Pearl Of Elk Grove, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Elk Grove Village, Illinois.
- Location
- 1920 Nerge Road, Elk Grove Village, Illinois 60007
- CMS Provider Number
- 145689
- Inspections on file
- 47
- Latest survey
- December 19, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Pearl Of Elk Grove, The during CMS and state inspections, most recent first.
Surveyors identified multiple failures in medication security, labeling, and administration, including an RN repeatedly leaving a medication cart unlocked and unattended during medication passes, an unlabeled cup containing several tablets found on a medication cart, and a medicine cup with multiple pills left on a resident’s bedside table. Staff acknowledged that carts must be locked when not attended, medications must be labeled, and nurses must remain with residents until medications are taken. One resident with dementia, anxiety, and depression had orders allowing only specific vitamins and mouthwash to be left at the bedside, yet other medications were left unattended, contrary to facility policy.
During a COVID-19 outbreak, a nurse failed to follow the facility’s Acute Respiratory Illness and Enhanced Barrier Precaution (EBP) policies. The nurse was observed passing medications to multiple residents without wearing a mask, despite the outbreak status and the facility’s policy recommending masking for all healthcare personnel. The same nurse also applied a pain patch to a resident on EBP for wounds, an indwelling urinary catheter, and CRAB without wearing a gown, even though EBP required gown and glove use during high-contact care for residents with wounds or indwelling devices. These lapses occurred while most staff and visitors were otherwise observed using masks and hand hygiene.
A resident with multiple comorbidities, cognitive impairment, impaired mobility, and high fall risk had a care plan and call light assessment indicating she could use the call light and required it to be kept within reach. On multiple observations, her call light was found out of reach—once placed on a bedside table and another time on the floor—while she was in bed, despite staff acknowledging that she uses the call light for assistance and that it should always be accessible. Staff interviews confirmed the facility’s policy that residents able to use the call light must have it accessible at all times to request help, but this was not followed for this resident.
A deficiency was identified when a resident’s post-fall assessment and documentation were not completed according to the facility’s Fall Prevention and Management Policy. The resident’s fall event record remained incomplete and marked as “In Progress,” with no details entered. Staff interviews revealed that an agency nurse on duty at the time of the fall did not complete the electronic Fall Event form or document new interventions, and although a soft copy form was filled out by the fall team, it was never entered into the electronic record and the intervention date was not updated. This failure occurred despite policy requirements for post-fall observation, assessment of the cause and injury potential, and a comprehensive physical assessment including head-to-toe exam, VS, ROM, and neuro checks as indicated.
The facility failed to follow PASRR requirements by not initiating Level II evaluations or updated Level I screenings for three residents with identified or newly developed mental illness diagnoses. One resident developed multiple psychiatric conditions and experienced discharges and readmissions without any subsequent PASRR evaluations. Another resident, initially excluded from PASRR after a Level II review, later received diagnoses of PTSD, anxiety, psychosis, recurrent depression, and bipolar disorder and was started on several psychotropic medications, yet no updated Level I screening or referral was made. A third resident had an initial Level I screen indicating suspected mental illness or developmental disability and later received additional psychiatric diagnoses and psychotropic medications, but no Level II evaluation was completed, despite the facility’s policy requiring Level I screening for all admissions/readmissions and referral for Level II when mental disorder, ID, or related conditions are identified.
A resident with documented anxiety disorder, bipolar disorder, recurrent major depressive disorder, psychosis, and dementia was admitted without a required PASRR Level I (and, if indicated, Level II) screening being completed prior to admission. Social services staff later confirmed that no PASRR was done before the resident entered the facility and that they generally depend on hospitals to provide PASRR documentation and on a visiting psychiatric NP to identify new or possible MD/ID/related conditions. Review of a subsequent PASRR Level I notice showed it was not completed until months after admission, despite facility policy requiring a Level I PASRR screen for all potential admissions regardless of payer source.
A resident with bilateral below-knee amputations, abnormal gait, and a history of falls reported falling while transferring from a wheelchair to a lounge chair using a wobbly table for support. The resident later demonstrated that the lounge table was unstable, and an RN confirmed the table was wobbling and unsafe, while housekeeping reported it had long been wobbly and that maintenance had been informed. The maintenance director stated he was unaware of the issue until after the fall, and the incident report did not identify furniture as an environmental factor, despite facility policy requiring an environmental assessment after falls.
Two residents were not protected from abuse, with one experiencing repeated sexual abuse by a CNA during incontinence care, confirmed by a hospital sexual assault exam, and another subjected to physical abuse by a fellow resident with dementia and aggressive behaviors. Both residents had care plans identifying them as at risk for abuse, but staff failed to prevent these incidents despite documented risk factors and prior aggressive episodes.
A resident with multiple chronic conditions reported to a CNA that another CNA had verbally abused them by repeatedly telling them to 'shut up.' The CNA recognized this as verbal abuse but did not immediately report the allegation to the administrator or DON, as required by facility policy, due to concerns about possible repercussions. The facility's abuse prevention policy mandates immediate reporting of such allegations, which did not occur in this instance.
Nursing staff, including an LPN and an RN, repeatedly administered medications to multiple residents well after the scheduled times, with some morning medications given as late as the afternoon. Staff cited workload and medication cart issues as reasons for the delays, and management referenced a one-hour window for administration that was not reflected in facility policy. Residents affected had complex medical conditions, and the late administration was confirmed through observation, interviews, and record review.
The facility failed to maintain full body mechanical sling lifts, resulting in residents being unable to get out of bed in a timely manner. One lift had exposed wires and another had not been maintained since 2019. Residents expressed frustration over delays in participating in activities due to the lack of functioning equipment. The maintenance staff reported not receiving formal repair requests, indicating a breakdown in communication and adherence to the facility's work order policy.
A resident with multiple diagnoses, including dementia, experienced adverse outcomes due to the facility's failure to monitor and report side effects of the antipsychotic medication Seroquel. Despite being on high-risk medications, the facility did not document side effects or communicate effectively with the prescribing NP, leading to excessive sedation, increased falls, and hospitalization.
A facility failed to resolve grievances about a resident with OCD who was observed touching food trays and removing lids with bare hands, raising concerns about hygiene. Despite multiple residents reporting the issue during meetings, no effective action was taken. Staff, including RNs and the Social Service Director, acknowledged the behavior, but the DON did not document any follow-up, violating the facility's grievance policy.
The facility failed to provide adequate nursing staff, resulting in deficiencies in resident care. A resident with serious health conditions was not properly monitored, leading to a delayed notification of their deteriorating condition and subsequent death. Other residents experienced inadequate grooming and cold meals due to insufficient staffing and reliance on agency staff. The facility's staffing policy was not adhered to, contributing to these issues.
A facility failed to promptly notify a resident's family, physician, and hospice provider about a significant change in condition. The resident, with diagnoses including paraplegia and heart failure, was found with noisy breathing and an untouched meal tray. Despite awareness of the condition, the agency nurse delayed informing the family and providers, resulting in late communication about the resident's choking incident and subsequent death.
The facility failed to provide adequate nail care for three residents dependent on staff for ADL assistance. One resident had long, dirty nails and reported infrequent nail cutting by staff. Another had sharp, dirty nails and stated no one cut them. A third resident had a painful broken nail with a dirty band-aid. Staff interviews confirmed CNAs were responsible for nail care, typically done on shower days, but failed to meet the facility's policy for grooming and hygiene.
The facility failed to serve meals at palatable temperatures, affecting three residents. Observations showed that sweet potatoes and beans were served below 100°F, contrary to the facility's policy of maintaining food at 135°F or above. The Food Service Director noted ongoing issues with timely meal distribution. Residents reported receiving cold food, with meal tray temperatures recorded below the required standard. The Administrator and DON acknowledged the expectation for meals to be served at appropriate temperatures.
