Pearl Of Joliet, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Joliet, Illinois.
- Location
- 306 North Larkin Avenue, Joliet, Illinois 60435
- CMS Provider Number
- 145372
- Inspections on file
- 41
- Latest survey
- October 17, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Pearl Of Joliet, The during CMS and state inspections, most recent first.
A resident receiving tube feeding was observed lying flat in bed while the feeding was infusing, contrary to physician orders and facility policy requiring the head of bed to be elevated 30-45 degrees. CNAs indicated they believed elevation was only necessary when turning the resident, while the DON confirmed elevation is required during tube feeding to prevent complications.
A resident being treated for a UTI did not receive the ordered initial dose of Levofloxacin IV or a scheduled dose of Meropenem due to medication unavailability and lack of documentation. Nursing notes indicated the antibiotic was not available and would be delivered later, but there was no record of administration, and the DON confirmed the absence of documentation or pharmacy authorization requests as required by facility policy.
The facility did not maintain hot food temperatures during meal service, as observed through interviews and direct temperature checks. Multiple alert and oriented residents reported receiving lukewarm or cold meals, and food items were found to be served well below the required holding temperature. Staff delivered meals using non-insulated carts and without plate warmers, contrary to facility policy requiring food to be served at safe and appetizing temperatures.
Staff did not consistently wear gowns during high-contact care activities for residents on Enhanced Barrier Precautions (EBP), including those with a history of Candida Auris, end stage renal failure with IV access, and multidrug-resistant organisms. Despite posted EBP signage and facility policy requiring gown and glove use for such care, CNAs and a nurse were observed providing hygiene, incontinence care, and vital sign checks without proper protective equipment.
A resident with complex medical needs developed extensive skin rashes and redness in the groin, perineal area, buttocks, and under the breasts, which were not properly assessed, monitored, or treated by staff. Orders from a wound care NP for barrier and antifungal creams were not consistently implemented, and required documentation and physician notification were not completed. The resident experienced prolonged pain and discomfort due to these failures.
The facility failed to conduct thorough abuse investigations, affecting all residents. In one case, a CNA reported an LPN being verbally discourteous to a resident, but the investigation lacked interviews and documentation. Another case involved an alert resident, but there was no documentation of interviews. A third investigation also lacked evidence and documentation, despite the facility's policy requiring comprehensive investigations.
The facility failed to maintain proper kitchen sanitation and food storage, affecting 133 residents. Observations revealed dusty vents, improper sanitizing solution levels, and a dishwasher not reaching the required temperature. Unlabeled and spoiled food items were found in the walk-in cooler, and resident refrigerators lacked thermometers and temperature logs. Dented cans were improperly stored, posing a risk of foodborne illness.
The facility failed to provide necessary care for residents with decreased ROM, as evidenced by the lack of application of prescribed splints and supportive devices. Residents with conditions such as hemiplegia and contractures were observed without their required devices, despite having physician orders. The restorative staff were often reassigned, leading to a lack of consistent care and potential worsening of residents' conditions.
The facility failed to maintain a safe environment by not securely storing oxygen cylinders and cleaning supplies, and by not keeping residents' beds at a safe height. Several residents, including those at risk for falls, had their beds and overbed tables left in high positions. Unrestrained oxygen tanks were found in residents' rooms and the medication room, and cleaning chemicals were accessible in unlocked closets, contrary to facility policies.
A resident with severe cognitive impairment was found with hemorrhoidal cream at her bedside, which she used for lubrication rather than its prescribed purpose. The facility failed to assess her ability to self-administer medication, as required by policy. Staff confirmed the resident did not have orders to self-administer or store medications at her bedside.
The facility failed to ensure call lights were within reach for three residents, including one with hemiplegia and another with a self-care deficit. Despite care plans and facility policy requiring accessible call lights, they were placed out of reach, forcing residents to scream for help.
The facility failed to protect residents from verbal and mental abuse, involving an LPN who allegedly yelled at a resident with cognitive impairment and hearing loss, criticized another resident's toileting habits, and belittled a third resident over outside medication. The facility's investigation was incomplete, and the LPN's behavior did not meet facility standards.
A facility failed to report an allegation of verbal abuse involving a resident to the Illinois Department of Public Health. A CNA reported that a nurse was verbally discourteous to a resident, including shouting and telling the resident to 'shut up.' Despite the facility's policy requiring immediate reporting, the administrator confirmed that neither the initial nor final reports were sent to IDPH.
A resident with multiple medical conditions was found wearing both an incontinence brief and pad, without being on a toileting program. The facility's staff confirmed this practice, which contradicts the facility's policy and could lead to skin breakdown. The resident's care plan did not include a scheduled toileting program, despite the facility's policy to maintain personal hygiene for dependent residents.
A resident with a midline IV catheter experienced inadequate care, as the dressing was saturated with blood and lacked documentation of changes. The facility's policy requires dressing changes every 48 hours if gauze is present, but this was not followed. The DON confirmed no documentation of dressing changes, and the resident's POS showed no orders for catheter care, leading to a deficiency in maintaining the catheter.
