resident 1's Tramadol was not in stock for two days, during which her pain levels were recorded. Resident 2, who was readmitted to the facility after hospitalization, did not receive her prescribed Oxycodone for several days due to delays in processing the new prescription. The Director of Nursing acknowledged that controlled substances require additional steps, which can delay availability. Despite the resident's high pain levels, the medication was not administered until six days after her readmission. The facility lacked a policy for ordering prescription refills, contributing to the delay in providing necessary pain management for the residents.
Failure to Provide Adequate Supervision for High-Risk Residents
Penalty
Summary
The facility failed to provide necessary one-on-one supervision to prevent elopement and falls for three residents. Resident R3, who was moderately cognitively impaired and at high risk for elopement, had a physician order for one-on-one supervision. Despite this, R3 was able to leave the facility with her boyfriend without staff knowledge on multiple occasions. Staff members were aware of R3's tendency to wander and her need for supervision, yet they allowed her to be outside unsupervised with her boyfriend, who frequently visited and took her to his car. Resident R1, diagnosed with encephalopathy and delirium, was also at risk for elopement and required one-on-one supervision. However, R1 managed to exit the facility, leading to a violent incident in the parking lot where staff had to intervene. The staff's failure to maintain continuous supervision allowed R1 to leave the facility, resulting in a situation that required police and medical intervention. Resident R7, with a history of falls and severe cognitive impairment, required one-on-one monitoring due to increased fall risk. The facility failed to ensure continuous supervision, as there were gaps in monitoring when staff left without notifying others. This lack of supervision was evident when a CNA left the building without ensuring that another staff member was present to monitor R7, leaving the resident unsupervised for a period.
Failure to Provide Consistent Wound Care Leads to Severe Complications
Penalty
Summary
The facility failed to consistently provide wound treatments for a resident, resulting in severe complications. The resident, who was cognitively intact and had multiple medical conditions including an open wound on the right lower leg, osteomyelitis, and type 2 diabetes, was supposed to receive wound care with xeroform petrolatum dressing every Monday, Wednesday, and Friday. However, documentation showed that the dressing was not changed as scheduled on August 16, 2024, and the facility could not provide evidence of the treatment being signed off. This lapse in care led to the development of maggots in the wound, necessitating the resident's transfer to the hospital for further evaluation and treatment. Interviews and observations revealed that the resident had complained about discomfort and the sensation of something crawling in the wound over the weekend, but the nursing staff did not assess or change the dressing. The resident's friend, another resident, also attempted to advocate for the dressing change but was dismissed by the nurse, who cited HIPAA concerns. The nurse acknowledged seeing the treatment administration record indicating the dressing had not been changed since August 14, 2024, but did not take action because the resident did not explicitly complain of discomfort at that time. The facility's Director of Nursing (DON) stated that the resident had a history of noncompliance with dressing changes, although this was not documented. The DON expected the nurse to assess the wound when the resident reported discomfort. The facility's policy on skin management and wound documentation emphasizes the importance of consistent monitoring and documentation, which was not adhered to in this case, leading to the resident's hospitalization and diagnosis of acute on chronic osteomyelitis, as well as infections with MRSA and other bacteria.
Deficiency in Call Light System During Facility Renovations
Penalty
Summary
The facility failed to ensure that a working call system was available in each resident's bathroom and bathing area, affecting 14 out of 15 residents reviewed for call lights. Observations revealed that rooms on the 500 hall, specifically rooms 509-515, lacked covers and protections over exposed bulbs. Additionally, the nurse's station had an old call light box with disconnected and uncapped wires, and no call lights were observed to be functioning during the observation period. Multiple residents, including R2, R3, R4, R5, R1, R6, and R7, were found to have no call lights affixed to the walls or portable call lights in their rooms or bathrooms. Interviews with residents confirmed the absence of any call system to request assistance. The facility's call light policy, revised in September 2023, mandates that call lights be within residents' reach at all times, yet this was not adhered to. The facility has been undergoing renovations for approximately nine months, which has contributed to the lack of functional call lights. Staff members, including the Maintenance Director and the Administrator, acknowledged the ongoing remodeling and the absence of working call lights in several rooms. Despite the provision of bells as a temporary measure, these were reported missing, leaving residents without a reliable means to call for help.
