Pa Peterson At The Citadel
Inspection history, citations, penalties and survey trends for this long-term care facility in Rockford, Illinois.
- Location
- 1311 Parkview Avenue, Rockford, Illinois 61107
- CMS Provider Number
- 145751
- Inspections on file
- 60
- Latest survey
- March 2, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Pa Peterson At The Citadel during CMS and state inspections, most recent first.
Surveyors found that the facility did not consistently implement ordered pressure ulcer prevention and treatment measures. A resident at high risk for pressure ulcers was observed in bed without ordered heel boots in place and with an unplugged, nonfunctioning air mattress, despite a care plan calling for these interventions. Another at-risk resident was found in bed with heel boots off and heels resting directly on the mattress, with slight redness noted, and reported that staff only sometimes applied the boots. In addition, a resident with a sacral pressure ulcer did not receive the wound physician’s ordered Dakin’s solution treatment for several days, as the facility’s orders initially specified only wound wash and Silvadene, contrary to the physician’s documented plan.
A resident with chronic pain and end stage renal disease did not receive a prescribed Fentanyl patch for several days because the medication was not available in the facility. Despite pharmacy deliveries and the medication being listed in the emergency narcotic supply, confusion among nursing staff and delays in obtaining a current prescription led to a gap in pain management.
Staff did not consistently use required PPE or perform hand hygiene during high-contact care for several residents on Enhanced Barrier Precautions, including those with wounds and incontinence. CNAs were observed failing to change gloves or wash hands between dirty and clean tasks, and not wearing gowns as required, despite facility policies and staff knowledge of proper infection control procedures.
The facility did not consistently provide enough CNAs on a unit with 36 residents, resulting in delayed incontinence care, residents remaining in bed past breakfast, and incomplete showers. Staff and residents reported frequent delays in call light responses and unmet basic care needs, with staffing schedules confirming multiple shifts with insufficient CNA coverage.
Three residents did not receive timely or appropriate care for wounds and pain as ordered, including delayed initiation of wound treatments, lack of documentation, and failure to administer prescribed pain relief or obtain a specialist consult. Nursing staff did not follow protocols for assessment, documentation, and implementation of physician orders upon admission.
The facility did not timely assess or implement wound care interventions for three residents with pressure ulcers, including failure to initiate ordered treatments, incomplete documentation of wound care, and lack of proper offloading of heels as required by care plans and physician orders. Observations and staff interviews confirmed that pressure-relieving devices were not consistently used, and wound care assessments were missing or delayed.
Two residents with contractures and limited range of motion did not consistently receive prescribed splint application, and staff failed to document splint use or refusals. One resident with left-sided paralysis was repeatedly observed without his splint, and another resident with hemiplegia reported not receiving assistance to apply his splint. Care plans and staff documentation did not reflect the required interventions or resident refusals.
A resident with dementia, Alzheimer's disease, and a history of fractures, who was identified as high risk for falls and required substantial assistance for transfers, was moved from a chair to a bed by two CNAs using improper technique—holding under the arms and by the waistband—without a gait belt, contrary to facility policy and guidelines. Staff interviews confirmed that a gait belt or mechanical lift should have been used for safe transfer.
A resident's steel oxygen cylinders were found unsecured, with one tank leaning against a wall in a closet and another against a bedside table. An LPN confirmed that unused oxygen tanks should be stored in the designated storage room, in accordance with the facility's policy requiring cylinders to be secured in racks, carts, or stands and not left free-standing.
A resident alleged that money was missing from her purse after a CNA was present in her room. The facility did not document interviews with staff or other witnesses, nor did it include written or signed statements in the investigation file, contrary to its own policies. The investigation lacked thoroughness and proper documentation.
A resident without cognitive impairment reported that a CNA failed to provide requested assistance with his wheelchair and blankets during the night shift, instead leaving the wheelchair out of reach and refusing to help with covers. The resident felt upset and not treated properly, and these concerns were reported to the DON. The facility failed to ensure the resident was consistently treated with dignity and respect, as required by policy.
Two residents with diagnoses including dementia, Alzheimer's disease, and anxiety received PRN anti-anxiety medications without required stop dates. Orders for clonazepam and lorazepam were found to be ongoing without time limits, despite facility policy and DON statements that such medications should have a 14-day stop date.
Three dependent residents with significant cognitive and physical impairments did not receive timely incontinence care as required by their care plans and facility protocol. Staff found these residents with saturated incontinence briefs and, in one case, a strong urine odor and soiled bedding, despite no refusals of care. Interviews confirmed that incontinence care should be provided at least every two hours, but this standard was not met.
Surveyors found that two residents' medications, including morphine for pain and diazepam for seizures, were not properly labeled or dated when opened. One medication label was illegible and nearly detached, and both medications were outdated at the time of inspection. The DON confirmed that these medications should have been dated, labeled, and renewed as required.
A resident who had previously refused earlier versions of the pneumococcal vaccine was not offered the current pneumonia vaccine (PCV20) as required by facility policy and CDC guidelines. The Infection Control Preventionist had not discussed the updated vaccine with the resident, and there was no documentation that the vaccine had been offered.
A resident with dementia and cognitive impairment did not receive necessary assistance with oral and denture care, resulting in unclean dentures that had not been removed or cleaned for about a week. The LPN acknowledged past assistance but confirmed daily cleaning was not performed. The DON noted daily oral care is standard, yet no refusals were documented despite a shower sheet indicating refusal. The facility's ADL policy was not followed.
Two residents in a shared room experienced a deficiency in their living environment due to a piece of wallpaper falling down, revealing a black substance that appeared to be mold. The wallpaper had been in this condition for over 10 days, and the Maintenance Director was not informed until much later. The facility failed to ensure a safe, clean, and homelike environment for the residents, one of whom had moderate cognitive impairment and the other severe cognitive impairments.
The facility failed to document controlled medications in the narcotic reconciliation binder for several residents. Discrepancies were found between the recorded and actual number of pills during a medication count. An RN admitted to not documenting the medications during the morning pass, contrary to facility policy, which requires immediate documentation after administration.
The facility failed to store controlled medications under a double lock in the medication room. Observations revealed that the refrigerator containing controlled medications, including Lorazepam, was not locked. Staff confirmed that the refrigerator should be locked when unattended. The facility's policy requires schedule II-IV medications to be stored in separately locked compartments, which was not followed.
A facility failed to prevent the misappropriation of medications when an RN was suspected of taking a resident's Levaquin. Despite reports from other staff and available surveillance, the facility did not review footage to verify the claims. The RN admitted to taking and later disposing of the pills, highlighting deficiencies in medication safeguarding and investigation procedures.
A facility failed to report an allegation of medication misappropriation involving a nurse who admitted to taking and disposing of a resident's antibiotic. The incident was not reported to the Illinois Department of Public Health as required by the facility's policy, despite the nurse's admission. The facility's investigation concluded there was no drug diversion, leading to the deficiency.
A facility failed to thoroughly investigate an allegation of medication misappropriation involving a resident's Levaquin. Two nurses reported seeing another nurse take the medication, but the investigation was incomplete, lacking interviews with potential witnesses and a review of video footage. The nurse later admitted to taking the pills for personal use.
The facility failed to ensure staff followed the Abuse Prevention Policy when an Activity Aide observed suspicious behavior between two residents but delayed reporting it to administration for about five hours, contrary to the policy's requirement for immediate reporting.
The facility failed to report suspected sexual abuse between two residents in a timely manner. An activity aide observed suspicious behavior but delayed reporting it to the administration. The potentially victimized resident, who has cognitive impairments, later expressed discomfort about the other resident's actions. The facility's policy requires immediate reporting of such incidents, but this protocol was not followed, leading to a deficiency.
A resident with severe cognitive impairment experienced a fall resulting in ankle swelling, but the facility failed to notify the resident's POA about the fall, the swelling, and an X-ray order. Despite the facility's policy requiring such notifications, the POA only learned of the X-ray through an invoice, highlighting a communication breakdown within the facility.
A resident with multiple health issues experienced increased lethargy and confusion, prompting her POA to request lab tests and a UA. The facility delayed entering these orders, and the resident's condition was not promptly addressed. An antibiotic was eventually prescribed, but the POA was not informed, highlighting a deficiency in care.