The facility failed to document the pharmacy's monthly Medication Regimen Reviews (MRR) recommendations and physician responses for two residents. The ADON admitted to missing recommendations and a lack of a proper tracking system, while the DON emphasized the need for escalation if no response is received. The facility's policy requires timely communication and documentation, which was not followed.
A resident with multiple health conditions was found storing opened bottles of Miracle Whip and horseradish sauce on her windowsill, despite needing refrigeration. The facility had removed personal refrigerators, leaving the resident without proper storage options. The administrator acknowledged the issue, noting that the facility's policy requires regular inspections and proper food storage.
A CNA failed to wear a gown when entering the room of a resident on contact precautions for MRSA, despite facility policy and signage indicating the need for full PPE. The resident had multiple diagnoses, including MRSA, requiring strict adherence to infection control protocols. The CNA realized the mistake after entering, and the DON confirmed the necessity of wearing both a gown and gloves in such situations.
The facility failed to use an antibiotic use protocol tool for two residents on antibiotics, as confirmed by the IP and DON. One resident was on Ciprofloxacin for a UTI, and another on Meropenem for a positive sputum culture, without the McGeer's tool being completed. This tool is essential for ensuring appropriate antibiotic use, as per the facility's policy.
A resident's bed was found with side rails extending five inches on both sides, creating a potential entrapment hazard. An LPN confirmed the risk of the resident becoming stuck between the rails due to the space between the bed rail and mattress. The DON acknowledged the need for regular inspections to prevent such safety risks.
A resident at high risk for skin breakdown developed a Stage 3 pressure ulcer due to the facility's failure to conduct effective skin assessments and address skin issues. Despite orders for regular skin checks, staff did not notice or report the resident's skin condition, resulting in untreated open and bloody skin areas.
A resident's family requested information to install a camera in the resident's room during a care conference, but the facility failed to provide the necessary information or follow up on the request. The resident, who required assistance with daily activities, was moderately impaired. Despite the facility's policy allowing cameras, the request was not addressed within the expected timeframe, resulting in a violation of the resident's rights.
A resident with anxiety disorder did not receive scheduled doses of Buspirone, Clonazepam, and Hydroxyzine over several days due to a failure in the medication reordering process. Despite the resident's reports and staff awareness, the medications were not reordered in time, leading to increased stress for the resident.
A resident with a history of pressure injuries developed new stage 2 and stage 3 pressure injuries on the right hip, which were not promptly reported or treated by the facility staff. The CNA initially failed to report the wounds, and the LPN was unaware until later notified. The facility's protocols for immediate reporting and treatment of skin alterations were not followed, resulting in a deficiency.
A resident with fragile skin and a history of skin tears did not receive proper assessment and treatment orders for her wounds. The Wound Care Nurse was unaware of the resident's active wounds, and the facility failed to document or obtain treatment orders in the EMR. The Hospice RN changed dressings without access to the EMR, and the Director of Nursing expected staff to report skin issues, but the EMR lacked active wound care orders, leading to a deficiency.
The facility failed to maintain a clean and homelike environment for residents, as observed during an inspection. The bedroom floors were found to be dirty, with accumulated dirt, dust, and debris, including plastic pieces from PPE packaging. Residents and a family member expressed dissatisfaction with the cleanliness, and a housekeeper acknowledged that some rooms had not been swept for days, despite daily cleaning expectations. Resident Council Meetings had previously documented concerns about the need for cleaning.
The facility failed to provide timely incontinence care and assistance with ADLs for three residents. Two residents were found with saturated briefs, with the last change occurring several hours prior. Another resident was left in bed for an extended period without being offered assistance to get up, despite expressing a desire to do so. The DON confirmed that staff are required to check and change residents every two hours and assist them in getting up unless medically contraindicated.
A facility failed to monitor and check glucose blood sugar levels for a resident with a history of Diabetic Ketoacidosis, resulting in hospitalization for DKA. The resident's blood glucose levels were consistently elevated despite insulin doses, and there was no documentation of rechecking sugar levels or notifying the physician.
A resident scheduled for eye surgery was fed toast and cereal despite having an NPO order, leading to the rescheduling of the surgery. Interviews confirmed the staff's failure to follow the physician's order.
The facility failed to maintain a resident's bed equipment, specifically the bed control cord, which had approximately two inches of exposed wires. The resident involved is a [AGE] year old female with osteoarthritis, type 2 diabetes, and bilateral cataracts. The issue was observed on two separate occasions, and the Director of Maintenance was notified on the same day as the second observation.
Failure to Elevate Head of Bed During Tube Feeding
Penalty
Summary
Facility staff failed to maintain the head of bed at the required 30-45 degree elevation while a resident's tube feeding was infusing. During an observation, the resident was found in a flat position in bed with tube feeding of Nepro 1.8 Cal infusing at 40 mL per hour via feeding pump. Certified Nursing Assistants (CNAs) present during care stated that they believed it was acceptable for the resident to remain flat during tube feeding unless the resident was being turned side to side. The Director of Nursing (DON) later clarified that the head of bed should be elevated during tube feeding to prevent vomiting or aspiration. Review of the resident's physician orders and facility policy confirmed that the head of bed should be elevated to 30-45 degrees during tube feeding unless otherwise ordered.