Resident Subjected to Verbal Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from verbal abuse by an employee, specifically a Certified Nursing Assistant (CNA), which was substantiated through interviews and witness statements. The incident involved a resident with diagnoses including Schizophrenia, Asthma, Seizure Disorder, and Anxiety, who was moderately cognitively impaired and required supervision with Activities of Daily Living (ADLs). The resident was verbally abused by the CNA, who called him derogatory names during an altercation about the placement of an ice scoop. Witnesses, including another resident and a housekeeper, confirmed that the CNA yelled and cursed at the resident. The housekeeper intervened when it appeared the resident was about to physically retaliate. The CNA admitted to cursing but claimed it was done quietly. The incident was reported by another resident to the CNA Coordinator, who then confronted the CNA and subsequently reported the incident to the Administrator. The facility's policy on abuse prevention was not adhered to, as the resident was subjected to verbal abuse, which is against the facility's commitment to maintaining a resident-sensitive and secure environment. The investigation concluded that the allegation of abuse was substantiated, leading to the termination of the CNA involved.
Resident Ingests Bleach Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure that residents do not have access to hazardous chemicals, resulting in a resident with altered mental status and schizophrenia ingesting a liquid containing bleach. The resident, who has a history of major depressive disorder, schizophrenia, and other mental health issues, was found drinking from a bottle containing bleach. This incident led to the resident being transported to the hospital for evaluation and medical treatment. The resident's care plan indicated that he has impaired memory and difficulty with decision-making, and staff were instructed to provide clear explanations and orientation to the environment to increase his comfort and awareness. On the day of the incident, a CNA found the resident sitting in his room with a bottle of unknown liquid. The resident was unable to verify if any amount was ingested due to his mental status. The resident was sent to the hospital, where it was confirmed that he had ingested bleach. The hospital's evaluation showed no immediate respiratory issues or significant injuries, and the resident was returned to the facility without new orders. However, the incident highlighted the resident's vulnerability and the need for strict supervision to prevent access to hazardous substances. Further investigation revealed that bleach wipes were found in the resident's bedside table, which were accessible to him. Staff interviews confirmed that the resident has a tendency to eat and drink anything within his reach, and it was noted that the bleach wipes should have been locked away and not in the resident's room. The facility's policy on hazardous chemicals mandates that such substances should be handled in a manner that poses no substantial hazard to human health, and the presence of bleach wipes in the resident's room was a clear violation of this policy.
Failure to Protect Residents from Abuse and Conduct Proper Investigations
Penalty
Summary
The facility failed to ensure residents were free from abuse, resulting in multiple incidents of resident-to-resident altercations. One incident involved a resident with severe cognitive impairment and multiple mental health diagnoses biting another resident during a verbal disagreement. The facility did not document the incident in the progress notes or conduct a thorough investigation. Another incident involved a resident being thrown out of a wheelchair and nearly having their head smashed by another resident. The facility failed to provide a complete investigation report for this incident as well, and the Director of Nursing and Administrator were unable to locate the necessary documentation. In another case, a resident reported being poked and hit by another resident during an argument over a food cart. The facility's follow-up investigation concluded that the incident was a misunderstanding and not a deliberate attempt to harm. However, the investigation was deemed unsubstantiated, and the facility did not provide a comprehensive investigation report. Additionally, there were multiple incidents involving a resident who was bitten, hit, and involved in physical altercations with other residents. The facility failed to document these incidents properly and did not conduct thorough investigations. The facility also failed to investigate injuries of unknown origin for two residents. One resident complained of lower back pain and was later found to have fractures in the T9 and T10 vertebrae, but no investigation was conducted to determine the cause. Another resident reported being physically touched by a staff member and had visible bruising, but the facility did not provide an investigation report. Overall, the facility's failure to document and investigate these incidents adequately resulted in a lack of protection for the residents from abuse and neglect.