A resident with significant weight loss did not receive recommended nutritional supplements, such as ice cream and health shakes, despite a dietitian's recommendations. The resident's weight dropped from 180.6 to 159.2 pounds, and her dietary needs were not consistently met, with her daughter having to request ice cream repeatedly. The facility was also out of ice cream, and the administrator was unaware of this shortage.
A resident who had major back surgery experienced issues with IV antibiotic administration, including late doses and lack of documentation. The facility's MAR showed the antibiotic Cefazolin was administered late 30 times, and some doses were marked as not given without explanation. Staff interviews revealed confusion and improper documentation practices regarding medication administration.
The facility failed to perform and document dressing changes as ordered for two residents. One resident's dressing on the right calf was loose and not changed as needed, while another resident's elbow dressing was not changed daily as required. The Director of Nursing confirmed that dressing changes should be documented, but the Treatment Administration Records showed missed changes. The facility's policy on non-sterile dressings was not adhered to.
A resident with a history of respiratory issues was not given an as-needed nebulizer treatment despite wheezing and having physician orders for such treatment. The resident's care plan lacked documentation for nebulizer treatments, and staff interviews revealed that the necessary medication was not administered, although it was available in the facility's medication dispensing machine.
A resident did not receive scheduled evening medications due to a failure in timely medication order entry and access to the medication dispensing machine. The resident, who had multiple serious health conditions, was admitted from the hospital and required medications that were not administered as scheduled. The facility's medication dispensing machine contained the necessary medications, but they were not accessed, and the pharmacy delivered the medications later that night.
A resident with dementia in an LTC facility was found with multiple bruises, suspected to be caused by contact with bed side rails. The resident's care plan lacked specific interventions for his agitation and restlessness, despite known behaviors. Staff interviews revealed inconsistent use of protective measures, highlighting a deficiency in adhering to the facility's dementia care policy.
A resident with complex medical conditions was readmitted to a facility with conflicting medication orders, leading to a deficiency in care. Despite being NPO and having a PEG tube, medications were administered orally due to unclear orders. The resident's tube feeding orders were not transcribed, resulting in a lack of nutritional support. Staff failed to clarify the orders, contributing to the deficiency.
The facility failed to implement Enhanced Barrier Precautions (EBP) for four residents with conditions requiring such measures, including wounds and infections. Staff did not use gowns during wound care, and no PPE or isolation signs were present, despite the facility's policy mandating these precautions to prevent the spread of multidrug-resistant organisms.
The facility failed to assess and monitor a resident's ankle, resulting in an infection and hospital admission for surgical repair. Another resident had untreated open wounds on her thighs and groin, which were not documented or addressed by the staff. The facility did not adhere to its policies on skin integrity and perineal care, leading to significant health issues for the residents.
The facility failed to prevent and adequately care for pressure ulcers in three residents. One resident developed a Stage III pressure injury due to inadequate monitoring and reporting by staff. Another resident's heel boots were not consistently applied, worsening a Stage III heel ulcer. A third resident's pressure ulcer assessments were not conducted weekly, and an air mattress was not provided as ordered. These deficiencies highlight lapses in following care plans and facility policies.
A resident experienced a significant weight loss of 20.3% over 25 days due to the facility's failure to conduct in-person dietary assessments and weekly weight monitoring as ordered. The resident, who had a history of colon cancer and severe malnutrition, was not assessed by a Registered Dietician or Certified Dietary Manager upon admission, leading to a lack of intervention for the resident's declining weight.
The facility did not follow its standardized recipe for chili, affecting all 127 residents. The cook prepared the chili using a personal recipe, resulting in a watery, soup-like dish lacking key ingredients like tomato sauce, green peppers, and onions. This deviation from the facility's policy was confirmed by resident feedback and a test tray evaluation.
The facility failed to follow proper infection control practices, including not changing gloves during resident care, not donning required PPE for contact isolation, and not implementing Enhanced Barrier Precautions for residents with wounds or medical devices. These actions were observed among CNAs and a Nurse Practitioner, leading to potential cross-contamination and infection risks.
The facility failed to provide timely incontinence care and repositioning for several residents, resulting in skin irritation and open wounds. Residents were left in soiled briefs for extended periods, and staff admitted to not following the facility's protocol of providing care every two hours. This deficiency affected residents with mobility impairments and cognitive issues, leading to moisture-associated skin damage and excoriation.
A resident who expressed a desire to receive the COVID-19 vaccine was not administered the vaccine, despite being admitted to the facility four months prior. The Infection Preventionist confirmed the resident's wish to be vaccinated but was unsure why it had not been done. The facility's policy emphasizes the importance of offering the vaccine in accordance with CDC guidelines.
A facility failed to apply a splint for a resident's left hand contracture, as observed over several days. The resident, who was supposed to wear a splint, did not receive assistance from staff, and the splint was found unused in the room. A CNA was unaware of any instructions for its use. The resident's discharge from occupational therapy included recommendations for a splint and passive range of motion exercises, but there were no physician's orders or documentation in the care plan or computer system, indicating a lack of communication and follow-through.
The facility failed to supervise two residents, one who was smoking unsupervised and another at risk for aspiration pneumonia while eating. A resident was found smoking near the facility's entrance without staff, against policy requiring supervision in designated areas. Another resident with Parkinson's and dysphagia was left alone during meals, despite needing supervision due to impaired swallowing. These actions violated the facility's safety protocols.
The facility failed to provide proper incontinence and catheter care for three residents, leading to potential infection risks. CNAs cleaned a resident's perineal area incorrectly, contrary to policy. Another resident's catheter bag was placed on the bed, causing urine back-flow, while a third resident's catheter was found on the floor, causing discomfort. These actions violated the facility's policies on perineal and catheter care.
The facility failed to offer the pneumonia vaccine to three residents, despite having a policy to assess and offer the pneumococcal vaccine series upon admission and on an ongoing basis. One resident received the PCV13 in 2015 but was not offered the PPSV23. Another resident received the PCV13 in early 2023 but was not offered the PPSV23, which was due. A third resident had no vaccination records since admission. The Infection Preventionist confirmed the oversight, acknowledging the failure to adhere to the facility's vaccination policy.
The facility failed to administer medications as ordered, resulting in a 24.14% error rate. An LPN did not observe a resident taking medications and failed to apply a Lidocaine patch. Another resident missed a dose of Debrox ear drops due to unavailability. The facility's policy requires medications to be administered safely and as prescribed.
A facility failed to label a multi-dose insulin pen with an open date for a resident. The resident had an order for a Lantus Solostar pen, and it was found that the pen, delivered over a month prior, was not labeled with an open date. Both an RN and the DON confirmed the requirement for labeling insulin pens upon opening.
A resident with cognitive impairment and behavioral issues was administered Haldol twice due to aggressive behavior without prior notification to their representative. The facility's policy requires prompt notification of significant changes, which was not followed, leading to a deficiency. The resident's daughter was informed only after the first incident, expressing concern over the lack of timely communication.
Two residents were physically abused by peers in separate incidents. One resident, without cognitive impairment, was assaulted by a roommate with a history of aggressive behavior after a confrontation over personal belongings. Another resident with moderate cognitive impairment was hit by a peer with known behavioral issues. Staff intervened, and the aggressive peer was sent for psychiatric evaluation.
A resident with cognitive impairment and multiple diagnoses exhibited aggressive behaviors that were not properly documented or addressed in their care plan. Staff intervened with Haldol injections, but lacked consistent non-pharmacologic interventions. Interviews revealed confusion and inadequate protocol adherence, with the facility's policy on individualized interventions not being followed.