Missed Antibiotic Doses Due to Medication Unavailability and Documentation Lapses
Penalty
Summary
The facility failed to administer the ordered initial dose of an antibiotic to a resident being treated for a urinary tract infection (UTI). The nurse practitioner's progress note documented a plan to treat the resident with Levofloxacin IV, starting with a 750 mg dose, followed by a 500 mg dose every 48 hours, and Meropenem 500 mg IV daily. The Medication Administration Record (MAR) showed a missed dose of Meropenem on 9/14/25 and no documentation of the administration of the initial Levofloxacin 750 mg dose on 9/13/25 or 9/14/25. Nursing notes indicated that Levofloxacin was not available and would be delivered later, but there was no documentation that the dose was ever administered. The Director of Nursing confirmed there was no documentation of the administration of either the Meropenem dose or the initial Levofloxacin dose, and no authorization requests were received from the pharmacy for the one-time Levofloxacin dose. Facility policy requires prompt reporting of medication discrepancies and omissions, but this was not documented in this case.
Failure to Serve Meals at Palatable and Safe Temperatures
Penalty
Summary
The facility failed to maintain palatable and appetizing food temperatures when serving meals to residents. Observations and interviews with several alert and oriented residents revealed consistent complaints that food was being served lukewarm or cold. A family member also reported that a former resident frequently complained about cold food. During meal service observations, food carts were delivered to the dining room and resident rooms using non-insulated carts covered with plastic zippered covers. Staff were seen setting up trays and serving food without the use of plate warmers or metal heating plates, which are important for maintaining food temperature. Temperature checks of food trays revealed that hot foods, such as turkey with gravy and cornbread dressing, were served at temperatures significantly below the required holding temperature of 135°F, with some items measured as low as 50.1°F. The Dietary Manager confirmed that food temperatures are checked in the kitchen before delivery, but acknowledged that the lack of metal heating plates and insulated carts contributed to the inability to maintain appropriate temperatures during transport and service. Facility policy requires that food be served at safe and appetizing temperatures, but this standard was not met during the survey period.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to adhere to standard infection control practices regarding the use of gowns during care for residents on Enhanced Barrier Precautions (EBP). Observations revealed that staff did not wear gowns while providing high-contact care to three residents who were on EBP due to conditions such as a history of Candida Auris, end stage renal failure with IV access, and a history of multidrug-resistant organisms. Specifically, two CNAs provided hygiene care to a resident with a history of Candida Auris without donning gowns, despite EBP signage being present. Another CNA provided incontinence care to a resident with an AV fistula and IV midline catheter, who was also receiving IV antibiotics, without wearing a gown. Additionally, a nurse checked vital signs at the bedside of a resident with a wound, indwelling urinary catheter, and history of KPC, again without wearing a gown, even though EBP signage was posted. Interviews and record reviews confirmed that these residents were on the facility's EBP list and that staff were expected to wear gowns and gloves during high-contact care activities, as outlined in the facility's EBP policy and posted signage. The policy specifically required gown and glove use for activities such as dressing, bathing, hygiene, incontinence care, and device care for residents on EBP. Despite these clear expectations and procedures, staff failed to consistently implement the required infection control measures during the observed care activities.
Failure to Assess, Treat, and Monitor Resident Skin Conditions
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident who developed significant skin abnormalities, including a rash and redness in multiple areas. Despite the presence of a care plan and specific orders from a wound care nurse practitioner to keep the skin clean and dry, apply barrier and antifungal creams, and monitor the affected areas, staff did not consistently implement these interventions. Documentation shows that the resident's skin issues, including redness and rash in the groin, perineal area, buttocks, and under the breasts, were present for several months without adequate assessment, monitoring, or treatment. Staff did not complete required wound or skin event documentation in risk management, nor did they notify the physician or wound care nurse of changes or worsening conditions. Direct observations revealed that the resident, who was dependent on staff for all activities of daily living and had multiple complex medical diagnoses, was left in a soiled incontinence brief for over four hours. The resident's skin was found to be bright red, with extensive rash and evidence of pain during care. Staff failed to apply barrier cream as ordered, citing lack of access to supplies, and did not follow through with timely application of zinc oxide ointment. The wound care nurse practitioner's recommendations for antifungal and barrier cream application, as well as regular reassessment, were not documented as being followed, and there was no evidence of ongoing measurement or evaluation of the skin condition. The facility's own policies required head-to-toe skin assessments by licensed nurses upon admission, weekly skin checks, daily CNA observations, and prompt documentation and follow-up of any abnormalities. However, there was no documentation of physician notification, wound or skin event completion, or follow-up assessments for the resident's ongoing and worsening skin issues. The lack of adherence to care plans, provider orders, and facility policies resulted in the resident experiencing prolonged pain and discomfort due to untreated and unmonitored skin conditions.