Failure to Ensure Safe Coffee Temperature and Supervision of Construction Area
Penalty
Summary
The facility failed to ensure that a resident's coffee was served at a safe temperature, resulting in hot coffee being spilled on a resident, causing burns to the resident's thigh and abdomen. The resident, who has multiple diagnoses including legal blindness, severe cognitive impairment, and various mental health conditions, sustained partial thickness burns. The incident was not documented in the facility's incident reports or nurse's notes, and there was no clear record of how the accident occurred. Interviews with staff revealed that the coffee machine was not functioning correctly, and there was no policy on heat or burns in place at the facility. Additionally, the facility failed to provide adequate supervision to prevent residents from accessing areas under construction. Despite signs indicating that the area was off-limits, the doors to the construction area were not locked, and no staff were observed monitoring the entrance. A resident was able to enter the construction area without any issues, where various tools and instruments were left unattended. The alarm on the exit door at the end of the hall did not sound when opened, further indicating a lack of proper supervision and safety measures. These deficiencies highlight significant lapses in the facility's safety protocols and supervision, leading to preventable accidents and potential hazards for the residents. The lack of proper documentation and policies exacerbates the risk of harm to residents, particularly those with severe impairments and vulnerabilities.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to provide appropriate interventions to address significant weight loss for a resident diagnosed with Hemiplegia, Hemiparesis following Cerebral Vascular Accident, Weakness, Dysphagia, and Gastronomy tube status. The resident was admitted with a weight of 268 pounds and experienced a 16.98% loss of body weight, amounting to 45.5 pounds, in less than two months. Despite being on a tube feeding regimen, the resident's weight continued to decline, and the facility did not adequately monitor or adjust the nutritional plan in response to the weight loss. The Registered Dietician was not notified of the weight loss in a timely manner, and the care plan was not updated to address the resident's nutritional needs effectively. The resident's weight was documented multiple times, showing a consistent decline, yet no significant changes were made to the feeding regimen until much later. The facility's policy on tube feeding was not followed, as the resident continued to lose weight despite being on a prescribed nutritional plan. Interviews with staff revealed a lack of awareness and understanding of the resident's weight loss and the necessary interventions to address it. The Registered Dietician confirmed that a resident on a tube feeding should not be losing weight and acknowledged that they were not informed of the weight loss until a care conference was held, leading to a delayed adjustment in the feeding plan.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored, prepared, and held in a manner that prevents potential contamination and food-borne illness, affecting all 112 residents. Observations revealed that the walk-in refrigerator had rust and peeling paint, with paint chips falling onto stored food, including a box of pizza crusts. The food temperature logbook lacked documentation for pureed food temperatures during lunch service. Additionally, health shakes in the cooler were not labeled with the date they were opened, only showing the shipment date, making it impossible to determine their freshness. The ice scoop was improperly stored inside the ice machine, with the handle covered in ice, which is against the facility's policy. The Dietary Manager confirmed these issues and acknowledged the expectations for proper labeling and storage practices were not met. Further observations showed that pureed meat and vegetables were left out of the steam table during lunch service, and their temperatures were not monitored. When checked, the pureed meat and rice were found to be below the required 135 degrees Fahrenheit. Some plates with under-temperature food were served to residents, while others were reheated. The Director of Nursing and the Registered Dietician both confirmed that food should be held at the correct temperature to prevent food-borne illnesses. The facility's policies on food preparation, ice handling, and receiving were not followed, contributing to the deficiencies observed during the survey.
Failure to Identify Causative Organisms for Infections
Penalty
Summary
The facility failed to identify the causative organism for infections, which hindered their ability to track and trend current infections and prevent further infections. This deficiency was observed in multiple instances across several months. For example, in December 2023, a resident with a urinary tract infection (UTI) and altered mental status was treated with Macrobid, but the organism causing the UTI was not documented. Similar issues were noted in January 2024, where another resident's UTI was resolved without identifying the causative organism. In February 2024, a resident had a UTI, but no cultures were ordered to identify the organism. In November 2023, another resident with a UTI was treated with antibiotics, but again, the causative organism was not documented. The Director of Nursing acknowledged that the organisms should be documented in the Infection Control Log to ensure proper treatment and to understand the infections present in the facility. The facility's policy on Infection Control Program Content, dated September 2023, emphasizes the importance of identifying infections and using data to prevent their spread. However, the facility failed to adhere to these guidelines, as evidenced by the lack of documentation of causative organisms in their Infection Surveillance Monthly Reports. This failure has the potential to affect all 112 residents living in the facility.