Failure to Implement Pressure Ulcer Prevention and Wound Treatment Orders
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention interventions for residents at risk and to follow a wound physician’s treatment orders for an existing pressure ulcer. One resident with a high Braden risk score had physician orders for protective heel boots to both feet at all times and an air mattress, and her care plan identified risk factors including impaired cognition, incontinence, impaired mobility, and impaired nutrition. During observation, her heel boots were on the bedside table, her heels were resting directly on the mattress, and her air mattress was not plugged in or functioning, with no indicator lights on. The wound LPN confirmed that the resident should always have heel protection boots on and a functioning air mattress, and later stated that interventions for this resident included an air mattress, heel boots at all times, frequent incontinence care, and frequent repositioning. Another resident with a moderate Braden risk score was observed in bed with protective heel boots present in the room but not on his feet; one boot was on the dresser and one on the floor, and his heels were directly on the mattress with slight redness noted bilaterally. This resident reported that staff sometimes put the boots on and sometimes did not, and the wound LPN stated that this resident was at risk due to immobility and that his interventions included heel boots when in bed, turning every two hours, and nutritional supplements. The facility also failed to implement the wound physician’s specific treatment orders for a resident with a sacral pressure ulcer. A specialty physician’s initial wound evaluation documented an unstageable sacral pressure ulcer with necrotic and viable tissue and ordered daily and as-needed application of sodium hypochlorite (Dakin’s) solution, silver sulfadiazine 1%, and a bordered gauze dressing. A subsequent evaluation showed the wound as a stage 3 sacral pressure ulcer that was not at goal due to infection. However, the physician’s order sheet initially contained an order to cleanse the sacrum with wound wash, pat dry, apply Silvadene to the wound bed, and cover with bordered foam daily and as needed, with no order to cleanse with Dakin’s until several days after the initial wound evaluation. The wound LPN stated that the wound nurse inputs all new physician orders into the record and that all wound physician orders should be followed, and clarified that wound wash is a gentle cleanser while Dakin’s is a bleach solution used for debridement and as an antimicrobial. The wound physician stated he orders Dakin’s when he suspects infection, described it as a strong wound cleanser, and said he expected staff to follow his orders. The facility’s own pressure ulcer and wound prevention/management policy states that residents with pressure ulcers should receive necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing.
Failure to Provide Timely Pain Medication Due to Medication Unavailability
Penalty
Summary
The facility failed to ensure that a prescribed pain medication, Fentanyl 12mcg/hr transdermal patch, was available and administered as ordered for a resident with multiple diagnoses, including end stage renal disease, hemiplegia, and chronic pain. The resident's care plan required pain management, and physician orders specified the application of the Fentanyl patch every 72 hours. However, the medication administration record showed that the patch was not applied for a period of seven days, and progress notes indicated the medication was not available during this time. Interviews with nursing staff revealed confusion regarding the ordering and availability of the Fentanyl patch. One LPN stated the patch was not in the facility for several days, despite the pharmacy delivering medications multiple times daily and the medication being listed in the facility's emergency narcotic supply. The Director of Nursing confirmed that a current prescription was needed for the pharmacy to supply the narcotic and that the process involved contacting the nurse practitioner if a prescription was missing. Documentation showed the prescription was received on one date, but the medication was not delivered until several days later, and the patch was not applied until even later, resulting in a gap in pain management for the resident.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
Facility staff failed to follow infection prevention and control protocols for residents on Enhanced Barrier Precautions (EBP) and during incontinence care. Certified Nursing Assistants (CNAs) were observed not donning required personal protective equipment (PPE), such as gowns and gloves, when providing care to residents with wounds or those on EBP. In multiple instances, staff did not change gloves or perform hand hygiene when moving from contaminated to clean areas during incontinence care. For example, one CNA provided care to a resident with urine and stool in the incontinence brief without changing gloves or performing hand hygiene, and did not wear a gown as required by EBP protocols. Similar failures were observed with other residents, including not changing gloves or performing hand hygiene after cleaning soiled areas and before handling clean items or applying dressings. Additionally, a CNA was observed providing care to a resident with pressure wounds without wearing a gown or gloves initially, and only applied gloves after handling the resident's oxygen tubing. The facility's policies require the use of gowns and gloves for high-contact care activities for residents with wounds or indwelling devices, and mandate hand hygiene and glove changes between dirty and clean tasks. Interviews with staff, including the Director of Nursing and Infection Prevention Nurse, confirmed the expectation for proper PPE use and hand hygiene, but these practices were not consistently followed during the observed care events.
Failure to Provide Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to ensure adequate nursing staff were scheduled to meet the needs of all residents on the third floor, which housed 36 residents. On multiple occasions, only two CNAs were assigned to care for all residents on the unit, despite the facility's stated goal of three CNAs per shift. Staff interviews confirmed that CNAs were sometimes pulled from the third floor to cover shortages elsewhere, resulting in insufficient staffing. Observations revealed that incontinence care was delayed, with several residents found in saturated briefs during the morning, and some residents remained in bed past breakfast time due to lack of available staff. Staff, including CNAs and an LPN, reported difficulty completing all required tasks such as showers, toileting, and getting residents up for meals when staffing was below the intended level. The staffing scheduler and unit manager acknowledged that the unit sometimes operated with only two CNAs when call-offs occurred and replacements could not be found. Review of staffing schedules showed multiple shifts with only one or two CNAs assigned, and on one date, no CNA was listed for the third floor. Resident and family interviews, as well as resident council meeting minutes, documented ongoing concerns about delayed call light responses, unmade beds, and inconsistent provision of basic care such as passing ice water. Residents reported waiting one to two hours for call lights to be answered and noted that staff sometimes turned off call lights without addressing their needs. These issues were repeatedly raised in resident council meetings over several months, indicating a persistent problem with inadequate staffing and unmet resident needs.
Failure to Provide Timely and Appropriate Wound and Pain Management
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and residents' needs for three residents. One resident, admitted with multiple diagnoses including dementia and incontinence, experienced significant vaginal pain during peri care. The certified nursing assistant did not apply the prescribed cream for pain relief, instead using Vaseline, and did not notify the nurse for further assessment. Although there were existing orders for A and D ointment and lidocaine cream, these were not administered as directed, and there was no evidence that a gynecology consult ordered for a labial growth was completed. Another resident was observed with a foam dressing on his right elbow, which had a skin tear. Despite having orders for specific wound care treatments upon admission, no treatment was initiated for the elbow wound until four days after admission. Documentation showed a delay in transcribing and implementing wound care orders, contrary to facility protocol requiring orders to be entered onto the treatment administration record within one hour of admission. A third resident was found with a foam dressing to the gluteal cleft and had a history of moisture-associated skin damage (MASD) and vascular wounds. Although the after-hospital care plan included detailed wound care instructions, there were no wound treatment orders or documentation of treatment for the MASD until five days after admission. The wound care nurse confirmed that wound assessments and treatments were not completed in a timely manner, and the required documentation was missing for these residents.
Failure to Assess and Implement Pressure Ulcer Care and Offloading Interventions
Penalty
Summary
The facility failed to assess and implement timely treatment interventions for pressure wounds and did not ensure that pressure-relieving interventions were in place for three residents with pressure wounds. For one resident, although the admission and after-hospital care plan indicated a sacral pressure wound and ordered zinc paste treatment, there was no evidence of treatment initiation or wound care orders for the sacrum documented in the treatment administration record or order summary report. Another resident had multiple pressure wounds identified on admission, including to the groin, sacrum, and both posterior thighs, with specific wound care orders from the hospital. However, no wound treatment orders were transcribed, and no treatments were initiated for the thigh wounds until six days after admission. Additionally, the groin and sacrum wounds were not addressed in the treatment administration record, and wound care nurse assessments for these residents were not available prior to a specific date. A third resident was observed with a wound vacuum on the left heel and a pressure reduction boot only on the right foot, despite orders and care plans specifying that both heels should be offloaded and protective boots should be used when in bed. Observations showed the left heel resting directly on the bed without a boot, and the resident was unaware of why only one boot was applied. Staff interviews confirmed that standard care requires offloading both heels, and if boots are not available, alternative methods such as pillows or wedges should be used. Facility policies required prompt transcription of physician orders and full skin assessments, which were not followed in these cases.
Failure to Apply and Document Splint Use for Residents with Contractures
Penalty
Summary
The facility failed to ensure that splints were applied as ordered for two residents with contractures and limited range of motion. One resident with a history of stroke and left-sided paralysis was observed multiple times without his prescribed left hand splint, despite care plan interventions specifying daily use as tolerated. The resident reported that staff did not apply the splint or perform exercises for his contracted arm, and there was no documentation of refusals or splint application in the resident's records for the relevant period. The Director of Nursing confirmed that if there was no documentation, the intervention was not performed, and the resident was only referred to therapy after the deficiency was identified. Another resident with hemiplegia and reduced mobility was also found without a splint, and there were no physician orders for splint placement in the records. The care plan noted occasional refusals to wear the splint, but there was no documentation of such refusals. The resident stated he would wear the splint if staff assisted, but staff tasks did not include splint application. The Director of Nursing confirmed that splint use should be documented and that splints are intended to prevent worsening contractures, but no consistent documentation or evidence of splint application was found for this resident.