Inadequate Abuse Investigations
Penalty
Summary
The facility failed to conduct thorough abuse investigations, which has the potential to affect all residents. In one instance, a CNA reported hearing an LPN verbally discourteous to a resident, R81, who is legally deaf and moderately cognitively impaired. The facility's investigation was incomplete, as there was no evidence of an interview with R81 or a written statement from the LPN involved. The investigation included statements from other staff, but these were related to a separate Human Resources incident. Additionally, resident interviews conducted were undated, lacked specific questions about the incident, and did not include staff names. In another case, the facility's investigation into an abuse allegation involving R29 was insufficient. The final report indicated that R29 was alert and oriented, yet there was no documentation of an interview with R29 or any other residents. The administrator claimed to have spoken with R29, but this was not documented. The investigation relied on random patient and staff interviews, which did not yield any complaints, but lacked thorough documentation and evidence. A third investigation concerning R252 was similarly inadequate. The facility provided initial and final reports but no other investigatory evidence. The administrator stated that there were no staff interviews and that resident interviews were verbal and undocumented. The final report mentioned staff interviews and random resident inquiries about safety, but these were not substantiated with documentation. The facility's abuse policy requires comprehensive investigations, including interviews with all relevant parties and documentation, which were not adhered to in these cases.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to maintain the kitchen in a manner that prevents foodborne illness, affecting 133 residents receiving dietary services. During an inspection, it was observed that the vents over the stove were dusty, and the sanitizing solutions in the red buckets and the three-compartment sink were not within the manufacturer's recommended range of 200-400 ppm. The dishwasher failed to reach the required sanitizing temperature of 180 degrees Fahrenheit, with the highest recorded temperature being 99 degrees Fahrenheit. The Dietary Manager and Morning Cook confirmed these discrepancies, noting that the automated sanitizer dispenser was not functioning properly, and the dishes could not be verified as sanitized. In the walk-in cooler, several food items were found unlabeled or improperly dated, including cheese, pickles, sandwiches, and various meats. Some items, such as tomatoes and green peppers, were visibly spoiled. The facility's policy requires that leftovers and open foods be clearly labeled with a discard date, but this was not adhered to. Additionally, staff personal food was stored in the kitchen refrigerator without proper labeling, contrary to the facility's policy. The resident refrigerators on the first and second floors lacked thermometers, and temperature logs were not maintained. The first-floor refrigerator contained expired chocolate milk and unlabeled take-out containers, while the second-floor refrigerator also had unlabeled containers and felt warm. The Maintenance Director confirmed the absence of thermometers and blank temperature logs. Furthermore, the dry storage area contained dented cans that were not marked, posing a risk of botulism if used. The facility's policy requires dented cans to be stored separately or returned to the vendor, which was not followed.
Failure to Provide ROM Care for Residents
Penalty
Summary
The facility failed to provide appropriate care for residents with decreased range of motion (ROM), as evidenced by the lack of assessment, treatment, services, devices, and care planning. Five residents were identified as not receiving the necessary interventions to manage their conditions, which included hemiplegia, hemiparesis, and contractures. Despite having physician orders for splints and other supportive devices, these were not consistently applied, leading to potential worsening of their conditions. Resident R114, who was admitted with hemiplegia and hemiparesis following a stroke, had a physician order for a resting hand splint to manage contractures. However, observations over several days showed that the splint was not applied, and the resident's left hand remained closed into a fist. The Director of Rehab and Restorative Aide confirmed the necessity of the splint to prevent contractures, yet it was not utilized as ordered. Similarly, Resident R86, with a history of cerebral infarction, had orders for a resting hand splint, but it was not applied consistently. The restorative staff, who were responsible for applying the splints, were often reassigned to work as CNAs, leaving the residents without the necessary restorative care. This lack of adherence to physician orders and care plans was also evident in the cases of Residents R46, R94, and R99, who were observed without their prescribed splints or other supportive devices, indicating a systemic issue in the facility's management of residents with impaired mobility.