The facility failed to implement a fluid restriction for a resident with CHF and did not conduct daily weights for two residents with CHF. One resident was unaware of their fluid restriction, and the facility did not list them on the fluid restriction sign. Observations showed multiple fluid containers at the resident's bedside and fluids on their meal tray. Additionally, records for two residents showed missing entries for daily weights, indicating a failure to monitor for fluid retention as prescribed.
A resident with hemiplegia and hemiparesis was not provided with a required arm sling during transfers and while seated, despite recommendations in her admission papers and physician notes. Staff were unaware of the need for the sling, and it was not included in the care plan, leading to the resident being without necessary support for her left arm.
The facility failed to provide adequate supervision and safety measures for residents, including a resident with dysphagia who was not cued during meals, a resident transferred unsafely with a mechanical lift by one CNA instead of two, and a high-risk fall resident whose call light was not within reach.
The facility failed to ensure PRN anti-anxiety psychotropic medications had a specified duration or end date for four residents. Orders for Lorazepam and Xanax were issued without stop dates, contrary to the facility's policy requiring PRN orders not to exceed 14 days unless documented otherwise by a physician.
The facility failed to dispose of expired medications for two residents. An RN/Infection Preventionist found an insulin pen and a bottle of liquid medicated mouthwash in the medication refrigerator, both past their expiration dates. The facility's policy requires expired medications to be removed and destroyed, but this was not adhered to.
A facility failed to ensure staff wore gowns during high contact care for a resident on Enhanced Barrier Precautions (EBP). A CNA provided care without a gown, despite PPE availability and signage indicating EBP. The resident had a gastrostomy tube and was on EBP to prevent MDRO transmission. The facility's policy requires gown and glove use during high contact activities, confirmed by the RN/Infection Preventionist.
A facility failed to thoroughly investigate a sexual abuse allegation involving two residents. A CNA reported witnessing a male resident exposing himself and attempting a sexual act with a female resident. The facility did not interview all potential witnesses or staff present at the time, and interviews were delayed, leading to an incomplete investigation. The female resident has severe cognitive impairment, while the male resident is cognitively intact with dementia-related behaviors.
A male resident with known hypersexual behaviors was moved to a room next to a cognitively impaired female resident without protective interventions, leading to an incident of attempted sexual abuse. The facility failed to implement measures to prevent such incidents despite the male resident's history of inappropriate behaviors.
A facility failed to update a care plan for a resident with a history of inappropriate sexual behaviors, leading to a resident-to-resident sexual assault incident. Despite the resident's known diagnoses and previous incidents, the care plan was not revised to include new interventions after an incident of kissing other residents. The facility's policy requires care plan updates for significant changes, but no documentation was made following the incident or room change.
A facility failed to ensure a resident was seen by their attending physician as per policy. The resident, with multiple diagnoses including Parkinson's Disease and dementia, was not documented to have been seen by their primary care physician until several months after admission. The facility's policy requires a physician to conduct a history and physical within 72 hours of admission, which was not adhered to, resulting in a deficiency.
A resident with multiple health conditions was mistakenly given a medication not prescribed for them by an agency nurse, leading to adverse symptoms. The nurse failed to verify the medication against the MAR and did not report the error immediately to the DON. The incident was investigated, but the exact medication error could not be determined.
A resident with Alzheimer’s and schizoaffective disorder was not permitted to return to the facility after a behavioral hospitalization, despite prior assurances that his behaviors could be managed. The facility failed to provide proper discharge notice and did not communicate effectively with the resident's family.
A resident, dependent on staff for ADLs and always incontinent, reported not being changed in a timely manner by agency CNAs, leading to discomfort and redness. The resident, who has no cognitive impairment, had previously reported these issues to the DON. Grievance logs confirmed the resident's complaints of inadequate care on specific occasions.
A dependent resident fell from bed and sustained a head injury after a CNA attempted to provide incontinent care alone, contrary to the requirement for two staff assists. The resident, with a history of falls and other medical conditions, was admitted to the ICU with a subdural hematoma. Staff interviews confirmed the need for two assists for dependent residents, and the facility's administrator acknowledged the oversight after reviewing the resident's MDS documents.
A resident experienced significant weight loss due to the facility's failure to monitor and address their nutritional needs. Despite requiring assistance with eating and having specific dietary recommendations, the resident's weight was not properly tracked, and significant changes were not communicated to the dietician. Observations showed the resident was often hungry and not consistently assisted with meals, leading to inadequate nutritional intake.
A resident with severe cognitive impairment fell and hit her head, but the LTC facility failed to complete accurate neurological assessments and post-fall documentation. Staff accounts of the incident were inconsistent, and the resident's condition was not properly monitored, leading to her transfer to the hospital with a swollen and bruised eye.
The facility failed to serve meals according to the planned menu, leading to inadequate nutritional intake and significant weight loss for some residents. Residents expressed frustration and emotional distress due to the poor quality and inconsistency of meals, often relying on food brought in by family members. The dietitian confirmed concerns about residents not meeting daily nutritional requirements due to missing items like milk and juice.
The facility failed to provide palatable meals, leading to weight loss, emotional distress, and financial hardship for residents. Meals often did not match dietary needs or preferences, were served cold, and lacked seasoning. Residents, including those with specific dietary restrictions, reported significant dissatisfaction and resorted to purchasing outside food. Despite awareness, the facility's management did not effectively address these issues, causing residents to feel neglected and frustrated.
The facility failed to document and resolve resident grievances, affecting all 151 residents. Issues included poor food quality, lack of activities, and restricted patio access. Despite numerous complaints, the facility's grievance records did not reflect these concerns, indicating a lack of proper documentation and follow-up. The opening of a new dementia unit led to the cancellation of night activities, exacerbating resident dissatisfaction.
The facility failed to provide timely ADL care, particularly toileting hygiene, to residents dependent on staff assistance. Several residents reported long wait times for help, especially during PM and Night shifts, with some experiencing physical discomfort due to delays. The Resident Council President canceled a meeting in frustration over unresolved complaints about inadequate staffing and response times. The DON acknowledged the need for regular checks but lacked a formal policy to ensure compliance.
The facility failed to reorder medications timely for two residents, resulting in missed doses of prescribed eye medications. One resident reported that his eye drops were lost after being handed to a nurse, and he did not receive them as needed. Another resident experienced inconsistencies in receiving her eye drops, with staff sometimes failing to reorder them. The facility's policy to reorder medications four days in advance was not followed.
A resident's Ozempic pen was lost by the facility, causing a delay in her diabetes medication administration. The resident's family had to replace the medication at their own expense. The facility's records incorrectly showed the medication was administered on time, and a grievance was filed by the family.
Failure to Secure, Label, and Properly Administer Medications
Penalty
Summary
The deficiency involves failure to secure and properly label medications and to ensure medications are administered in accordance with facility policy. During early morning medication passes, a registered nurse repeatedly left a medication cart unlocked and unattended while administering medications to multiple residents, despite the facility’s Medication Storage Policy requiring medication carts to be locked when not attended by authorized personnel. The DON confirmed that all medications should be locked in the medication cart so that only nurses have access. In a separate observation of another medication cart, a surveyor and a registered nurse found a medication cup containing seven unlabeled tablets, with only “250mg Vit C” written on the cup and no other means to identify the tablets. The nurse stated she had not used that cart during her shift, could not identify the medications, and acknowledged that medications should be labeled. Another deficiency was identified when a medicine cup containing four different colored pills was found on a resident’s bedside table during unit rounds. The assigned RN stated she had been pulled away to another resident and did not intend to leave the pills at the bedside, while the resident reported that this nurse leaves medications with her all the time. The DON stated that nurses are required to remain with residents for the duration of medication administration to ensure medications are completely taken and that she was not aware of any resident in the facility authorized to self-administer medications. The resident’s order summary showed diagnoses including unspecified dementia, anxiety disorder, and depression, and indicated that only specific items (PreserVision AREDS and TheraBreath Oral Rinse) may be left at the bedside for self-administration. The facility’s Medication Administration policy requires staff to remain with the resident to ensure the resident swallows the medication.