Failure to Ensure Infection Preventionist Presence
Penalty
Summary
The facility failed to ensure that an Infection Preventionist (IP) was working in the building at least part-time, which has the potential to affect all 112 residents. On 4/9/2024, the surveyor requested the name and documentation of the facility's IP. The Interim Administrator identified V27 as the IP and provided certification for V27's training. However, it was later revealed by the Director of Nursing and the Assistant Director of Nursing that V27 was on maternity leave and not working part-time in the facility. They mentioned that V7, the Wound Nurse, was filling in for V27, but V7 did not have the necessary certification for the IP role. The Interim Administrator confirmed that V27 was on maternity leave and that V7 was not the IP, nor did he have the required certification. Staffing schedules for the past 14 days did not document V27 working in the facility. The facility's assessment, revised on 4/1/2024, indicated that the IPCP was designed to meet current standards of practice and the needs of the facility population, staff, and community. However, there was no policy on having an IP working in the facility. The facility's Long-Term Care Facility Application for Medicare and Medicaid, CMS 671, dated 4/9/2024, documented a census of 112 residents. Despite the facility's assessment and documentation, the absence of a qualified IP working part-time in the facility was a significant deficiency. The Interim Administrator's statement that V27 was still considered the IP despite being on maternity leave, and the lack of a policy on having an IP working in the facility, contributed to the deficiency. The facility failed to ensure continuous and qualified infection prevention and control oversight, which is critical for the health and safety of the residents.
Lack of Proof of Continuing Education for CNAs
Penalty
Summary
The facility failed to provide proof of continuing education for Certified Nursing Assistants (CNAs), which has the potential to affect all 112 residents. On 4/16/2024, the Interim Administrator (V1) and the Director of Nursing (V2) were unable to provide the requested continuing education certificates. V1 stated that the Human Resources person responsible for tracking this information was on vacation and that they did not have any proof of continuing education. V2 also confirmed that they did not track continuing education and were unaware of any policy regarding it. By 4/17/2024, the facility still had not provided any proof of continuing education for staff. V1 acknowledged that continuing education is typically required and integral to training development, and mentioned that the facility holds monthly in-services on various topics. However, no documentation was available to verify compliance with continuing education requirements.
Failure to Provide Behavioral Health Training for Staff
Penalty
Summary
The facility failed to ensure behavioral health training for all employees, which has the potential to affect all 112 residents living in the facility. The facility provided documentation of in-services on various topics such as abuse, safety, notification policies, enhanced monitoring, resident rights, showers, skin issues, and rashes. However, there were no in-services provided regarding behavioral health services. Interviews with staff, including the Director of Nursing, Licensed Practical Nurses, Certified Nursing Assistants, and the Minimum Data Set Coordinator, confirmed that they had only received training on abuse and not on behavioral health. The facility's Facility Assessment, updated on 4/1/24, documented that the facility strives to offer the necessary training required to better meet the residents' needs, including those with chronic physical and mental illnesses, post-acute conditions, psychiatric/mood disorders, and substance use disorders. The assessment indicated that 80 residents required behavioral health needs, and 17 residents had active or current substance use disorders. Despite this, the facility did not provide the required training on person-centered care, caring for residents with mental and psychological disorders, non-pharmacological interventions, and care for residents with substance abuse disorders as documented in their assessment.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to ensure allegations of abuse, neglect, or mistreatment were thoroughly investigated and interventions were put into place to prevent further potential abuse, neglect, exploitation, or mistreatment for several residents. For instance, an incident involving two residents who entered a verbal disagreement that escalated to a physical altercation, resulting in one resident biting the other, was not thoroughly investigated. The facility was unable to provide a final report or evidence of staff or resident interviews related to the altercation. Additionally, there was no documentation of protective actions taken aside from separating the residents and providing supervision. This lack of thorough investigation and documentation was consistent across multiple incidents involving different residents, including physical altercations and injuries of unknown origin. In another case, a resident was thrown out of his wheelchair by another resident, resulting in abrasions. The facility failed to provide a final report or evidence of a thorough investigation, including staff or resident interviews. There was no documentation of protective actions taken to ensure the safety of the residents involved. Similarly, another resident reported being physically touched by a staff member, resulting in bruising and bright red blood to the right lower extremity. The facility did not conduct an investigation into this injury of unknown origin, and no documentation was provided when requested. The facility's failure to conduct thorough investigations and document protective actions extended to other incidents as well. For example, a resident complained of lower back pain, and subsequent medical examinations revealed a fracture vertebrae. However, the facility did not conduct an investigation into the injury of unknown origin. Additionally, an incident involving a disagreement over access to a meal cart escalated to a physical altercation between two residents. The facility's follow-up investigation report concluded that the altercation was due to a misunderstanding and not a deliberate attempt to harm. However, the facility's abuse policy and prevention program were not adequately followed, as there was no evidence of a thorough investigation or documentation of protective actions taken to ensure the safety of the residents involved.