Unsafe Storage and Bed Positioning in LTC Facility
Penalty
Summary
The facility failed to ensure a safe environment for residents by not securely storing oxygen cylinders and cleaning supplies, and by not maintaining residents' beds at a safe height. Several residents, including those at risk for falls, were found with their beds and overbed tables in high positions, contrary to their care plans which specified that beds should be kept low to minimize fall risk. Staff members, including CNAs and LPNs, were observed leaving beds in high positions, and there was a lack of communication and understanding among staff regarding the importance of maintaining beds at a safe height for all residents, regardless of their fall risk score. Additionally, oxygen tanks were found unrestrained and unholstered in residents' rooms and the second-floor medication room, posing a potential hazard. The facility's policy requires oxygen tanks to be stored in holders to prevent mechanical shock and combustion risks. Furthermore, the housekeeping closet and soiled utility room were left unlocked, with unsecured cleaning chemicals accessible, despite the facility's policy that such areas should be locked to prevent resident access. These oversights indicate a failure to adhere to safety protocols designed to prevent accidents and ensure resident safety.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for self-administration of medication, specifically hemorrhoidal ointment. The resident, who had severe cognitive impairment, was observed with a tube of hemorrhoidal cream on her bedside table. She reported using the cream for lubrication between her butt cheeks to help her sit, rather than for its intended use as prescribed. The resident stated she did not have hemorrhoids and was unaware of who provided her with the cream. The facility's policy requires an interdisciplinary team assessment to determine if self-administration is safe, which was not conducted in this case. The resident's medical history included gastrointestinal hemorrhage, chronic obstructive pulmonary disease, morbid obesity, type 2 diabetes mellitus, congestive heart failure, gout, and repeated falls. Despite having an order for hemorrhoid cream to be applied rectally, the resident had not received assistance with its application since the previous year. Facility staff, including an LPN and RN, confirmed that the resident did not have orders to self-administer or store medications at her bedside. The Director of Nursing stated that residents with severe cognitive impairment should not have medications at their bedside, and the cream should not be used as a barrier cream.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents, leading to a deficiency in accommodating their needs and preferences. Resident R114, who was admitted with hemiplegia and hemiparesis following a cerebral infarction, was found with her call light placed on a side dresser, out of her reach. Despite her care plan indicating that the call light should be within reach due to her limited mobility and weakness, she was unable to use it and had to resort to screaming for help. The Director of Nursing confirmed that call lights should be attached to the bed linen or wrapped around the side rail to ensure accessibility. Resident R2, who is cognitively intact and at risk for falls, had her call light placed near her shoulder, making it difficult for her to reach. She expressed the need for the call light to be closer to her hand. Similarly, Resident R44, also cognitively intact with a self-care deficit and decreased mobility, had her call light wedged between the bed frame and side rail, making it inaccessible. Despite multiple observations, her call light remained out of reach, and she reported having to scream for assistance. The facility's policy requires that call lights be accessible to residents capable of using them, but this was not adhered to in these cases.
Failure to Protect Residents from Verbal and Mental Abuse
Penalty
Summary
The facility failed to protect residents from verbal and mental abuse, as evidenced by incidents involving three residents. One resident, who is moderately cognitively impaired and legally deaf, was allegedly verbally abused by an LPN during a medication pass. The CNA reported overhearing the LPN yelling at the resident to 'stop that' and 'shut up.' The facility's investigation into the incident was incomplete, as there was no written statement from the LPN, and the resident was not properly interviewed due to his hearing impairment. Another resident, with intact cognition, reported being verbally criticized by the same LPN regarding his toileting habits. The resident described the interactions as hostile and found the LPN's behavior to be inappropriate and offensive. The facility's report acknowledged that the LPN's demeanor did not meet facility standards and noted similar negative interactions with other residents, but it did not specify whether the abuse allegation was substantiated. A third resident, also with intact cognition, recounted an incident where the LPN yelled at her for having outside medication in a package from her sister. The resident felt belittled and humiliated by the LPN's actions. The facility's abuse policy defines verbal and mental abuse and emphasizes a no-tolerance philosophy, yet the incidents suggest a failure to adhere to these standards, resulting in the residents' experiences of verbal and mental abuse.
Failure to Report Verbal Abuse Allegation to IDPH
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident to the Illinois Department of Public Health (IDPH). The incident involved a Certified Nursing Assistant (CNA) who alleged that a facility nurse was verbally discourteous to a resident, identified as R81. The CNA reported overhearing the nurse speaking disrespectfully to the resident, including shouting and telling the resident to 'shut up' loudly. Despite the facility's policy requiring immediate reporting to the state licensing agency after assessing the resident and removing the alleged perpetrator, the initial and final incident reports were not sent to IDPH. The facility's administrator, who also serves as the Abuse Coordinator, acknowledged that neither the initial nor the final reports were sent to IDPH, despite believing they had been. The administrator confirmed that the fax verifications provided did not include the necessary details to show that the reports were actually sent. The facility's abuse policy mandates that a complete written report of the investigation's conclusion, including the steps taken in response to the allegation, be sent to the Department of Public Health within five days of the occurrence. This failure to report constitutes a deficiency in the facility's handling of the abuse allegation.
Inadequate Incontinence Care and Lack of Toileting Program
Penalty
Summary
The facility failed to properly assess and implement a toileting program for a resident, identified as R32, who was incontinent of bowel and bladder. During an observation, it was noted that R32 was wearing a disposable incontinence brief with an additional disposable incontinence pad inside the brief. This practice was confirmed by R32, who stated that she wore the briefs and pads for protection and was not on a toileting program or schedule. The Certified Nursing Assistant (CNA) assisting R32 mentioned that the resident drinks a lot of coffee and water, which was used to justify the use of both the pad and the brief due to heavy urine output. The Restorative Nurse, identified as V15, acknowledged that residents should not wear both an incontinence brief and a pad inside the brief, as it could lead to skin breakdown. It was confirmed that R32 was not on a toileting program. R32's medical history includes conditions such as hemiplegia, hemiparesis, diabetes, hypertensive chronic kidney disease, chronic obstructive pulmonary disease, major depressive disorder, and dysphagia. The facility's policy on Supporting Activities of Daily Living (ADL) emphasizes the necessity of providing services to maintain good nutrition, grooming, and personal hygiene for residents unable to perform these activities independently, yet R32's care plan lacked a scheduled toileting program.