Failure to Follow Masking and Enhanced Barrier Precaution Policies During COVID Outbreak
Penalty
Summary
The deficiency involves the facility’s failure to follow its Acute Respiratory Illness Policy and Enhanced Barrier Precaution (EBP) Policy during a facility-wide COVID-19 outbreak. Upon entry, the survey team was informed by the front desk receptionist and the Director of Nursing that the facility was in COVID outbreak status, with masks and hand sanitizer available in the lobby and most staff and all visitors observed wearing masks and performing hand hygiene. Despite this, on 12-17-25, a registered nurse (V3) was observed passing medications to three residents (R45, R12, and R137) without wearing a mask, even though V3 acknowledged that the facility was in outbreak status and that staff were to wear masks and wash their hands to prevent the spread of infection. The facility’s Acute Respiratory Illness Policy dated 11-14-25 documented that the facility would recommend masking for all healthcare personnel and visitors during a facility-wide outbreak. The facility also failed to follow its EBP Policy for a resident on Enhanced Barrier Precautions. On 12-17-25 at 5:27 PM, V3 was observed providing direct patient care by applying a pain patch to R44, who had physician orders for EBP due to wounds, an indwelling urinary catheter, and CRAB, without wearing a gown. V3 stated that R44 was on EBP but claimed not to have directly touched the resident, only the pain patch that touched the resident. The EBP policy, reviewed 6-25, documented that EBP is an approach of targeted gown and glove use during high-contact resident care activities for residents with wounds or indwelling medical devices, or with infection or colonization with MDROs. These failures had the capacity to affect four residents in a total sample of 31.
Failure to Keep Call Light Within Reach for High Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow its Call Light Policy by not ensuring a resident’s call light was within easy reach. A female resident with secondary parkinsonism, Alzheimer’s disease, type 2 diabetes, anxiety, bipolar disorder, hypertension, gout, hyperlipidemia, and hypothyroidism was re-admitted to the facility and had documented ADL self-care deficits, unsteady gait, impaired mobility, cognitive impairment, and dependence on staff for ADLs and transfers. Her fall care plan, which identified her as high risk for falls with poor safety awareness and cognitive deficits, included an intervention requiring that her call light be kept within reach and that she be encouraged to use it for assistance, with prompt response to all requests. A Call Light Ability Screen documented that she was able to follow instructions and demonstrate use of the call light and was able to use it. During room rounds on multiple days, surveyors observed that the resident’s call light was not accessible. On one occasion, the call light string was on top of the bedside table and not within the resident’s reach while she was awake and resting in bed; when asked, a CNA stated it was placed there because the resident “always plays with the call light” and did not answer how the resident could request assistance when it was out of reach. On another observation, while the resident was in bed eating breakfast, the call light cord was positioned away from her with the end of the string on the floor, and the CNA stated the resident likely threw it onto the floor, while also confirming the resident uses the call light to request assistance. Floor mats were present on both sides of the bed to prevent injury in the event of a fall. Other interviewed staff, including an RN, an LPN, and another CNA, stated that call lights should always be within residents’ reach so they can call for assistance and that failure to do so could lead to falls, and they described the importance of placing or clipping the call light close to residents. The facility’s Call Light Policy required that residents capable of using the call light appropriately have their call light accessible at all times.
Failure to Complete Required Post-Fall Assessment and Documentation
Penalty
Summary
The deficiency involves the facility’s failure to follow its Fall Prevention and Management Policy by not completing a required post-fall assessment and documentation for one resident after a fall. Record review showed that the resident’s Fall Event dated 3-16-25 remained marked as “In Progress” with no information entered. The Restorative Nurse stated that this event occurred before she assumed her role and that she had no knowledge of the incident, explaining that the nurse on duty is responsible for completing the Fall Event form. The DON reported that the nurse on duty at the time of the fall was an agency nurse who did not complete the Fall Event form and did not enter any new interventions. Although the fall team completed a soft copy Fall Event form and decided to continue current interventions, they did not enter the form into the computer because the DON was not the nurse on duty at the time, and the intervention date was not updated. As a result, the resident’s Fall Event dated 3-16-25 was not completed as required by the facility’s Fall Prevention and Management Policy, which calls for post-fall observation, assessment of the cause of the fall and potential for injury, and a physical assessment including head-to-toe assessment, vital signs, range of motion, and neurological assessment as indicated. This failure affected one resident out of three reviewed for falls in a total sample of 31 residents, and was identified through interviews with staff and review of the resident’s fall documentation and the facility’s policy.
Failure to Initiate Required PASRR Level II Evaluations for Residents With Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to initiate required PASRR Level II evaluations and updated Level I screenings for residents with identified or newly developed mental illness diagnoses. For one resident, an initial OBRA Level I screening completed shortly after admission indicated no reasonable basis to suspect mental illness or developmental disability. However, over time this resident developed multiple psychiatric diagnoses, including dementia with behavioral disturbance, major depressive disorder, unspecified psychosis, and depression, and experienced discharges and readmissions. Despite these new psychiatric diagnoses and readmissions, the Social Service Coordinator confirmed that no additional PASRR evaluations were completed, and the Social Service Director stated that a new Level I should have been submitted before readmission but was not. Another resident had a PASRR Level I screen that resulted in a referral for a Level II onsite evaluation, and the subsequent Level II outcome determined the resident was excluded from PASRR with no qualifying diagnosis and no level of care, with instructions that no further Level II screening was required unless there was a significant change in status suggesting serious mental illness, intellectual disability, or developmental disability. After this determination, the resident was diagnosed with post-traumatic stress disorder, anxiety disorder, unspecified psychosis, recurrent mild major depressive disorder, and bipolar disorder, and was prescribed multiple psychotropic medications including duloxetine, diazepam, olanzapine, and quetiapine. The Social Service Coordinator acknowledged that no updated Level I screening or referral to the state-designated PASRR authority was made after these new mental health diagnoses were identified and stated that this referral was missed. A third resident had a PASRR Level I pre-screening completed prior to admission, which indicated a reasonable basis to suspect the presence of a developmental disability or mental illness. Subsequent record review showed that this resident later received additional psychiatric diagnoses, including bipolar disorder and unspecified psychosis, and was prescribed medications such as Ativan, buspirone, and duloxetine. The Social Service Coordinator explained that the interdisciplinary team discusses new diagnoses in daily morning meetings and that once a new mental illness diagnosis is identified, a PASRR Level II is required and is the responsibility of Social Services. However, the Coordinator confirmed that no PASRR Level II screening had been completed for this resident, and the Social Service Director confirmed there was no Level II on file. The facility’s admission criteria policy requires Level I PASRR screening for all admissions and readmissions and referral for Level II when criteria for mental disorder, intellectual disability, or related condition are met, but this process was not followed for these residents.
Failure to Complete Required PASRR Screening Prior to Admission
Penalty
Summary
The deficiency involves the facility’s failure to complete required Pre-admission Screening and Resident Review (PASRR) Level I and, if indicated, Level II screenings prior to admission for one resident with multiple documented mental health diagnoses. The resident, an adult male, was initially admitted on 9/5/2025 with diagnoses including anxiety disorder, bipolar disorder, recurrent moderate major depressive disorder, unspecified psychosis not due to a substance or known physiological condition, and unspecified dementia, with onset dates for these conditions ranging from 2010 to 2020. During interview and record review, the Social Service Coordinator and Social Service Director acknowledged that no PASRR had been completed for this resident prior to admission, despite the presence of these mental health conditions in the record. Surveyors later reviewed a PASRR Level I outcome notice dated 12/17/2025, which showed a determination of “No Level II Required – No SMI/ID/RC,” confirming that the PASRR process was not initiated until well after the resident’s admission. The Social Service staff stated they typically receive PASRR documentation from the hospital for new admissions and rely on a psychiatric NP who visits weekly to help identify residents with new or possible mental disorders, intellectual disabilities, or related conditions after admission. They also stated that the social service department is responsible for making referrals to the state-designated authority when such conditions are identified. The facility’s written Admission Criteria policy, reviewed on 4/12/2025, requires that all new admissions and readmissions be screened for MD, ID, or related disorders per the Medicaid PASRR process and specifies that the facility conducts a Level I PASRR screen for all potential admissions regardless of payer source, which was not followed in this case.