Failure to Use Proper Transfer Technique for High-Risk Resident
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including dementia, Alzheimer's disease, osteoarthritis, and a history of right femur fracture, was not transferred safely by staff. The resident was identified as high risk for falls and required substantial to maximal assistance for transfers, as documented in her care plan and Minimum Data Set. Despite these requirements, two CNAs transferred the resident from her chair to her bed by holding her under the arms and by the waistband of her pants, without the use of a gait belt. The resident did not bear any weight during the transfer. Interviews with the Director of Nursing and one of the CNAs confirmed that facility policy requires the use of a gait belt for transfers involving two staff members, and that a mechanical lift should be used if the resident is unable to stand. The facility's own guidelines specify the proper use of a gait belt and recommend a mechanical lift for non-weight-bearing residents. The observed transfer method did not follow these protocols, creating a situation where the resident could have been injured.
Improper Storage of Oxygen Cylinders
Penalty
Summary
The facility failed to ensure proper storage of steel oxygen cylinders for a resident receiving respiratory services. During observation, one oxygen tank was found leaning against the wall in the resident's closet area, and another was leaning against the bedside table near the head of the resident's bed. Both oxygen tanks were not secured to keep the cylinders upright. An LPN confirmed that when the oxygen tank is not in use, it should be stored in the designated oxygen cylinder storage room. The facility's Oxygen Safety Policy requires all oxygen cylinders to be stored in racks with chains, sturdy portable carts, or approved stands, and never left free-standing or in any resident room or living area.
Failure to Document and Conduct Thorough Investigation of Alleged Monetary Misappropriation
Penalty
Summary
The facility failed to conduct a thorough investigation and maintain proper documentation regarding an allegation of monetary misappropriation involving a resident. The resident reported that a significant amount of money was missing from her purse after a certified nursing assistant (CNA) was present in her room. The administrator acknowledged that while some night shift staff were interviewed by phone, no written or typed records of these interviews were created or maintained. Additionally, video footage was not reviewed, and the only documentation present was the administrator's notes on the resident's statements. No written or signed statements from employees or other residents were included in the investigation file. The facility's own policies require that interviews with witnesses and involved parties be documented in writing, signed, and dated, and that the final investigation report include these interviews. However, the investigation file lacked any such documentation, and staff confirmed that it was not their practice to type out or retain employee interview statements. This lack of thorough documentation and failure to follow established policy resulted in an incomplete investigation of the alleged abuse.
Failure to Ensure Resident Dignity and Respect During Night Shift Care
Penalty
Summary
A resident with no cognitive impairment reported concerns regarding the treatment received from staff during the night shift. The resident stated that a staff member did not place his wheelchair within reach as requested, instead leaving it across the room, which caused distress. On another occasion, when the resident requested assistance with his blankets, the staff member told him to do it himself. The resident expressed that he required help and wanted to be treated properly, and he reported these concerns to the Director of Nursing (DON). The DON confirmed that the resident had previously brought up a concern about not having his pants put on at night as requested, but was not aware of the wheelchair and blanket issues until informed by the surveyor. The facility's policy states that each resident should be cared for in a manner that promotes their well-being, satisfaction, self-worth, and self-esteem. The observations and interviews indicate that the resident was not consistently treated with dignity and respect by staff, as required by facility policy.
Failure to Ensure PRN Psychotropic Medications Had Stop Dates
Penalty
Summary
The facility failed to ensure that as-needed (PRN) anti-anxiety medications had appropriate stop dates for two residents reviewed for chemical restraints. One resident, admitted with diagnoses including dementia, major depressive disorder, Alzheimer's disease, anxiety disorder, unspecified psychosis, and insomnia, had active orders for clonazepam and lorazepam for anxiety, both lacking stop dates. Another resident, admitted with Alzheimer's disease and insomnia, had an active PRN order for lorazepam for agitation/restlessness without a stop date. According to the Director of Nursing, PRN psychotropic medications should have a 14-day stop date, and monitoring for these stop dates is the responsibility of nursing leadership. The facility's policy defines chemical restraint as a psychotropic medication used to treat identified medical symptoms, typically in PRN form.
Failure to Provide Timely Incontinence Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADL), specifically incontinence care, for three dependent residents. For one resident with diagnoses including unspecified psychosis, Meniere's disease, and osteoarthritis, the care plan required cleaning the peri-area with each incontinence episode. However, on the day of observation, the resident had not been cleaned up for the day and was found with a completely saturated incontinence brief after having breakfast in bed. Another resident with dementia, Alzheimer's disease, and major depressive disorder, who required substantial staff assistance for toileting and hygiene, was also not cleaned up for the day. This resident was found with a saturated incontinence brief, a damp incontinence pad with a dark urine circle, and a strong urine odor in the room, with liquid noted on the bathroom floor. The resident did not refuse care or display aggressive behaviors during assistance. A third resident, diagnosed with epilepsy, muscle weakness, cognitive communication deficit, and mixed incontinence, was observed lying in bed with a saturated incontinence brief. Staff confirmed that incontinence care had not yet been performed for this resident. Interviews with CNAs and the Director of Nursing indicated that incontinence care should be provided at least every two hours or more, in accordance with the facility's protocol. Despite this, the observed residents had not received timely incontinence care, resulting in saturated briefs and unaddressed hygiene needs.
Failure to Properly Label, Date, and Store Medications
Penalty
Summary
Surveyors observed that the facility failed to ensure medications were properly labeled and dated when opened for two residents. During inspection of medication carts on two separate units, it was found that one resident's morphine sulfate, used for palliative pain management, was opened but not dated, and the controlled drug receipt indicated the medication had been delivered previously. Another resident's diazepam, administered for seizures, had a label that was illegible and nearly detached, and the medication was also opened without being dated. Additionally, the diazepam had expired approximately four months prior, and the controlled drug receipt showed it had been delivered almost two years ago. The Director of Nursing confirmed that medications should be dated when opened, labels should be legible, and expired medications should be renewed. Both the morphine and diazepam were found to be outdated at the time of the survey. These findings were based on direct observation, staff interviews, and review of medication records, and involved residents with significant medical needs, including palliative care and seizure management.
Failure to Offer Pneumonia Vaccination per Policy
Penalty
Summary
The facility failed to offer a current pneumonia vaccination to a seventy-seven-year-old male resident who had previously refused the pneumococcal polysaccharide vaccine (PPSV23) and the pneumococcal conjugate vaccine (PCV13) in 2021. During an interview, the Infection Control Preventionist confirmed that the facility follows CDC guidelines and currently offers the PCV20 vaccine, which should be offered upon admission and when residents are eligible. However, there was no documentation that the resident had been offered the current pneumonia vaccine, and the Infection Control Preventionist had not discussed vaccination with the resident prior to the interview. The facility's policy requires offering pneumococcal vaccines in accordance with CDC recommendations, but this was not documented for the resident in question.
Failure to Provide Adequate Oral and Denture Care
Penalty
Summary
The facility failed to provide necessary assistance with oral and denture care for a resident with a self-care deficit. The resident, who has a medical history including dementia, type 2 diabetes mellitus, and mild cognitive impairment, was observed with unclean dentures that had not been removed or cleaned for about a week. The resident indicated that neither he nor the staff had brushed his dentures during this period. The resident's Minimum Data Set documented a need for partial to moderate assistance with oral hygiene, which was not adequately provided. The Licensed Practical Nurse (LPN) responsible for the resident acknowledged having assisted with denture care in the past but confirmed that dentures should be removed daily for cleaning. The Director of Nursing (DON) noted that oral care should be provided daily and is typically done during morning care. However, there was no documentation of the resident refusing denture care in the progress notes for the last 30 days, despite a shower sheet indicating a refusal. The facility's policy on Activities of Daily Living (ADLs) emphasizes the importance of providing necessary care to maintain residents' hygiene, which was not adhered to in this case.
Failure to Maintain a Homelike Environment Due to Wallpaper and Mold Issue
Penalty
Summary
The facility failed to maintain a homelike environment for two residents, R1 and R6, as observed on December 10, 2024. In their shared room, a piece of wallpaper next to the window was falling down, revealing a black substance on both the wallpaper and the wall. The wallpaper, which was white, was detached from the top of the window to the bottom, measuring approximately 17 inches in width and 4 feet in height. The black substance, which appeared to be mold, covered about half of the unattached wallpaper and had a fuzzy appearance. R1, who has a moderately impaired mental status, reported that the wallpaper and black areas had been in this condition for 10-14 days. R6, with severe cognitive impairments, had been in the room for over 10 days, during which time the wallpaper had remained unchanged. The Maintenance Director, V10, was not informed of the issue until the morning of December 10, 2024. V10 stated that staff should have reported the problem sooner, as most repairs are typically completed within 24 hours. The facility's failure to address the deteriorating condition of the wallpaper and the potential presence of mold in a timely manner compromised the residents' right to a safe, clean, and homelike environment. The issue was visible from the hallway and had been noted by R6's family, who visited daily. The lack of prompt communication and action regarding the maintenance issue led to the deficiency in providing a homelike environment for the residents involved.