Failure to Maintain Midline IV Catheter
Penalty
Summary
The facility failed to provide necessary care for a resident with a midline intravenous (IV) catheter, leading to a deficiency in maintaining the catheter. The resident, who has a diagnosis of unspecified hearing loss, was observed with a midline IV catheter in the right upper arm, where the dressing was saturated with serosanguinous blood. The dressing lacked documentation of the time, date, or staff initials indicating when it was last changed. The resident communicated that the catheter had been in place for about a month, was last used and flushed the previous month, and could not recall the last dressing change. The Director of Nursing (DON) confirmed that there was no documentation of midline catheter dressing changes in the Medication Administration Record (MAR) or Treatment Administration Record (TAR). The facility's policy requires dressing changes every 48 hours if gauze is present under the transparent dressing, but the DON was unaware of this requirement. The resident's Physician Order Sheet (POS) indicated an order for IV antibiotic infusion, but no IV medications were administered in February, and there were no orders for dressing changes or catheter care. The facility's policy outlines the need for regular dressing changes and documentation, which was not adhered to in this case.
Incomplete Documentation of Medication Regimen Reviews
Penalty
Summary
The facility failed to provide completed documentation of the pharmacy's monthly Medication Regimen Reviews (MRR) recommendations along with the physician or prescriber responses for two residents, R55 and R64, out of a sample of 30. For R55, the consultant pharmacist completed MRRs on several occasions, but the facility did not provide the referenced reports or documentation of the physician's responses. The Assistant Director of Nursing (ADON) acknowledged the need for a better tracking system and admitted that some recommendations were missing and not always scanned into the Electronic Medical Record (EMR). The Director of Nursing (DON) stated that the ADON should escalate the issue to the Medical Director if there is no response from the physicians. Similarly, for R64, the facility did not provide the referenced reports or documentation of the physician's responses to the pharmacist's recommendations. The facility's policy requires that comments and recommendations concerning medication therapy be communicated in a timely fashion, enabling a response before the next MRR. The policy also states that if the prescriber does not respond in a reasonable time, the DON or consultant pharmacist may contact the Medical Director. However, the facility failed to adhere to these guidelines, resulting in incomplete documentation of the MRR process.
Improper Storage of Resident's Personal Food Items
Penalty
Summary
The facility failed to ensure proper storage of a resident's personal food items, leading to a deficiency. A resident, identified as R45, was observed with opened bottles of Miracle Whip and horseradish sauce stored on the windowsill in her room, despite both items requiring refrigeration after opening. The resident, who was cognitively intact and had multiple diagnoses including chronic obstructive pulmonary disease and heart failure, stated that she used to have a refrigerator in her room, but it was removed by the facility. As a result, she had no alternative storage for her personal food items. The facility's administrator confirmed that personal refrigerators were no longer available and acknowledged that the condiments should be refrigerated to prevent potential health issues. The facility's Food Storage policy mandates regular inspections and immediate disposal of improperly stored food, which was not adhered to in this instance.
Failure to Use Proper PPE in Isolation Room
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols by not wearing the appropriate personal protective equipment (PPE) before entering an isolation room. This deficiency was observed when a Certified Nursing Assistant (CNA), identified as V11, entered the room of a resident diagnosed with MRSA without wearing a gown, despite the presence of a sign indicating contact precautions. The resident, identified as R447, had multiple diagnoses including an infection of an amputation stump and MRSA, necessitating contact precautions as per the physician's order sheet and care plans. The CNA acknowledged the oversight, stating that they realized the mistake after entering the room to assist the resident. The Director of Nursing (DON), identified as V2, confirmed that MRSA requires contact precautions, which include wearing both a gown and gloves before entering the isolation room. The facility's policy on transmission-based precautions also mandates the use of a disposable gown upon entering and removing it before leaving the room to prevent contamination. This incident highlights a lapse in following established infection control protocols, specifically regarding the use of PPE in isolation settings.
Failure to Utilize Antibiotic Use Protocol Tool
Penalty
Summary
The facility failed to utilize an antibiotic use protocol tool for residents who were placed on antibiotics, affecting two out of five residents reviewed for antibiotic stewardship. The Infection Preventionist (IP), identified as V4, acknowledged that the McGeer's tool, which is used to screen for infections and guide antibiotic use, was not completed for these residents. Resident R27 was receiving Ciprofloxacin for a urinary tract infection, and the tool was not used to assess the necessity of the antibiotic. Similarly, Resident R120 was on Meropenem for a positive sputum culture, and again, the McGeer's tool was not utilized to determine if the antibiotic was warranted. The Director of Nursing (DON), identified as V2, confirmed that the McGeer's tool is a critical component of the facility's antibiotic stewardship program, intended to ensure antibiotics are prescribed appropriately. The facility's policy, reviewed in June 2024, mandates the use of a surveillance tracking form to document antibiotic usage and outcomes, which was not adhered to in these cases. This oversight indicates a lapse in following established protocols for antibiotic stewardship, potentially impacting the quality of care provided to the residents involved.