Failure to Identify and Correct Wobbly Lounge Table Contributing to Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure common areas were free of accident hazards and to conduct an adequate post-fall environmental assessment. A resident with an admission date of 12/06/2025 had diagnoses including unspecified fall, other abnormalities of gait and mobility, acquired absence of both legs below the knee, and abnormal posture. On 12/16/2025, the resident was observed in bed with discoloration on the left eyebrow and reported having fallen in the lounge area on 12/14/2025. The resident stated that they stood up from their wheelchair to transfer to a regular chair by holding onto a table in the middle of the lounge, but the table was wobbly and they fell onto their left side. During the same observation, the resident demonstrated how the fall occurred and touched the table, which was noted to be wobbling. On 12/16/2025 at 10:52 AM, a RN (V12) touched the same lounge table and confirmed it was wobbling, stating it was not safe for anyone who would want to sit by it. However, V12 later stated that at the time of the fall she did not check the table and only visually checked the surroundings, and when the resident’s wife called asking if there was any broken furniture where the resident fell, V12 reported there was none based on her visual check. Housekeeping staff (V18) reported that whenever she cleaned the table in the lounge, it was wobbling and that she had informed maintenance about it. The Maintenance Director (V19) stated he was not aware the table was wobbling until the morning of 12/16/2025. The facility’s incident report for the 12/14/2025 fall documented that the resident was observed on the floor sitting, trying to get into a chair in the lounge, and under predisposing environmental factors, “None of the Above” was checked and “Furniture” was not checked. This was inconsistent with the facility’s Fall Prevention and Management policy, which requires an environmental/physical assessment to identify environmental/physical risk factors as part of post-fall management.
Failure to Protect Residents from Sexual and Physical Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in significant deficiencies. One resident, who was cognitively intact and required assistance with incontinence care, reported being sexually abused by a Certified Nursing Assistant (CNA) on multiple occasions during personal care. The resident described inappropriate sexual touching, including the CNA using his gloved hand and fingers on her vaginal and rectal areas, causing pain and discomfort. The resident stated that these incidents occurred after she no longer had a roommate and that she initially did not report them out of fear, but ultimately disclosed the abuse to her family after the most recent incident. A hospital sexual assault examination confirmed trauma consistent with the resident's account, and the resident decided to pursue criminal charges. The CNA denied the allegations, but facility records confirmed he was assigned to care for the resident on the relevant dates. Another deficiency involved the facility's failure to protect a resident from physical abuse by another resident. The aggressor, who had dementia and a schizoaffective disorder, exhibited confusion and aggressive behaviors, including two documented incidents in which he physically assaulted another resident in the dining room. Witnesses, including CNAs and an LPN, observed the aggressor striking the other resident in the head and being nonredirectable during the altercations. The assaulted resident, who also had dementia and was confused, was unable to recall the incidents due to her cognitive impairment. The aggressor was transferred to the hospital for his behavior after both incidents, and staff reported that loud noises or agitation appeared to trigger his aggression. Both residents involved in these incidents had care plans indicating they were at risk for abuse and trauma. The facility's policies outlined procedures for abuse prevention, identification, and management, but the events described demonstrate that these measures were not effectively implemented to prevent abuse. The facility's investigation reports characterized the resident-to-resident altercations as accidental, but staff statements and care plans indicated a pattern of aggressive behavior and risk factors that were not adequately addressed.
Failure to Immediately Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to follow its abuse prevention policy by not immediately reporting an allegation of verbal abuse made by a resident. The resident, who had multiple diagnoses including chronic obstructive pulmonary disease, peripheral vascular disease, chronic kidney disease, and a right below the knee amputation, informed a CNA (V4) that another CNA (V3) had told the resident to 'shut up' multiple times during care. V4 recognized this as verbal abuse and advised the resident to report it to his sister or a manager, but did not report the allegation himself. V4 stated that he refrained from reporting the incident because he did not know V3 and was concerned about possible repercussions. The administrator (V1), who is also the abuse coordinator, confirmed that staff are expected to immediately report any abuse allegations to either himself or the DON. The facility's abuse prevention policy requires employees to report any suspected or observed abuse immediately to the administrator or an immediate supervisor, who must then report it to the administrator. In this case, the required immediate reporting did not occur.
Failure to Administer Medications at Scheduled Times
Penalty
Summary
The facility failed to ensure that medications were administered at the correct scheduled times for 12 out of 13 residents reviewed for medication administration. Multiple observations on a single day revealed that medications scheduled for 9:00 AM were consistently given late, with some being administered as late as 1:53 PM. Nursing staff, including an LPN and an RN, were observed giving medications well past the scheduled times, and both staff members acknowledged the delays. The LPN stated that it was not possible to complete medication passes on time due to workload and issues with medication cart stocking, and the DON confirmed that the facility standard was to allow a one-hour window before and after the scheduled time, although this was not reflected in the facility's written policy. Residents affected by the late administration of medications had complex medical histories, including conditions such as diabetes, hypertension, chronic kidney disease, heart failure, COPD, and various neurological and psychiatric disorders. The late administration was not limited to a single staff member or shift; on one occasion, an agency nurse was observed attempting to give morning medications in the afternoon, prompting intervention from facility management. The Medication Administration Record (MAR) and resident face sheets confirmed that the medications were scheduled for earlier times and that the delays were not isolated incidents. Interviews with staff revealed that the delays were attributed to factors such as inadequate staffing, lack of medication cart restocking, and high resident acuity. The facility's policy on medication administration emphasized checking the MAR for the right medication, dose, route, patient, and time, but did not specify or authorize the practice of administering medications within a one-hour window before or after the scheduled time. Despite this, staff and management cited this as their standard practice, which was not supported by written policy.
Failure to Maintain Mechanical Sling Lifts
Penalty
Summary
The facility failed to maintain patient care equipment, specifically full body mechanical sling lifts, which resulted in residents being unable to get out of bed. During an inspection, it was observed that one of the lifts had exposed wires and a broken cover, and another lift had not undergone preventative maintenance since 2019. Despite the presence of a sign indicating that one lift was out of order, the maintenance staff reported not receiving any formal requests for repair through the facility's work order system. This lack of communication and maintenance led to significant delays in residents being able to participate in activities or even get out of bed. Residents expressed frustration with the situation, with one resident stating it took three hours to find a working lift, causing them to miss an activity. Another resident mentioned that they were waiting for new equipment to be delivered before they could be moved from their bed. The facility's policy requires staff to report maintenance needs, but it appears this process was not effectively followed, contributing to the deficiency in providing adequate care and accommodation for the residents' needs and preferences.
Failure to Monitor Antipsychotic Medication Leads to Adverse Outcomes
Penalty
Summary
The facility failed to adequately monitor and report the side effects of a resident's antipsychotic medication, Seroquel, which led to significant adverse outcomes. The resident, identified as R4, was admitted with multiple diagnoses, including vascular dementia and a history of falls. Despite being severely cognitively impaired and on high-risk medications, the facility did not document any side effects of the antipsychotic medication, nor did they effectively communicate with the prescribing psychiatric nurse practitioner (NP) about the resident's excessive sedation and increased fall risk. R4's care plan included monitoring for side effects and consulting with the pharmacy and medical doctor for dosage reduction when clinically appropriate. However, the care plan lacked specific resident-centered target behaviors or non-pharmacological approaches for managing the use of Seroquel. The facility's records showed that R4 experienced multiple falls and was frequently overly sedated, which was a concern raised by both his wife and the nursing staff. Despite these observations, the facility did not notify the psychiatric NP in a timely manner, which delayed appropriate adjustments to the medication regimen. The facility's policies on psychotropic drug use and behavior management emphasized the importance of monitoring for side effects and involving the resident's family in care planning. However, these policies were not effectively implemented in R4's case. The psychiatric NP noted that the facility should have informed her of the side effects sooner, and the geriatric NP had to make medication adjustments without proper coordination. This lack of communication and monitoring contributed to R4's hospitalization, increased falls, and inability to participate in rehabilitation care.