Failure to Ensure RN Coverage for 8 Consecutive Hours Daily
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) was working in the facility seven days a week for 8 consecutive hours, which has the potential to affect all 112 residents living in the facility. On 4/9/2024, staffing schedules were requested and reviewed, revealing no RN coverage on 3/7/2024. Further review of timecards confirmed the absence of RN coverage on 3/1/2024, 3/4/2024, and 3/7/2024. The Interim Administrator was unaware of any issues with RN staffing, and the Director of Nursing confirmed that all timecards for RN coverage had been provided, which documented the gaps in coverage. The facility's assessment and staffing policy indicate that the facility is licensed for 90 beds with an average daily census of 50 residents, requiring RN or LPN charge nurses for each shift. The policy also states that sufficient licensed and unlicensed nursing staff should be provided on each shift to maintain the highest practical physical, mental, and psychosocial well-being of each resident. Despite this policy, the facility failed to meet the required RN coverage, as documented in the staffing schedules and timecards provided.
Failure to Locate and Replace Missing Clothing
Penalty
Summary
The facility failed to locate and replace missing clothing for five residents, leading to a deficiency in maintaining a safe, clean, comfortable, and homelike environment. Resident R13, who was moderately cognitively impaired, reported missing all her underwear. Despite a grievance being filed and some underwear being found, the issue persisted. The Housekeeping Supervisor and Social Service Designee acknowledged the problem but did not fully resolve it, as evidenced by the ongoing complaints from R13 and other residents during group meetings and individual interviews. Resident R103, who was cognitively intact, reported missing underwear, jeans, and t-shirts. Despite a note in the laundry room listing the missing items and a grievance being filed, the facility only partially recovered the missing clothing. The Resident Council Meeting Minutes also documented ongoing issues with timely return of clothes from the laundry. Similarly, Resident R70, who was cognitively intact, reported missing clothes, including underwear, socks, and pants, which were not found even after three weeks. Resident R64, who was alert and oriented, had multiple items of clothing and personal belongings go missing, including socks, jeans, boots, and a bedspread. His family repeatedly reported the missing items and provided receipts for reimbursement, but the facility failed to replace them. Additionally, Resident R100, who was moderately cognitively impaired, reported that all her clothes were missing, and despite receiving some replacement clothes from unmarked laundry, the issue persisted. The facility's policies on missing items and personal property were not effectively implemented, leading to unresolved grievances and dissatisfaction among residents and their families.
Failure to Ensure Correct Antibiotics for UTIs
Penalty
Summary
The facility failed to ensure that residents were given the correct antibiotics for the organisms causing their infections. For four residents reviewed for antibiotic stewardship, there was no culture and sensitivity (C&S) testing conducted to confirm that the prescribed antibiotics were appropriate for treating their urinary tract infections (UTIs). Specifically, Resident 20 received Macrobid without a documented organism causing the UTI, Resident 58 received Keflex without a C&S test, Resident 67 was prescribed Ciprofloxacin without a culture ordered by the medical doctor, and Resident 78 was given Nitrofurantoin Macrocrystal without a C&S test to determine the appropriate antibiotic. The facility's Infection Surveillance Monthly Reports for the respective months did not document the causative organisms for the UTIs in these residents. The Director of Nursing acknowledged that the organisms should be documented to ensure proper treatment and to monitor what infections are present in the facility. The facility's Antibiotic Stewardship Policy, revised in January 2018, indicates that treatment recommendations should be based on the likely UTI site and facility-specified culture and antibiotic sensitivity data, which was not followed in these cases.