Failure to Identify Bed Entrapment Hazard
Penalty
Summary
The facility failed to identify a potential entrapment hazard on a resident's bed, which was observed during a survey. Specifically, the bed and overbed table of a resident were left in a very high position, and the side rails extended approximately five inches on both sides of the bed. This created a risk of the resident rolling over and becoming stuck between the rails. A Licensed Practical Nurse (LPN) confirmed that the bed rails were too far apart from the mattress and bed frame, posing a safety risk. The Director of Nursing (DON) acknowledged that both Maintenance and Nursing staff should ensure there is no space between the bed rail and mattress to prevent injury or entrapment. The facility's policy, dated January 17, 2025, mandates regular inspections of bed frames, mattresses, and bed rails to identify potential entrapment areas.
Failure to Identify and Address Skin Breakdown
Penalty
Summary
The facility failed to identify and address a resident's skin breakdown, resulting in the development of a Stage 3 pressure ulcer. The resident, who was admitted with multiple diagnoses including hemiplegia, hypertension, and respiratory dependence, was at a very high risk for skin breakdown according to assessments. Despite orders for daily and weekly skin checks, the resident's skin issues went unnoticed until a Wound Care Coordinator observed several areas of open, broken, and bloody skin on the resident's buttocks. The resident's care plan aimed to maintain clean and intact skin, but no skin assessments for impaired or open skin were completed since admission. Staff interviews revealed that CNAs providing incontinence care did not notice any skin issues, and the resident's skin was not dressed or treated prior to the discovery of the ulcer. The CNAs did not report any concerns to the nursing staff, and the LPN on duty had not been treating the resident for any skin concerns. The facility's Wound Prevention and Healing policy required skin inspections during showers and as scheduled, but these were not effectively carried out, leading to the oversight of the resident's skin condition.
Failure to Provide Information for Camera Installation in Resident's Room
Penalty
Summary
The facility failed to provide necessary information to a resident's family regarding the installation of a camera in the resident's room, which is a violation of the resident's rights to a dignified existence and self-determination. The resident, who was moderately impaired and required assistance with various activities of daily living, had a care conference on December 5, 2024, where the family expressed the desire to have a camera installed in the resident's room. Despite this request, the facility did not follow through with providing the necessary information or addressing the request in a timely manner. The family member, V31, reported that they had contacted the Director of Social Services, V6, on December 11, 2024, to request information about the camera installation policy, but did not receive a follow-up. The facility's staff, including V5 and V6, were unclear about the status of the request, and the Administrator, V1, was not aware of the request. The facility's policy allowed for cameras, but the request was not addressed within the expected 72-hour timeframe. The lack of communication and follow-up resulted in the failure to honor the resident's rights, as the family was not provided with the necessary information to proceed with the camera installation.
Failure to Provide Scheduled Anxiety Medications
Penalty
Summary
The facility failed to provide a resident with his scheduled anxiety medications as ordered, affecting one resident reviewed for pharmacy services. The resident, who was cognitively intact and had a history of anxiety disorder among other diagnoses, did not receive his prescribed doses of Buspirone, Clonazepam, and Hydroxyzine over several days in December 2024. The resident reported being out of these medications and expressed increased stress due to the lack of medication. Despite communicating with staff and a Nurse Practitioner, the issue was not resolved promptly. Interviews with facility staff revealed a breakdown in the medication reordering process. Licensed Practical Nurses (LPNs) acknowledged the importance of timely reordering to prevent medication shortages, yet the resident's medications were not reordered in time. The Director of Nursing confirmed that communication with the pharmacy began only after the medications had run out, leading to a delay in receiving the necessary medications. The facility's policy required controlled substances to be reordered when a five-day supply remained, but this protocol was not followed, resulting in the deficiency.
Failure to Report and Treat New Pressure Injuries
Penalty
Summary
The facility failed to report and address new skin alterations for a resident with a known history of pressure injuries. The resident, who had multiple diagnoses including a history of pressure injuries, was found to have new facility-acquired pressure injuries on the right hip, specifically a stage 3 and a stage 2 cluster. These injuries were not assessed or treated promptly upon identification, as required by the facility's protocols. During an observation, the resident was found in the same position for an extended period, and a Certified Nurse Assistant (CNA) initially reported no wounds. However, upon further inspection, the CNA discovered open areas on the resident's right hip, which had been observed earlier in the shift but not reported. The CNA then notified a Licensed Practical Nurse (LPN), who was unaware of the wounds until that moment. The LPN assessed the wounds, identified them as pressure injuries, and initiated basic wound care. The Wound Care Nurse (WCN) and Wound Care Aide (WCA) later assessed the wounds, confirming the presence of newly acquired pressure injuries. The facility's policy required immediate reporting and treatment of skin alterations, which was not followed in this case. The resident's care plan and orders emphasized the need for daily skin assessments and prompt notification of wound care staff for any issues, which were not adhered to, leading to the deficiency.