Failure to Document Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were properly documented as administered in the narcotic reconciliation binder for eight out of nine residents reviewed for controlled medications. During a medication reconciliation count, discrepancies were found between the number of pills recorded in the narcotic binder and the actual number of pills in the medication cards for several residents. For instance, one resident's Tramadol Hydrochloride showed 25 pills in the binder but only 24 in the medication card, and another resident's Norco showed 28 pills in the binder but only 27 in the medication card. These discrepancies were observed during a surveyor's medication count with a registered nurse (RN) who admitted to not documenting the administered medications in the binder during the morning medication pass. The RN involved in the medication pass acknowledged the failure to document the controlled medications immediately after administration, which is against the facility's policy. The Director of Nursing and another RN confirmed that the proper procedure is to sign the narcotics out in the binder once they are taken out of the cart and placed in the medication cup. The facility's policy, revised in April 2019, requires the individual administering the medication to initial the resident's medication administration record (MAR) after giving each medication and before administering the next ones. This failure to document in real-time could lead to medication errors, as noted by the staff.
Controlled Medications Not Double Locked
Penalty
Summary
The facility failed to ensure that controlled medications were stored under a double lock in the medication room, as required by their policy and procedure. During an observation, it was found that the refrigerator in the medication room, which contained controlled medications, was not locked. The lock was resting on the latch but was open, allowing access to the medications inside. Specifically, 10 ml of Lorazepam 2 mg/ml for one resident and an opened bottle containing 1.5 ml of Lorazepam 2 mg/ml for the same resident were found in the unlocked refrigerator. Additionally, a container with 30 ml of Lorazepam 2 mg/ml for another resident, along with two ABHR suppositories, was also stored in the unlocked refrigerator. Lorazepam is classified as a schedule IV-controlled medication, which requires secure storage. Interviews with facility staff, including the Director of Nursing and a registered nurse, confirmed that the refrigerator should be locked when a nurse is not present in the medication room due to the presence of controlled medications. The facility's policy, dated December 2017, mandates that all drugs classified as schedule II of the Controlled Substances Act be stored under double locks, and schedule II-IV medications must be maintained in separately locked, permanently affixed compartments. The failure to adhere to these storage requirements resulted in the deficiency noted during the survey.
Misappropriation of Resident Medications by RN
Penalty
Summary
The facility failed to prevent the misappropriation of medications for a resident, identified as R2, who had multiple diagnoses including a methicillin-resistant staphylococcus aureus infection and a stage 4 pressure ulcer. The Medication Administration Records (MARs) indicated that R2 was prescribed Levaquin, an antibiotic, which was administered as ordered. However, an allegation arose involving a registered nurse (RN), identified as V4, who was suspected of taking medications from the facility. The incident was reported by two nurses, V5 and V9, who claimed to have witnessed V4 taking medications from a medication card and placing them in his pocket. V3, the VP of Clinical Operations, conducted an investigation and discovered discrepancies in the medication delivery records. V4 initially denied the allegations but later admitted to taking the pills, claiming he intended to keep them for personal use but ultimately disposed of them by flushing them down the toilet. Despite the availability of surveillance cameras, the facility did not review the footage to verify the claims. The facility's abuse policy requires immediate reporting and investigation of any allegations of misappropriation. However, the investigation was delayed, and critical steps, such as reviewing video footage, were not taken. The facility's failure to document the return of medications to the pharmacy further complicated the investigation. The report highlights a lack of evidence to conclusively prove drug diversion, but the admission by V4 and the failure to follow proper procedures indicate a deficiency in safeguarding resident medications.
Failure to Report Medication Misappropriation
Penalty
Summary
The facility failed to report an allegation of misappropriation of medications to the Illinois Department of Public Health (IDPH) for a resident. The incident involved an allegation made by two nurses that another nurse had taken medications, specifically Levaquin, an antibiotic prescribed to a resident. The facility's administrator was informed of the allegation and notified the VP of clinical operations, who conducted an investigation. The VP determined that two orders of the medication had been delivered due to a previous issue with locating the medication in the cart, and concluded that there was no evidence of drug diversion. As a result, the VP did not report the incident to IDPH, believing that the regulations required reporting only if there was physical harm or injury to a resident. However, during the investigation, the nurse accused of taking the medication admitted to taking the pills and flushing them down the toilet at home. Despite this admission, the facility did not initially report the incident to IDPH, which is a requirement according to their abuse policy and procedure. The policy mandates that an initial report to the state licensing agency should be made immediately after assessing the resident and removing the alleged perpetrator. The failure to report the incident as required by the facility's policy and state regulations constitutes a deficiency in the facility's handling of the situation.
Failure to Investigate Medication Misappropriation
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation of misappropriation of medication involving a resident's Levaquin. On 10/2/2024, two nurses, V5 and V9, reported seeing another nurse, V4, taking medications and putting them in his pocket. The facility's administrator, V1, was informed of the incident and attempted to contact V4, who had already left for the day. The following morning, V3, the VP of Clinical Operations, interviewed the reporting nurses and confirmed that they identified the medication as belonging to a resident, R2. V3 also spoke with V4, who initially denied taking the medications but later admitted to taking them for personal use and subsequently disposing of them at home. Despite the availability of video surveillance, no one reviewed the footage to verify the incident. The investigation was incomplete as it did not include interviews with other potential witnesses or residents, except for R2, who confirmed receiving all prescribed doses of Levaquin. The facility's abuse prevention policy requires a comprehensive investigation, including interviews with all individuals who may have knowledge of the incident. However, the investigation only documented interviews with V4, V5, V9, and the facility's pharmacy, failing to meet the policy's standards. The lack of a thorough investigation and failure to review available video evidence contributed to the deficiency in addressing the misappropriation allegation.
Failure to Follow Abuse Prevention Policy
Penalty
Summary
The facility failed to ensure that staff followed the Abuse Prevention Policy, as evidenced by an incident involving two residents. The policy requires direct care staff to report suspicious bruises, lacerations, or other abnormalities of unknown origin immediately. However, an Activity Aide observed a resident acting suspiciously while tucking blankets around another resident, who was in bed and did not attend a scheduled activity. Despite noticing the unusual behavior, the Activity Aide did not report the incident immediately and instead informed another aide. The incident was reported to the administration approximately five hours later, which was not in compliance with the facility's policy for immediate reporting of potential abuse or neglect.
Failure to Timely Report Suspected Abuse
Penalty
Summary
The facility failed to ensure timely reporting of suspected sexual abuse involving two residents. An activity aide observed one resident acting suspiciously while tucking a blanket around another resident, which raised concerns of inappropriate behavior. Despite these suspicions, the aide did not immediately report the incident to the administration. The situation was further complicated by the fact that the resident who was potentially victimized has cognitive impairments, described as having the mind of a child, while the other resident is noted to be highly intelligent and autistic. The delay in reporting was significant, as the incident was not brought to the attention of the administration until several hours later, after the potentially victimized resident expressed discomfort and concern about the other resident's behavior. The facility's policy on abuse prevention requires staff to report any suspicious behavior or signs of abuse immediately to the administration. However, in this case, the staff failed to adhere to this protocol, resulting in a delay in addressing the potential abuse. The police were eventually involved, and interviews were conducted with the residents, but the initial failure to report promptly was noted as a deficiency. The administration was informed of the situation only after multiple staff members and the resident himself raised concerns, highlighting a breakdown in the facility's abuse reporting procedures.
Failure to Notify POA of Resident's Fall and Medical Orders
Penalty
Summary
The facility failed to notify a resident's Power of Attorney (POA) regarding a reported fall, new onset of right ankle swelling, and an X-ray order. This deficiency was identified for one of the three residents reviewed for nursing care. The resident, who had severe cognitive impairment, reported that her ankle was swollen due to a fall that occurred a few months prior. Despite the resident's condition and the facility's policy requiring notification of the resident's representative in such situations, the POA was not informed of the fall, the ankle swelling, or the X-ray order. The Director of Nursing and the nurse practitioner were informed of the resident's condition, but the family was not notified as directed. The POA only became aware of the X-ray through an invoice and expressed frustration over the lack of communication from the facility. The facility's policy mandates notification of the resident's representative to ensure informed decision-making regarding care and treatment, which was not adhered to in this case.