Failure to Address Grievances Regarding Unsanitary Practices
Penalty
Summary
The facility failed to resolve grievances related to unsanitary practices involving a resident, identified as R2, who was observed touching food trays and removing plate lids with bare hands. This issue was reported by multiple residents, including R1, R3, R4, R5, and R6, who expressed concerns about the potential spread of germs. Despite these grievances being raised during group and food focus meetings, no effective action was taken to address the situation. R2, who is alert and has obsessive-compulsive disorder (OCD), was seen interfering with food trays, which was acknowledged by staff members, including registered nurses and the Social Service Director. The Food Service Manager confirmed that complaints about R2's behavior were reported to the Director of Nurses (DON), but there was no documented follow-up or resolution. The facility's grievance policy requires grievances to be logged and investigated promptly, but this was not adhered to in this case. The Director of Nurses admitted to being aware of the complaints but failed to document any follow-up actions. The facility's failure to address and resolve these grievances constitutes a deficiency in honoring residents' rights to voice grievances without reprisal and ensuring a sanitary environment.
Staffing Deficiencies Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in several deficiencies. One resident, who had diagnoses including paraplegia, congenital hydrocephalus, heart failure, and was under palliative care, was found with noisy breathing and an untouched meal tray. The agency CNA was unaware of the resident's condition, and the agency RN had not notified the family or provider of the change in condition. The family was informed of the resident's choking and subsequent death much later, causing distress. The hospice was also notified late, preventing timely intervention. Other residents experienced inadequate grooming and meal services. Two residents had long, dirty fingernails, indicating a lack of personal care. Another resident had a broken fingernail with a dirty band-aid, which was not addressed promptly. Additionally, multiple residents reported receiving cold meals, with meal tray temperatures recorded below acceptable levels. The food service staff acknowledged that meal trays were not distributed on time, leading to cold food being served. The facility's reliance on agency staff contributed to these issues, with a significant portion of the staff being from an agency over the weekend. The resident council meeting minutes highlighted complaints about the slow response time of agency staff. The Director of Nursing acknowledged the staffing issues and mentioned that many agency staff were placed on Do Not Rehire, leading to a shortage of providers. The facility's policy stated the need for sufficient staff with the necessary skills and competency, which was not met in this instance.
Failure to Timely Notify Family and Providers of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the family, physician, and hospice provider in a timely manner about a significant change in condition for a resident. During an observation, the resident was found in bed with noisy breathing and an untouched meal tray. A Certified Nursing Assistant from an agency, unfamiliar with the resident, noted the resident's condition had been the same since morning. The Registered Nurse from the agency was aware of the condition but had not yet informed the family or provider. Later, a family member expressed concerns about care and staffing, noting that they were informed of the resident's choking incident and subsequent death only hours later. The hospice provider was notified of the resident's change in condition later than usual, which delayed their ability to provide comfort care. The resident's medical records indicated diagnoses of paraplegia, congenital hydrocephalus, heart failure, and palliative care, with moderate cognitive impairment and dependency on staff for daily activities. The Director of Nursing and other nursing staff confirmed that changes in condition should be communicated promptly, as per the facility's policy. However, this protocol was not followed in this instance, leading to a delay in communication with the resident's family and care providers.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide adequate nail care for residents who were dependent on staff for assistance with activities of daily living. Three residents were identified as having neglected nail care. One resident, who was cognitively intact and required assistance for daily activities, had quarter-inch long nails with blackish dirt underneath and reported that staff rarely cut their nails. Another resident, who was moderately cognitively intact and also required assistance, was observed with inch-long nails with sharp edges and brownish dirt, and stated that no one cut their nails. A third resident, who was minimally interviewable and had severely impaired cognitive abilities, had an inch-long nail with discoloration and a broken nail with a dirty band-aid, which was reported to be painful. Staff interviews revealed that Certified Nursing Assistants (CNAs) were responsible for nail care, which was typically performed on shower days. The Director of Nursing confirmed that nail care was the responsibility of CNAs and emphasized the importance of keeping nails short to prevent dirt accumulation and reduce the risk of infection. The facility's policy on Activities of Daily Living stated that appropriate care and services should be provided for residents unable to carry out ADLs independently, including grooming and personal hygiene. Despite this policy, the facility failed to ensure that these residents received the necessary nail care, leading to the observed deficiencies.
Failure to Serve Meals at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was served at palatable temperatures, affecting three out of five residents reviewed for meal service. During an observation of the lunch meal service, it was noted that the sweet potatoes and beans served to residents were below 100 degrees Fahrenheit, which is significantly lower than the facility's policy of maintaining food at 135 degrees or above before serving. The Food Service Director acknowledged the issue, stating that the problem persisted due to delays in distributing meals to residents' rooms, despite previous discussions with management. Residents R5, R6, and R7 all reported receiving cold food, with meal tray temperatures recorded well below the required standard. R5, who is cognitively intact, expressed dissatisfaction with the timeliness and temperature of the meals. R6, with moderate cognitive impairment, also noted that meals were often late and cold. R7, who requires assistance with daily activities, mentioned that the food was usually cold and that there was insufficient staff to distribute meals promptly. The facility's Administrator and Director of Nursing confirmed that residents are expected to receive food at a palatable temperature, yet the issue remained unresolved.
Failure to Implement Fluid Restrictions and Conduct Daily Weights for CHF Residents
Penalty
Summary
The facility failed to implement a fluid restriction for a resident diagnosed with congestive heart failure (CHF) and did not conduct daily weights for residents with CHF. One resident had a documented order for a fluid restriction of 2-2.5 liters per day, but the resident was unaware of this restriction, and the facility did not have the resident listed on the fluid restriction sign. Observations showed the resident had multiple fluid containers at their bedside, and their meal tray included fluids, indicating a lack of communication and implementation of the fluid restriction order. Additionally, two residents with CHF had orders for daily weights to monitor for fluid retention, but their records showed multiple missing entries for daily weights. The Medication Administration Record (MAR) and Weights and Vitals Summary for these residents indicated several days where weights were not recorded, demonstrating a failure to adhere to the prescribed monitoring protocol for CHF management.
Failure to Provide Arm Sling for Resident During Transfers
Penalty
Summary
The facility failed to ensure that a resident's left arm was supported by a sling during transfers and while seated in a wheelchair, as required for maintaining range of motion and preventing shoulder subluxation. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, was observed without a sling on multiple occasions. Despite a sign above the resident's bed indicating the need for a sling during transport, staff members, including a Certified Nursing Assistant and a Registered Nurse, were unaware of the requirement for an arm sling and had not seen the resident wearing one since admission. The Occupational Therapist confirmed that the resident should have a sling on her left arm during transfers and while seated to prevent subluxation. The resident's admission papers and physician progress notes indicated the necessity of a sling to support the left shoulder and reduce the impact of flaccidity. However, there was no physician order for the sling, and the nursing staff did not include it in the resident's care plan. This oversight led to the resident being transferred and seated without the necessary support for her left arm, contrary to the recommendations outlined in her admission documents.
Safety and Supervision Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure the safety of a resident with dysphagia by not providing necessary cues and supervision during meals. Resident R3, diagnosed with adult failure to thrive and dysphagia, was observed eating alone in her room without staff presence. Despite having a care plan that required alternating small bites with sips of liquid to prevent aspiration, R3 was not reminded to follow these safe swallowing strategies. The speech therapy notes indicated R3's severe cognitive impairment and the need for cues to follow safe swallowing strategies, yet the CNA responsible for R3 did not provide the necessary reminders. Additionally, the facility did not adhere to its policy requiring two staff members for mechanical lift transfers, as observed with resident R73. A CNA transferred R73 using a Hoyer lift alone, contrary to the care plan and facility policy, which mandates two caregivers for such transfers. Furthermore, resident R92, identified as high risk for falls, had a call light that was not within reach, compromising her ability to call for assistance. Despite being able to use the call light, it was found under the bed or draped over the head of the bed, not accessible to R92, who had a history of falls and required assistance for daily activities.