Failure to Assess and Obtain Treatment Orders for Resident's Skin Tears
Penalty
Summary
The facility failed to assess and obtain treatment orders for a resident with known skin tears, leading to a deficiency in providing appropriate treatment and care. The resident, who was at risk for skin integrity impairment due to fragile skin and a history of skin tears, was observed with multiple dressings on her extremities. The Wound Care Nurse was unaware of the resident's active wounds and found that the resident did not have treatment orders in her Electronic Medical Record (EMR). The resident's wounds were not assessed or documented by the facility prior to the surveyor's observation. The facility's staff, including the Registered Nurse and Hospice RN, were involved in changing the resident's dressings but did not ensure proper documentation or treatment orders were in place. The Hospice RN did not have access to the facility's EMR and relied on previous dressings for treatment. The Director of Nursing expected staff to assess and report skin abnormalities, but the resident's EMR lacked active wound care orders. The facility's policies required wound assessment and documentation, but these were not followed, resulting in the deficiency.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for six residents, as observed during an environmental inspection. The inspection revealed that the bedroom floors of these residents were dull, dirty, and covered with accumulated dirt, dust, and debris, including small pieces of plastic from personal protective equipment packaging. The floors also had stains and patches of dry, unidentified fluids. Interviews with residents and a family member confirmed the dissatisfaction with the cleanliness of the floors. A housekeeper admitted that some bedrooms had not been swept for days, despite the expectation that floors should be swept and mopped daily. Documentation from Resident Council Meetings from June through August 2025 also indicated ongoing concerns about the need for bedroom and floor cleaning.
Failure to Provide Timely Incontinence Care and Assistance with ADLs
Penalty
Summary
The facility failed to provide timely incontinence care and assistance with activities of daily living (ADL) for three residents. On September 25, a CNA provided incontinence care to a resident who was found saturated with urine and had a pasty bowel movement, with the last change occurring around 9 AM. Another resident was also found with a saturated brief, with the last change also occurring after breakfast. Both residents' urine was dark in color, indicating a lack of timely care. Additionally, a third resident was observed in bed for an extended period without being offered assistance to get up, despite expressing a desire to do so. The resident reported that staff often made excuses for not assisting her, leading her to stop asking for help. The Director of Nursing confirmed that staff are required to check and change residents every two hours and assist them in getting up unless medically contraindicated. All three residents were noted to be alert and oriented, requiring extensive to total assistance with ADL care.
Failure to Monitor Blood Glucose Levels
Penalty
Summary
The facility failed to monitor and check glucose blood sugar levels for a resident with a known history of Diabetic Ketoacidosis (DKA) and elevated blood sugars. This failure resulted in the resident needing hospitalization for DKA. The resident's blood glucose levels were consistently elevated, ranging from 345 mg/dL to 400 mg/dL, despite routine insulin doses and sliding scale orders. There was no documentation of rechecking the resident's sugar levels after dinner and at bedtime, nor was there any record of notifying the resident's physician about the consistent elevation of sugar levels despite the insulin doses. The resident, who has multiple diagnoses including type 2 diabetes mellitus with ketoacidosis, acute kidney failure, and congestive heart failure, was admitted to the facility after suffering a cardiac arrest. The resident's blood glucose monitoring log showed consistently elevated readings from May 21 to May 22, 2024. On May 23, 2024, the resident's blood sugar level was 600 mg/dL, and he displayed lethargy and slurred speech, leading to hospitalization with a diagnosis of DKA. The hospital report indicated that upon admission, the resident's blood glucose level was 810 mg/dL, and his ketones were very high. Interviews with facility staff and the resident's physician revealed that the standard glucose monitoring for brittle diabetics is 3-4 times a day and as needed. The staff should have rechecked the resident's sugar levels 2 hours after dinner and at bedtime and reported the resident's condition to the physician for potential new orders and medication adjustments. The lack of proper monitoring and communication with the physician contributed to the resident's hospitalization for DKA.
Failure to Implement Physician's NPO Order
Penalty
Summary
The facility failed to implement a physician's order for a resident who was scheduled for eye surgery. The resident, a [AGE] year old female with diagnoses including bilateral cataracts, had a physician's order to be NPO (Nothing by Mouth) from midnight and could only have clear liquids until 6:30 AM, along with specific medications with a sip of water. On the morning of the scheduled surgery, the resident was fed toast and cereal by the staff, leading to the rescheduling of the surgery. Interviews with the resident and various staff members confirmed that the NPO order was not followed, resulting in the delay of the medical procedure. The facility's policy requires Licensed Professional Nurses/Registered Nurses to follow physician orders, which was not adhered to in this instance.
Failure to Maintain Bed Equipment
Penalty
Summary
The facility failed to maintain a resident's bed equipment, specifically the bed control cord, which had approximately two inches of exposed wires. This deficiency was observed on two separate occasions, with the Administrator present during one of the observations. The resident involved is a [AGE] year old female with diagnoses including osteoarthritis, type 2 diabetes, and bilateral cataracts. The resident's daughter also reported the frayed wires. The Director of Maintenance was notified of the issue on the same day as the second observation. The facility's Safe Environment policy mandates maintaining all essential equipment in safe operating conditions, which was not adhered to in this instance.
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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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