Delayed Response to Suspected UTI in Resident
Penalty
Summary
The facility failed to provide timely services for a resident who experienced a change in condition, suspected to be a urinary tract infection (UTI). The resident, an elderly female with multiple diagnoses including congestive heart failure, type 2 diabetes, and major depressive disorder, showed increased lethargy and confusion. Her power of attorney (POA) expressed concerns during a care conference and requested lab tests and a urinalysis (UA) to investigate the change in condition. Despite these requests, there was a delay in entering the orders for the necessary tests, and the resident's condition was not promptly addressed. The unit manager confirmed that the orders for the UA and lab tests were not entered until several days after the initial request. The resident refused straight catheterization for the UA, and an antibiotic was eventually ordered based on her symptoms and lab results. However, the POA was not notified when the antibiotic was prescribed. The lack of timely action and communication regarding the resident's treatment for the suspected UTI constitutes a deficiency in the quality of care provided by the facility.
Failure to Provide Nutritional Supplements to Resident with Weight Loss
Penalty
Summary
The facility failed to ensure that a resident with significant weight loss received the recommended nutritional supplements. The resident, a female with multiple diagnoses including congestive heart failure, anorexia, and type 2 diabetes, was observed not receiving her prescribed dietary supplements, such as ice cream and health shakes, which were recommended by the dietitian to prevent further weight loss. On one occasion, the resident's breakfast tray was left uneaten, and there was no evidence of assistance provided to her, despite her need for help with meals. Additionally, the facility was out of ice cream, a key component of the resident's dietary plan, and the administrator was unaware of this shortage. The resident's weight had decreased significantly from 180.6 pounds to 159.2 pounds over a short period, triggering concern for significant weight loss. The dietitian had recommended specific dietary interventions, including milk with meals and ice cream with lunch, to address this issue. However, these recommendations were not consistently implemented, as evidenced by the resident's daughter having to repeatedly request ice cream for her mother. The facility's policy on weight assessment and intervention emphasizes the importance of monitoring and intervening in cases of undesirable weight loss, yet the necessary actions were not taken to ensure the resident's nutritional needs were met.
Failure to Administer IV Antibiotics Timely and Document Properly
Penalty
Summary
The facility failed to ensure the proper administration of an intravenous antibiotic for a resident who had undergone major back surgery and was on antibiotics for an infection. The resident reported issues with the IV antibiotics, including late administration, the IV being left connected after the medication was finished, and uncertainty about whether the antibiotic was received. The resident's Medication Administration Record (MAR) indicated that the antibiotic Cefazolin was ordered to be administered intravenously every 8 hours, but it was documented as late 30 times. Additionally, there were instances where the medication was marked as not given, with no explanation provided in the progress notes. Interviews with facility staff revealed that there was a lack of proper documentation and adherence to medication administration protocols. The RN Unit Manager acknowledged that the nurses have a window of one hour before and after the scheduled time to administer medications, but emphasized the importance of following physician's orders, especially for timed medications like antibiotics. It was noted that some LPNs were documenting the medication as not given without providing an explanation, and there was confusion about who should sign off on the administration of the IV antibiotic. The Director of Nursing confirmed that there was no documentation to prove that the antibiotic was administered on certain dates and reiterated the importance of administering antibiotics as ordered.
Failure to Perform and Document Dressing Changes
Penalty
Summary
The facility failed to ensure that daily dressing changes were completed as ordered and did not perform as-needed dressing changes when dressings were loose for two residents. For one resident, a registered nurse observed that the dressing on the resident's right calf was coming off and was dated two days prior. The physician's orders required the dressing to be changed three times a week and as needed for soilage or looseness, but the Treatment Administration Record (TAR) did not show any as-needed dressing changes until the surveyor notified the wound nurse. The resident's care plan did not include information related to skin tears and treatments, despite the resident having multiple diagnoses that could affect skin integrity. Another resident reported that their dressing on the right elbow was not changed daily as required by physician orders. The TAR showed that the dressing was not changed on several specific dates. The Director of Nursing confirmed that dressing changes should be documented on the TAR and acknowledged that if there is a blank spot, it indicates the dressing was not done. The facility's policy on non-sterile dressings requires verification of physician orders and documentation of treatment, but these procedures were not followed for the residents in question.
Failure to Administer Nebulizer Treatment for Wheezing Resident
Penalty
Summary
The facility failed to provide a resident with an as-needed nebulizer treatment when he was experiencing wheezing. The resident, who had a complex medical history including acute on chronic respiratory failure, congestive heart failure, and pneumonia, was not given the prescribed nebulizer treatment despite having physician orders for albuterol sulfate and ipratropium-albuterol solutions to be administered every four hours as needed for wheezing and shortness of breath. The Medication Administration Record indicated that the resident did not receive any nebulizer treatments on the day in question. Interviews with facility staff revealed that the Director of Nursing acknowledged that the resident should have been given a nebulizer treatment if he was wheezing. A Licensed Practical Nurse noted that the resident appeared unwell upon returning from the hospital and was not alert. The nurse also mentioned that the resident did not have the necessary medication for nebulizer treatments at the facility, although it was available in the medication dispensing machine. The resident's care plan did not include documentation related to nebulizer treatments, and there was a lack of ongoing monitoring documentation after the initial assessment.
Failure to Administer Scheduled Medications
Penalty
Summary
The facility failed to administer evening medications to a resident, identified as R1, who was reviewed for medications and respiratory treatments. R1 was admitted to the facility from the hospital at 2:00 PM and was noted to be mentally altered. The Medication Administration Record indicated that R1 was supposed to receive Entresto, Metoprolol Tartrate, and Hydralazine at 5:00 PM, but these medications were not signed off as given. The Director of Nursing (V2) explained that medication orders should be entered within the first hour of a resident's arrival, and medications can be obtained from the medication dispensing machine if not available from the pharmacy. However, R1's medications were not administered because they were not available at the facility at the time they were due. The Licensed Practical Nurse (V6) stated that she did not enter R1's medication orders into the system upon his return to the facility, and another nurse, V5, entered the orders for her. V6 confirmed that R1 did not receive any medications from her on the day in question because the medications were not present at the facility. The Registered Nurse (V5) confirmed that she only entered the medication orders into the system and that medications could be obtained from the dispensing machine if necessary. The facility's medication dispensing machine contained the required medications, but they were not accessed. The pharmacy delivered R1's medications later that night, at 11:25 PM, after the scheduled administration time.
Failure to Provide Individualized Dementia Care
Penalty
Summary
The facility failed to provide individualized interventions for a resident diagnosed with dementia who exhibited behaviors of agitation and restlessness while in bed. The resident, a Spanish-speaking male with a history of unspecified dementia, unsteadiness, weakness, hypertension, heart disease, and systemic lupus, was observed with multiple bruises, including a significant bruise above his left eyebrow. Despite the presence of these injuries, the staff was unable to determine the cause, although it was suspected that the bruises were due to contact with the side rail of the bed. The resident's care plan did not include specific interventions for his agitation and restlessness, which are known behaviors associated with his condition. Interviews with various staff members, including CNAs, LPNs, and the Unit Manager, revealed that the resident was confused, often attempted to get up without assistance, and was described as a 'wiggle worm' in bed. The staff had previously used pillows to pad the side rails, but this intervention was not consistently documented or implemented. The facility's policy on dementia care and behavior management emphasized the need for monitoring and appropriate interventions for behavioral changes, yet the resident's care plan lacked these necessary measures. This oversight contributed to the resident's injuries and the facility's failure to adhere to its own policy guidelines.