Failure to Specify Duration for PRN Psychotropic Medications
Penalty
Summary
The facility failed to ensure that PRN (as needed) anti-anxiety psychotropic medications had a specified duration or end date for four residents. Resident 66 had an active order for Lorazepam, an anti-anxiety medication, to be administered every two hours as needed for severe anxiety or nausea, starting from May 31, 2024, without a listed duration. Similarly, Resident 40 had a physician's order for Lorazepam to be taken every eight hours as needed for restlessness related to anxiety disorder, dated September 19, 2024, with no stop date provided. Resident 299's order summary showed an order for Lorazepam to be given every two hours as needed, starting on October 20, 2024, without a specified duration. Additionally, Resident 106 had an order for Xanax, another anti-anxiety medication, to be administered as needed twice a day starting from May 23, 2024, also lacking a stop date. The facility's policy on psychotropic drug use, revised on January 31, 2024, stated that PRN psychotropic medication orders should not exceed 14 days unless the attending physician or prescribing practitioner documents the necessity for an extension in the patient's chart.
Expired Medications Found in Facility Refrigerator
Penalty
Summary
The facility failed to dispose of expired medications in the medication refrigerator for two residents. During an observation on October 23, 2024, a Registered Nurse/Infection Preventionist, identified as V7, along with the surveyor, reviewed the medication room refrigerator. They found an insulin pen belonging to a resident, which had been opened on September 3, 2024, and had an expiration date of October 1, 2024, making it 22 days past its expiration. Additionally, the refrigerator contained a bottle of liquid medicated mouthwash for another resident, with an opened date of July 12, 2024, and a pharmacy sticker indicating it should be discarded after 14 days. V7 acknowledged that these medications were expired and should have been disposed of. The facility's Storage of Medications Policy, dated October 17, 2024, states that all expired medications must be removed from the active supply and destroyed in the facility, regardless of the amount remaining. However, this policy was not followed, leading to the presence of expired medications in the medication refrigerator.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff adhered to Enhanced Barrier Precautions (EBP) by not wearing gowns during high contact care activities for a resident. On October 21, 2024, a Certified Nursing Assistant (CNA) provided care to a resident on EBP without wearing a gown, despite the presence of personal protective equipment (PPE) and a sign indicating EBP outside the resident's room. The resident, a man with a history of hemiplegia, hemiparesis, dysarthria, gastrostomy status, and hypertension, was on EBP due to having a gastrostomy tube. The facility's policy requires gown and glove use during high contact activities, such as dressing and hygiene, to prevent the transmission of Multidrug Resistant Organisms (MDRO). The Registered Nurse/Infection Preventionist confirmed that staff are expected to wear gowns and gloves during such care activities.
Inadequate Investigation of Sexual Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation of a sexual abuse allegation, as required by their policy. On September 10, 2024, a CNA reported to the Administrator that she observed a male resident exposing himself and attempting to engage in a sexual act with a female resident. Despite this serious allegation, the facility did not interview all potential witnesses or staff present at the time of the incident, which is a critical step outlined in their abuse prevention policy. The facility's investigation was delayed and incomplete. Interviews with staff members were conducted six days after the alleged incident, contrary to the policy that requires interviews to be conducted as soon as possible. Additionally, the facility's documentation was lacking, as statements from the staff were not signed, and there was no evidence that all staff present during the incident were interviewed. This oversight in the investigation process led to the unsubstantiation of the sexual abuse allegation without a comprehensive review of all available information. The residents involved in the incident have significant medical histories. The female resident has severe cognitive impairment and requires substantial assistance with daily activities, while the male resident is cognitively intact but has a history of dementia with behaviors. The failure to properly investigate the incident has the potential to affect all 148 residents in the facility, as it undermines the safety and security measures intended to protect them.
Removal Plan
- V3 was interviewed regarding the allegation.
- All staff that were on the schedule the day of the allegation were reinterviewed.
- Law Enforcement report was made, Case #EGP24-018160.
- Facility staff assessed all residents in house with possible similar challenging behaviors to ensure that the safety of individuals is met at all times.
- Facility has reviewed the policy and procedure on investigating abuse allegations.
- Facility completed education with V1 (Administrator) regarding investigating abuse allegations by consultant, [NAME] President of Operations.
- Facility completed education with V2 (DON) regarding investigating abuse allegations consultant, [NAME] President of Operations.
- Facility completed education with V12 (Director of Clinical Services) regarding investigating abuse allegations, with V11 (CNO-Chief Nursing Officer).
- Facility completed education with clinical staff regarding investigating abuse allegations.
- Facility created an audit tool to measure thorough investigations of all abuse allegations.
- Facility Administrator and/or designee will monitor all abuse allegations for appropriateness to include ensuring all possible witnesses or potential witnesses to abuse allegations are interviewed.
- Administrator and/or designee will review audits weekly to ensure compliance with the measures put in place to address thorough investigation of all abuse allegations.
- AD HOC QAPI (Quality Assurance Performance Improvement) was initiated to discuss with QA Committee and Medical Director, Plan of Removal and to ensure that all corrective actions and safety measures are consistently implemented. Ad HOC QAPI was completed and implemented.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a female resident, R1, from sexual abuse by a male resident, R2, who had known sexual behaviors and public displays of affection. R2, who was cognitively intact but exhibited inappropriate behaviors, was moved from a secure Dementia Unit to a room next to R1 without any interventions in place to protect other residents. This led to an incident where R2 exposed himself and attempted to engage in non-consensual sexual contact with R1, who has severe cognitive impairment and is unable to consent to sexual relations. R2 had a history of inappropriate behaviors, including touching staff and other residents, and was known to have hypersexual behaviors potentially linked to his Parkinson's medication, pramipexole. Despite these known behaviors, the facility did not implement new interventions after R2 was moved to a new room. On the day of the incident, a CNA found R2 in R1's room with his pants down, attempting to put his penis in R1's mouth. The CNA immediately intervened and reported the incident to the facility administrator. The facility's lack of action and failure to implement protective measures for female residents after R2's room change resulted in immediate jeopardy. The facility's abuse prevention policy was not effectively enforced, as there was no documentation of interventions to address R2's behaviors after previous incidents. The facility's inaction and inadequate response to R2's known behaviors directly led to the deficiency and the subsequent immediate jeopardy situation.
Removal Plan
- Social Service Director conducted an audit of all residents with hypersexual behaviors.
- All female residents were assessed for potential sexual abuse by Social Service Director.
- Care plan review was initiated and completed.
- Policy was developed by Regional Social Service Consultant to address hypersexual behaviors that are not easily redirectable.
- Facility initiated in-services on facility's abuse program and policies to all shifts immediately after the incident and is on-going.
- All agency staff will receive the same training before the start of the shift.
- All staff who are not available at this time due to vacation or leave of absence will also receive the same training prior to start of shift upon return to work.
- In-services were provided and are being provided by Administrator, DON, and or Social Service and clinical supervisor.
- Facility Administrator and Social Service developed a process to ensure facility staff caring for a resident with the potential for abusing other residents are educated on specific interventions to prevent abuse and protect all residents.
- Facility Administrator, DON and Social Service provided in-services on all shifts on the following topics: Facility interventions and processes to ensure every effort will be taken to protect female residents from a resident with known sexual behavior.
- All direct patient care staff were educated specifically on interventions for R2 to prevent abuse and protect all residents.
- Management of Sexual Behavior policy.
- Administrator developed and utilized a QA tool to ensure that specific interventions for R2 are implemented by direct patient care staff as noted. This audit will be conducted twice weekly for four weeks.