Insufficient Nursing Staff Leads to Delayed Medication Administration
Penalty
Summary
The facility failed to ensure there was sufficient qualified nursing staff available at all times, resulting in delayed or missed medication administration for five residents. On 4/14/2024, there was no nurse present on the 100-hall during the morning shift, leading to residents not receiving their medications or blood glucose monitoring on time. Multiple residents, including those with diabetes, reported not receiving their insulin or having their blood sugar levels checked. Staff interviews confirmed the shortage, with only two nurses covering the entire building, and the Assistant Director of Nursing arriving late in the afternoon to assist. The facility's staffing schedules and medication administration records for 4/14/2024 corroborated the residents' accounts, showing that medications and blood glucose monitoring were given late or not at all. A grievance dated 3/28/2024 also documented ongoing issues with late medication administration. The facility's assessment and staffing policy indicated the need for adequate nursing services to meet residents' needs, but this was not achieved on the day in question.
Failure to Administer Medications and Perform Blood Glucose Monitoring as Ordered
Penalty
Summary
The facility failed to administer medications and perform blood glucose monitoring as ordered by the physician for five residents. On April 14, 2024, Resident 27 did not receive their 7:00 AM blood glucose monitoring, and Resident 61 did not have their blood glucose monitored at 8:00 AM. Resident 63 did not receive any of their morning medications or blood glucose monitoring at 8:00 AM. Similarly, Resident 64 did not receive their 8:00 AM medications or blood glucose monitoring at 8:00 AM and 11:00 AM. Resident 102 did not receive their 8:00 AM medications and reported that there was no nurse on the 100-Hall on the morning of April 14, 2024, leading to a delay in medication administration until after lunch. Interviews with staff and residents confirmed the absence of a nurse on the 100-Hall during the morning shift on April 14, 2024. Resident 102 and Resident 63 both reported not receiving their medications on time, with Resident 63 refusing to take their medications when they were finally offered late in the morning. Licensed Practical Nurse (LPN) V34 confirmed that she worked a double shift and was the only nurse available on the 400-Hall, with no nurse present on the 100-Hall or 200-Hall during the day shift. The Assistant Director of Nursing (ADON) acknowledged the short staffing issue and confirmed that she arrived at the facility around 1:20 PM, by which time the morning medications had not been administered. The facility's policy on medication administration emphasizes the importance of administering medications safely and appropriately to aid residents. However, due to staffing shortages and miscommunication, the facility failed to adhere to this policy, resulting in residents not receiving their medications and blood glucose monitoring as ordered. This deficiency was corroborated by multiple staff and resident interviews, highlighting a significant lapse in the facility's ability to provide consistent and timely pharmaceutical services.
Failure to Follow Physician's Orders for Pressure Ulcer Care
Penalty
Summary
The facility failed to treat a pressure ulcer per physician's order for a resident with multiple diagnoses, including Type 2 Diabetes, COPD, and contractures. The resident's care plan documented the presence of an unstageable pressure ulcer on the coccyx, with specific interventions such as the use of a low air loss mattress, regular skin assessments, and wound care per the wound care doctor. However, during an observation, an LPN provided wound care using normal saline instead of the prescribed Dakin's solution, stating that the wound nurse was on vacation and she was unsure of the correct procedure. This deviation from the physician's order was observed during incontinent care when the resident's pressure ulcer was noted to be red and open with a large amount of red drainage. The resident's wound care documentation showed a progression from an unstageable pressure ulcer with 100% necrosis to a Stage 4 pressure wound with increased dimensions. Despite the care plan's detailed interventions, the facility's failure to adhere to the prescribed wound care regimen contributed to the deficiency. The facility's policy required an order for all treatment protocols, but the LPN's uncertainty and incorrect wound care practice highlighted a lapse in following the physician's orders and the facility's guidelines.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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