Failure to Clarify Admitting Orders for Resident with PEG Tube
Penalty
Summary
The facility failed to clarify conflicting admitting orders for a resident who was readmitted after hospitalization, leading to a deficiency in providing necessary care and services. The resident, a male with multiple complex medical conditions including critical illness myopathy, sepsis, and end-stage renal disease, was readmitted with a PEG tube and an NPO order. However, the medication orders were conflicting, as they indicated administration by mouth, which was not appropriate given the resident's NPO status and PEG tube requirement. Upon the resident's arrival at the facility, there was a lack of communication and clarification regarding the correct route for medication administration. The LPNs involved did not adjust the medication orders to reflect the need for administration through the PEG tube, resulting in the resident receiving some medications orally, contrary to the NPO order. Additionally, the resident's tube feeding orders were not transcribed into the electronic medical record, leading to a failure in providing the necessary nutritional support. The Director of Nursing and a Nurse Practitioner confirmed that the orders should have been clarified, and the resident's wife noted the absence of tube feeding during her visits.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for four residents who were reviewed for infection control. These residents had various conditions that required EBP, such as acute osteomyelitis, local infections, cellulitis, and wounds. Despite these conditions, there were no signs on the residents' doors indicating isolation precautions, nor was any personal protective equipment (PPE) placed outside their rooms. Observations revealed that staff members, including a wound care nurse and a certified nursing assistant, wore gloves but did not wear gowns during wound treatments, which is contrary to the facility's policy. The Infection Prevention Nurse/Assistant Director of Nursing acknowledged that the facility was in the process of rolling out EBP but admitted that no such precautions were in place at the time. The facility's policy, revised in March 2024, mandates the use of gowns and gloves for residents with wounds or indwelling medical devices to prevent the transmission of multidrug-resistant organisms. However, the facility's list of residents on isolation did not include any on EBP, indicating a lapse in adherence to their own infection control guidelines.
Failure to Monitor and Treat Resident Wounds
Penalty
Summary
The facility failed to adequately assess and monitor a resident's ankle, leading to a severe infection. The resident, who had intact cognition, was observed with a swollen right lower leg and a gauze wrap around her ankle. Despite the resident's complaints of pain and a screw protruding from her ankle, the nursing staff did not report these findings to the appropriate medical personnel. The resident was later admitted to the hospital for surgical cleaning and repair of the infected ankle, which included removal of hardware and debridement due to a chronic postoperative infection. Another resident was found to have multiple open, bleeding wounds on her posterior thighs, buttock, and groin area, which had not been properly assessed or treated by the facility. Certified Nursing Assistants noted the condition had persisted for weeks, yet the wound nurse was unaware of these new skin alterations. The facility's records did not reflect any new treatment orders for these wounds, and the existing orders did not cover the affected areas. The facility's policies on skin integrity and perineal care were not followed, as the initial observations of skin conditions were not documented or reported for clinical assessment. The lack of adherence to these policies resulted in the failure to provide appropriate treatment and care for the residents' conditions, leading to significant health issues.
Failure in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention, resulting in a resident developing a Stage III pressure injury on the coccyx and Stage II injuries on both buttocks. The resident, who was admitted with conditions such as a compression fracture, morbid obesity, Type 2 Diabetes Mellitus, and congestive heart failure, required assistance for repositioning and toileting. Despite a care plan indicating the need for monitoring and documentation of skin injuries, the resident's pressure injuries were not identified until they had progressed to more severe stages. The CNA did not report the open areas to the nurse, and the wound care nurse was unaware of the new injuries until the following day. Another resident was found without heel boots, which were necessary to off-load pressure and protect a Stage III pressure ulcer on the left heel. The resident reported that the night shift did not put the boots on, and the wound nurse confirmed the importance of off-loading to prevent pressure on the heels. The care plan and physician's orders indicated the need for protective boots, but these were not consistently applied, contributing to the resident's pressure ulcer. A third resident with a facility-acquired left heel pressure ulcer did not have an air mattress in place, despite a physician's order and care plan intervention. The wound assessments were not conducted weekly as required, with a gap of 21 days between assessments. The Director of Nursing acknowledged the lack of documentation and the necessity for regular assessments to monitor the wound's condition. The facility's policies on skin integrity and pressure ulcer management were not followed, leading to these deficiencies.
Failure to Monitor and Assess Resident Leads to Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident, identified as R121, was assessed in-person by a Certified Dietary Manager or Registered Dietician upon admission. This oversight occurred despite R121's significant medical history, which included a recent hospitalization for gastrointestinal bleeding, surgery for colon cancer, and a diagnosis of severe protein malnutrition and caloric deficit. The resident was discharged from the hospital weighing 243 pounds and was admitted to the facility for skilled therapy services and rehabilitation. Upon admission, R121 was at risk for weight loss, and a physician's order required weekly weight monitoring for the first four weeks. However, the facility did not document any weights for R121 from the time of admission until a surveyor's intervention. When finally weighed, R121 had lost 49.4 pounds, a 20.3% decrease in weight over 25 days. The Registered Dietician and Certified Dietary Manager admitted to not assessing R121 in-person, relying instead on second-hand information from a dietary aide and nurses' notes. The facility's failure to conduct weekly weight checks and in-person dietary assessments contributed to the resident's significant weight loss. The Registered Dietician acknowledged that the weight loss could have been avoided with proper assessment and monitoring. The Nurse Practitioner confirmed that the resident should have been weighed weekly and assessed by dietary staff, noting that the weight loss was multifactorial but could have been identified earlier with proper monitoring.
Failure to Follow Standardized Recipe for Chili
Penalty
Summary
The facility failed to adhere to its standardized recipe for chili, impacting all 127 residents. On July 8, 2024, during the preparation of the noon meal, the chili served was observed to have a beef broth base instead of the required tomato base. The cook, identified as V25, admitted to preparing the chili according to her personal recipe, omitting essential ingredients such as tomato sauce, green peppers, and onions. This deviation from the facility's standardized recipe resulted in a chili that was watery and soup-like, as confirmed by a resident's feedback and a test tray evaluation. The facility's policy mandates the use of standardized recipes for food preparation, which was not followed in this instance.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed by staff, leading to potential cross-contamination and infection risks. During an observation, Certified Nursing Assistants (CNAs) V18 and V19 did not change gloves or wash hands between dirty and clean tasks while providing incontinence care to a resident with open wounds. The Director of Nursing confirmed that gloves should be changed, and hands washed between tasks to prevent infections, as per the facility's hand hygiene policy. In another instance, a CNA entered a resident's room, who was on contact isolation for VRE and MRSA infections, without donning the required personal protective equipment (PPE) except for a face mask and gloves. The CNA proceeded to reposition the resident and apply cream without adhering to the facility's policy that mandates wearing gloves and a protective gown for contact isolation. Similarly, a Nurse Practitioner entered another resident's room on contact isolation for MRSA infection wearing only a face mask, contrary to the facility's policy. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling medical devices, as required by their policy. The Infection Preventionist admitted that the facility had not yet rolled out these precautions. Several residents with open wounds and urinary drainage bags were not placed on EBP, despite the facility's guideline to implement such precautions for residents at increased risk of multidrug-resistant organism acquisition.
Failure to Provide Timely Incontinence Care and Repositioning
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for several residents who required staff support for toileting and incontinence care. Observations revealed that residents were left in soiled incontinence briefs for extended periods, leading to skin irritation and open wounds. For instance, one resident was found with red, open areas on the buttocks and a nickel-sized wound on the coccyx, while another resident had bright red skin in the groin area due to prolonged exposure to urine and stool. Several residents, including those with significant mobility impairments or cognitive issues, were not repositioned or cleaned in a timely manner. One resident with bilateral leg amputations was left in a soiled brief for over four hours, and another resident with a history of falls and recent spine surgery was not assisted to the bathroom despite being unable to go independently. The lack of timely care resulted in skin damage, including moisture-associated skin damage (MASD) and excoriation. The facility's staff, including CNAs and the Director of Nursing, acknowledged the lapses in care, with staff admitting to not having changed residents since the start of their shifts. The facility's protocol requires incontinence care and repositioning every two hours, but this standard was not consistently met, as evidenced by the observations and interviews conducted during the survey.
Failure to Administer COVID-19 Vaccine to Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R113, was provided the COVID-19 vaccine despite expressing a desire to receive it. R113's COVID-19 questionnaire, dated March 20, 2024, indicated that he accepted the offer for the vaccine. However, a review of his electronic medical record revealed that he had not received the vaccine, even though he had been admitted to the facility four months prior. On July 10, 2024, the Infection Preventionist, identified as V26, confirmed that R113 wanted the vaccine but had not been administered it, and she was unsure of the reason for this oversight. The facility's COVID-19 policy, dated May 28, 2023, outlines the importance of offering and counseling residents on the COVID-19 vaccine, in line with CDC and public health guidelines.