- All residents that are high risk for sexual abuse will be observed twice weekly to ensure that they are free from abuse and remain safe while residing in the facility.
- Administrator will randomly select five residents twice weekly and observations to be completed for four weeks.
- ADHOC QAPI (Quality Assurance Performance Improvement) was initiated to discuss with QA Committee and Medical Director, Plan of Removal and ensure that all corrective actions and safety measures are consistently implemented.
Failure to Update Care Plan for Resident with Sexual Behaviors
Penalty
Summary
The facility failed to update a resident's care plan after the resident exhibited sexual behaviors and public displays of affection, which necessitated a room change. This deficiency was identified during a review of a resident who was involved in a resident-to-resident sexual assault incident. The incident occurred when a CNA found the resident, R2, in another resident's room, attempting to engage in inappropriate sexual behavior. Despite the incident being reported to the facility administrator, the care plan was not updated to address the resident's behaviors. R2, who has multiple diagnoses including Parkinson's Disease, dementia with behaviors, and psychotic disorder with delusions, was admitted to the facility with a care plan that noted inappropriate or overly friendly behaviors. These behaviors included touching staff and making unwanted contact with others. Despite these documented behaviors, the facility did not implement new interventions following an incident on August 6, 2024, where R2 attempted to kiss other residents. The facility's failure to update the care plan after this incident contributed to the deficiency. The facility's Comprehensive Care Plan Policy requires that care plans be revised when there is a significant change in a resident's condition. However, the facility did not document any new interventions or updates to R2's care plan following the August 6 incident or the subsequent room change. This lack of documentation and failure to update the care plan to address R2's sexual behaviors and protect other residents led to the identified deficiency.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that a resident, identified as R2, was seen by their attending physician in accordance with the facility's policy. R2, who has multiple diagnoses including Parkinson's Disease, dementia with behaviors, anxiety, falls, psychotic disorder with delusions, insomnia, and depression, was admitted to the facility on an unspecified date. The facility's policy requires that each resident must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least every 60 days thereafter. Additionally, a complete history and physical must be completed by the physician within 72 hours after admission or five days prior. However, the facility did not have documentation to show that R2 was seen by their primary care physician, V8, until September 11, 2024, despite being admitted earlier. The physician, V8, stated that they usually see residents every six to eight weeks and mentioned that the initial history and physical for R2 was conducted by a Nurse Practitioner, which is against the facility's policy. The policy explicitly states that the history and physical must be completed by the physician and cannot be completed by a nurse practitioner or physician's assistant. This lack of adherence to the policy resulted in a deficiency as the required face-to-face visits and documentation were not completed in a timely manner as per the facility's guidelines.
Medication Error and Delayed Reporting in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident, identified as R1, was not administered a medication that was not prescribed for them. R1, who had multiple diagnoses including Charcot's Joint, Covid-19, Type II diabetes mellitus, and MRSA, reported that an agency nurse gave her a medication that looked different from her usual prescriptions. The nurse assured R1 that the medication was an antibiotic prescribed for her, but later returned to ask if R1 had taken it, admitting that mistakes sometimes happen. R1 experienced adverse symptoms such as nausea, dizziness, sweating, and diarrhea, and her blood pressure dropped after taking the medication. The incident was reported to another agency RN, V4, who investigated and found a capsule matching R1's description, identified as Duloxetine, a medication for depression, which was not prescribed for R1. The Director of Nursing (DON), V2, was informed of the incident the following day, and upon investigation, found that the agency nurse, V12, had left the medications with R1 without confirming them against the medication administration record (MAR). V12 was terminated from the facility, although not directly due to the medication error. The facility's policy requires that medication errors be reported immediately to the DON or a nurse manager, which did not occur in this case. The incident report and progress notes indicated that R1 experienced increased blood pressure and vomiting after taking the medication. The physician on call was notified, and R1's symptoms were monitored, but the exact medication error could not be determined. The facility's policy emphasizes the importance of verifying medications against the MAR and ensuring residents are given the correct medications, which was not adhered to in this instance.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to permit a resident, identified as R2, to return after a behavioral hospitalization, violating the bed-hold policy. R2, who has Alzheimer’s disease, schizoaffective disorder, diabetes, and cognitive communication deficits, was initially admitted to the facility with known aggressive behaviors. Despite being informed of R2's behavioral issues prior to admission, the facility assured R2's daughter that they could manage his condition. However, after R2 was hospitalized for aggressive behavior and subsequently stabilized at a behavioral health unit, the facility refused to readmit him without providing the required notice of discharge or transfer. The facility's social services and admissions staff failed to communicate effectively with R2's daughter, who was left without guidance on how to proceed with R2's return. The facility's administrator confirmed the decision not to readmit R2 was made without consulting the behavioral unit for updates on R2's condition. This lack of communication and failure to follow proper discharge procedures resulted in a deficiency related to the facility's handling of R2's case.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide incontinence care to a resident who is dependent on staff for activities of daily living. The resident, who has no cognitive impairment, is always incontinent for bladder functions and relies on staff for toileting. On multiple occasions, the resident reported not being changed in a timely manner by agency CNAs, resulting in the resident having to sit in a wet diaper and experiencing redness on their bottom. The resident had previously reported these concerns to the Director of Nursing, who acknowledged the issue and noted that the agency staff involved would not return. Grievance logs corroborate the resident's complaints of not receiving timely care with ADLs on specific dates.
Failure to Provide Adequate Assistance Leads to Resident Fall
Penalty
Summary
The facility failed to ensure that two staff members assisted a dependent resident during incontinent care, resulting in the resident falling from the bed and sustaining a left eye laceration. The incident involved a resident who was dependent on most activities of daily living, including toileting, hygiene, and rolling, and required assistance from two or more staff members. On the day of the incident, a Certified Nursing Assistant (CNA) attempted to provide care alone, believing she could manage without additional help. During the process, the resident attempted to grab a tray or table for stability, which slid away, causing the resident to lose balance and fall to the floor. The resident, who had a history of polyarthritis, falls, long-term use of blood thinners, and other medical conditions, was admitted to the ICU with a subdural hematoma following the fall. Interviews with staff, including registered nurses and a physical therapist, confirmed that dependent residents should always have at least two staff members assist with bed mobility and incontinent care to prevent falls and injuries. The facility's administrator acknowledged the requirement for two assists for such residents after reviewing the resident's Minimum Data Set (MDS) documents. The facility's fall prevention policy indicated that all residents at risk for falling should receive universal fall precaution interventions, with high-risk residents receiving individualized interventions as appropriate.
Failure to Monitor and Address Nutritional Needs Leads to Significant Weight Loss
Penalty
Summary
The facility failed to adequately monitor and address the nutritional needs of a resident, resulting in significant weight loss. The resident, who was cognitively impaired and required moderate assistance with eating, experienced an 11.5% weight loss in one month. Despite being on a high-calorie and high-protein diet with specific dietary recommendations following a rehospitalization, the resident's weight was not properly monitored, and significant weight changes were not communicated to the dietician. Observations revealed that the resident was often hungry, had difficulty accessing food and fluids, and was not consistently assisted with meals, leading to inadequate nutritional intake. The facility's policy required weekly weight monitoring for new admissions and readmissions, with additional monitoring for significant changes in condition or food intake. However, discrepancies in the resident's weight were not addressed, and the dietician was not informed of the significant weight loss. The Director of Nursing acknowledged that weight discrepancies should be assessed and referred to the dietician, but this protocol was not followed. The Registered Dietician Consultant confirmed that the resident's nutritional needs were reassessed too late, and part of the weight loss could have been avoided with proper monitoring and communication.