Failure to Apply Splint for Resident's Hand Contracture
Penalty
Summary
The facility failed to ensure that a splint was applied to a resident's left hand contracture, as observed during multiple instances over a three-day period. The resident, who was supposed to wear a splint on his contracted left hand, was seen without it on several occasions. The splint was found sitting on the windowsill in the resident's room, and the resident expressed that he was supposed to wear it but did not receive assistance from the staff to put it on. A Certified Nursing Assistant (CNA) confirmed that she had never seen the resident wearing a splint and was unaware of any instructions regarding its use. Further investigation revealed that the resident had been discharged from occupational therapy with recommendations for a restorative program that included the use of a left hand/wrist splint and passive range of motion exercises. However, there were no physician's orders for splint usage, and the tasks section in the computer system did not document the application or removal of the splint. Additionally, the resident's care plan lacked any interventions related to the application of the splint or passive range of motion, indicating a breakdown in communication and follow-through on the therapy recommendations.
Lack of Supervision for Smoking and Eating
Penalty
Summary
The facility failed to ensure adequate supervision for residents engaged in smoking activities and those at risk for aspiration pneumonia. One resident, identified as R5, was observed smoking unsupervised near the facility's front door, contrary to the facility's policy that requires residents to smoke in designated areas with staff supervision. Despite being cognitively intact and aware of the smoking policy, R5 was found with a lighter and cigarettes, which posed a fire hazard. The facility's smoking policy, dated July 2017, mandates that smoking is only permitted in designated areas outside the building, and residents must be supervised for safety reasons. Another resident, R83, who was at risk for aspiration pneumonia due to Parkinson's Disease and dysphagia, was left unsupervised while eating. R83's care plan required a modified diet of honey thick liquids and pureed foods, and the speech therapist had instructed staff to supervise residents on modified diets. However, R83 was observed eating breakfast alone in his room without staff supervision, despite recent downgrades in his diet due to coughing episodes. The lack of supervision during meals for R83, who requires assistance due to impaired swallowing, highlights a failure to adhere to the necessary precautions for residents with swallowing difficulties.
Improper Incontinence and Catheter Care
Penalty
Summary
The facility failed to provide proper incontinence care and catheter management, leading to potential infection risks for three residents. In one instance, two CNAs provided incontinence care to a resident with a soiled brief, cleaning the perineal area incorrectly from back to front, contrary to the facility's policy of wiping from front to back to prevent infections. The Director of Nursing confirmed the correct procedure should be from front to back, aligning with the facility's Perineal Care Policy. In another case, a resident with a urinary catheter was observed with the catheter bag improperly placed on the bed, causing back-flow of urine, which contradicts the facility's policy requiring the bag to be below the bladder level. Additionally, another resident's catheter was found on the floor, with the resident reporting discomfort and the CNA acknowledging the improper placement. The facility's policy mandates that catheter tubing and drainage bags be kept off the floor to prevent contamination.
Failure to Offer Pneumonia Vaccines to Residents
Penalty
Summary
The facility failed to offer the pneumonia vaccine to three residents, leading to a deficiency in their immunization practices. Resident 22's immunization records indicate she received the pneumococcal conjugate vaccine (PCV13) in June 2015 but has not been offered the pneumococcal polysaccharide vaccine (PPSV23) since then. Resident 82 received the PCV13 in February 2023 but has not been offered the PPSV23, which he was due for earlier this year. Resident 113's electronic medical record shows no vaccines have been administered since his admission, and there is no record of his vaccination history. The facility's policy, dated November 2022, states that all residents should be assessed for eligibility and offered the pneumococcal vaccine series upon admission and on an ongoing basis, but this was not adhered to in these cases. On July 10, 2024, the Infection Preventionist acknowledged that the facility offers both PCV13 and PPSV23 vaccines as part of the pneumonia vaccine series. However, the Infection Preventionist admitted that Resident 22 and Resident 82 had not been offered the PPSV23 vaccine, and there was no information on Resident 113's vaccination status due to a lack of records. This oversight indicates a failure to follow the facility's policy of assessing and offering the pneumococcal vaccine series to residents.
Medication Administration Deficiency
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 24.14%, which is significantly higher than the acceptable threshold of 5%. This deficiency was observed during a medication pass involving two residents. In the first instance, an LPN placed multiple medications into a cup and handed them to a resident along with a Lidocaine patch, without applying the patch or observing the resident take the medications. The Director of Nursing confirmed that no residents on that floor were authorized to self-administer medications, indicating a breach in protocol. In the second instance, a resident was supposed to receive Debrox ear drops as per a physician's order, but the LPN was unable to administer the medication because it was not available in the medication cart. The LPN acknowledged that the ear drops were on order and not yet received, resulting in the resident missing a scheduled dose. The facility's policy mandates that medications be administered safely, timely, and as prescribed, which was not adhered to in these cases.
Failure to Label Insulin Pen with Open Date
Penalty
Summary
The facility failed to properly label a multi-dose insulin pen with an open and/or expiration date for a resident identified as R32. The resident had an order for a Lantus Solostar pen to administer 10 units at bedtime. On July 8, 2024, it was observed that the insulin pen, delivered on June 1, 2024, with 200/300 units remaining, was not labeled with an open date in the unit's medication cart. This was confirmed by a Registered Nurse (RN) and the Director of Nursing (DON), both of whom acknowledged that insulin pens should be labeled with the date they are opened. The facility's Insulin Reference Chart indicates that a Lantus pen is viable for 28 days at room temperature.
Failure to Notify Resident's Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of a change in condition and the need to alter treatment. This deficiency was identified for one resident who had diagnoses including Parkinsonism, acute respiratory failure, pneumonia, chronic obstructive pulmonary disease, and hallucinations. The resident exhibited moderate cognitive impairment and behavioral issues, such as inappropriate verbal and physical behaviors towards staff and other residents. On two occasions, the resident became aggressive, leading to the administration of Haldol without prior notification to the resident's representative. The resident's daughter was informed of the incidents and the administration of Haldol only after the first incident had occurred. She expressed concern about not being notified promptly, especially since these behavioral episodes were new for the resident. The facility's policy requires prompt notification of the resident's representative in cases of significant changes in the resident's condition, which was not adhered to in this instance. The Director of Nursing acknowledged that the notification should have been made sooner, as the change in behavior and treatment alteration warranted immediate communication.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident. In the first incident, a resident with no cognitive impairment was physically assaulted by his roommate, who has moderate cognitive impairment and a history of verbal and aggressive behaviors. The assault occurred in the dining room when the resident noticed his roommate wearing his coat and confronted him. The roommate responded by punching him in the face multiple times. The staff intervened immediately, and the resident was moved to a different room. The assaulted resident expressed confusion about being placed in the dementia unit, as he does not have dementia. In the second incident, another resident with moderate cognitive impairment and no behaviors was physically assaulted by a peer who had a history of aggressive behavior. The assault occurred when the resident found the peer in her room and asked him to leave. The peer responded by hitting her, resulting in bruises and an abrasion. The peer was later sent for a psychiatric evaluation and did not return to the facility. The Director of Nursing acknowledged these incidents as resident-to-resident abuse and noted that the facility's policy is to prevent abuse from occurring.
Failure to Monitor and Respond to Resident's Behavioral Health Needs
Penalty
Summary
The facility failed to adequately monitor, document, and respond to the behaviors of a resident diagnosed with Parkinsonism, hallucinations, pneumonia, and acute respiratory failure. The resident, who was noted to have moderate cognitive impairment, exhibited aggressive behaviors that were not documented in the care plan. The care plan only included medication administration for hallucinations and anxiety, with no further interventions listed. Over a period of three days, the resident displayed aggressive behaviors, including attempting to hit others with a wheelchair, grabbing a nurse's necklace, and resisting care from CNAs. These incidents were not properly documented or addressed in the resident's care plan. Staff intervened by administering Haldol injections, but there was a lack of consistent non-pharmacologic interventions or individualized care strategies as per the facility's policy. Interviews with staff revealed confusion and a lack of clear protocol in handling the resident's behaviors. The Director of Nursing acknowledged the resident's recent increase in agitation and the need for staff to intervene when the resident posed a danger to themselves or others. However, there was a lack of awareness about the resident's injury during the incident, and staff actions may have exacerbated the resident's agitation. The facility's policy emphasized individualized interventions and non-pharmacologic approaches, which were not adequately implemented in this case.
Latest citations in Illinois
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