Failure in Post-Fall Documentation and Neurological Assessment
Penalty
Summary
The facility failed to ensure accurate completion of neurological assessments and post-fall documentation for a resident who experienced an unwitnessed fall and hit her head. The resident, who was admitted with severe cognitive impairment and various medical conditions, was found on the bathroom floor with a small cut above her left eye. Despite the fall, the facility did not complete the necessary post-fall documentation or include it in the resident's medical record, as required by their fall prevention and management policy. Multiple staff members, including CNAs and RNs, were involved in the incident, but there was confusion regarding who was responsible for the resident at the time of the fall. The documentation of the incident was inconsistent, with discrepancies in the accounts of the fall's circumstances and the resident's condition. The neurological assessments recorded in the resident's flow sheet were inaccurate, showing the resident as oriented, which contradicted her known baseline orientation. The facility's Director of Nursing acknowledged the lack of proper documentation and the inaccuracies in the neurological assessments. The facility's policy required a thorough post-fall assessment, including a neurological check and documentation of the event, which was not completed. The resident was eventually transferred to the hospital with a swollen and bruised left eye, indicating a potential oversight in monitoring and assessing the resident's condition post-fall.
Inadequate Meal Service and Nutritional Deficiency
Penalty
Summary
The facility consistently failed to serve food items according to their planned and approved menu, leading to inadequate nutritional intake for residents. This deficiency was observed through various instances where residents did not receive the meals as outlined in their tray tickets, resulting in significant weight loss for some residents, such as one with end-stage renal disease and diabetes, who experienced a weight decrease of 18 pounds over five months. The dietitian confirmed that the resident was not on a planned weight loss program and attributed the weight loss to insufficient calorie intake due to the facility's failure to serve the planned menu. Residents expressed feelings of sadness, anger, and frustration due to the poor quality and inconsistency of meals served. Many residents reported that they often received scrambled eggs regardless of the menu, and items like milk and juice were frequently missing from their trays. The facility's failure to provide adequate meals led some residents to rely on food brought in by family members, causing financial hardship. The dietitian expressed concern that the lack of 100% fruit juice and milk could result in residents not meeting their daily nutritional requirements. The facility's food service management was aware of the issues but failed to address them effectively. The food service manager admitted to not following the planned menu and was unaware of the unavailability of certain food items until the day they were to be served. Residents' grievances and complaints about the food quality and menu discrepancies were documented but not resolved, leading to ongoing dissatisfaction and emotional distress among the residents.
Consistent Failure in Meal Quality and Resident Dissatisfaction
Penalty
Summary
The facility consistently failed to provide palatable and appetizing meals to residents, leading to significant issues such as weight loss, emotional distress, and financial hardship. Residents reported receiving meals that did not match their dietary preferences or needs, with food often being served cold, unseasoned, or in insufficient quantities. For instance, a resident with end-stage renal disease and diabetes experienced significant weight loss due to the unpalatable meals, which did not adhere to her dietary restrictions. Despite having a good appetite, she resorted to ordering food from outside the facility, causing financial strain. Another resident with cognitive impairment and hypertension also suffered unintended weight loss due to inadequate energy intake. She expressed dissatisfaction with the lack of seasoning and variety in her meals, which led to her not consuming the provided food. The facility's dietitian acknowledged the weight loss but had not engaged with the resident to address her dietary concerns effectively. The resident's intake of supplemental nutritional items was inconsistent, further contributing to her weight loss. Multiple residents, including the Resident Council President, voiced their frustrations over the poor quality of food and the facility's failure to address their complaints. The residents reported that the food was often cold, lacked flavor, and did not match the menu descriptions. The facility's food service management was aware of these issues but had not implemented effective solutions. The residents felt neglected and expressed feelings of sadness, anger, and low self-worth due to the ongoing food quality issues.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to ensure resident grievances were documented and timely resolutions were provided, affecting all 151 residents. The Resident Council President expressed frustration over unresolved issues, including poor food quality, lack of activities, and restricted patio access. Despite numerous complaints about food service, such as cold meals and unappetizing presentation, no effective solutions were implemented. The facility's grievance records did not reflect these ongoing concerns, indicating a lack of proper documentation and follow-up. Multiple residents reported dissatisfaction with the facility's response to their grievances. One resident mentioned the loss of personal items and long wait times for assistance, while another highlighted the financial burden of purchasing outside food due to poor meal quality. The facility's grievance policy was not effectively implemented, as evidenced by the absence of written grievances for these issues. Staff members, including the Director of Nursing and Social Services, were unaware of many resident complaints, further demonstrating the facility's failure to address grievances adequately. The facility's policy on grievances lacked a defined timeframe for resolution, contributing to the ongoing dissatisfaction among residents. The opening of a new dementia unit led to the cancellation of night activities and restricted access to previously available spaces, exacerbating resident concerns. Despite the facility's policy encouraging feedback, the lack of documented grievances and unresolved issues suggests a systemic failure to address and resolve resident concerns effectively.
Deficiency in Timely ADL Care for Residents
Penalty
Summary
The facility failed to provide timely assistance with Activities of Daily Living (ADL) care, specifically toileting hygiene, to residents who required staff assistance. This deficiency was observed in six residents who were dependent on staff for toileting. One resident, who was always incontinent of bowel and bladder, was found sitting in urine-soaked clothing, indicating that his incontinence brief had not been checked or changed for several hours. The resident expressed concerns about staff reluctance to transfer him back to his wheelchair after changing his brief, as it required two staff members and a mechanical lift. He reported long wait times for assistance, sometimes up to several hours, and recounted an incident where he had to call the facility multiple times during the night to receive help. Another resident, who required substantial assistance for toileting, reported that there were not enough CNAs to provide timely care, particularly during PM and Night shifts. She described waiting for extended periods, sometimes resulting in physical discomfort and vomiting due to delayed urination. The resident also mentioned that agency CNAs were often on their phones or breaks, further delaying care. Similar issues were reported by other residents, including one who had to wait for assistance after soiling her brief, only to be told by a CNA that it was their break time. This resident noted longer wait times when agency CNAs were on duty compared to facility CNAs. The Resident Council President expressed frustration over the facility's failure to address ongoing complaints about long wait times for care, leading to the cancellation of a council meeting. Meeting minutes from previous months documented residents' concerns about inadequate staffing and long response times to call lights, particularly with agency CNAs. A family grievance also highlighted a case where a resident had to take himself to the bathroom due to long wait times. The Director of Nursing acknowledged that residents' incontinence briefs should be checked every two hours, but there was no formal policy in place to ensure this standard of practice was followed.
Failure to Reorder Medications Timely
Penalty
Summary
The facility failed to ensure medications were reordered in a timely manner, affecting two residents who required eye medications for dry eyes. One resident, who was cognitively intact, reported that he brought eye drops from his physician's office and handed them to a nurse, but the drops were lost, and he did not receive them as prescribed. The resident's MAR indicated that he had physician orders for three different eye medications, but he did not receive any doses of his two as-needed medications. A registered nurse supervisor confirmed that the medications were not ordered, and a licensed practical nurse admitted to misplacing the eye drops and failing to reorder them. Another resident, also cognitively intact, reported inconsistencies in receiving her prescribed eye drops. She mentioned that when she inquired about her medication, the nurse would sometimes find the drops and other times claim they needed to be reordered. The MAR for this resident showed missing records of her eye drops and other medications on specific dates. The facility's policy required medications to be reordered four days in advance, but this was not adhered to, leading to the deficiency.
Improper Storage of Diabetic Medication Leads to Delay
Penalty
Summary
The facility failed to properly store a resident's diabetic medication, leading to a delay in administration. The resident, who has type 2 diabetes among other health conditions, provided an Ozempic pen to the facility for her diabetes management. However, after receiving one dose, the pen was lost by the facility, resulting in the resident missing her scheduled dose by a day. The resident's family had to pay out of pocket to replace the missing medication, and the facility was notified of the issue. The Director of Nursing confirmed the delay in administration and noted discrepancies in the Medication Administration Record (MAR), which incorrectly showed the dose was given on time. The facility's policy requires a licensed nurse to document the delivery and storage of medications brought by residents, but this procedure was not followed, leading to the medication's loss. The family filed a grievance regarding the incident, and the facility was unable to locate the missing medication despite searching.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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