Pearl Of Naperville, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Naperville, Illinois.
- Location
- 200 Martin Avenue, Naperville, Illinois 60540
- CMS Provider Number
- 145045
- Inspections on file
- 41
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Pearl Of Naperville, The during CMS and state inspections, most recent first.
A resident who had long occupied the same room became upset when maintenance staff began packing her belongings and moving her to a different room without prior explanation or written notice, prompting a grievance questioning the reason for the move. Interviews revealed that the move was driven by planned remodeling, that the Admissions Director and SWD only obtained verbal consent from the resident’s family member and then from the resident during the move, and that they were unaware of any policy requiring written notification of room changes or notification of new roommates. This practice, applied to multiple residents reviewed for rights, resulted in room changes occurring without the required written notice to residents or their representatives.
The facility failed to ensure a clean, safe, and homelike environment, with strong urine odors, dirty and cluttered hallways, and resident rooms containing debris, food waste, and overflowing trash. Multiple residents with cognitive and physical impairments were found in unclean conditions, and staff confirmed that deep cleaning was not performed as required by facility policy, with no documentation of cleaning schedules or audits.
A resident with multiple diagnoses did not receive prescribed medications due to unavailability, as documented in the EMAR. The resident expressed frustration about the facility running out of medications, despite providing some from home. A medication cart audit confirmed missing medications, and the LPN acknowledged non-administration due to unavailability, contrary to the facility's policy.
The facility failed to ensure call lights were within reach for several residents, including those at risk of falls and with cognitive impairments. Observations showed that residents did not have access to their call lights, relying on staff rounds for assistance. Staff acknowledged the issue, and the facility's policy requires call lights to be accessible, but compliance was not ensured.
The facility failed to provide adequate ADL assistance, including incontinence care and bathing, for four residents. A resident with multiple health issues was found with a saturated brief and missed a scheduled shower. Another resident with ALS reported not receiving showers as scheduled, and documentation showed significant gaps. A third resident with acute kidney failure received only one shower in a month. The Resident Council President reported delays in incontinence care and missed showers, with documentation confirming a lack of recorded showers. The facility's policy requires regular showers for residents unable to perform ADLs independently, which were not consistently provided.
The facility failed to provide sufficient staffing to meet residents' needs, particularly during evening and night shifts. Several residents reported not receiving necessary care, such as showers and incontinence care, due to staff shortages. The facility's policy on ADL support was not followed, and staff expressed concerns about the workload and difficulty in providing quality care.
Two residents reported a lack of dignified care and timely assistance in an LTC facility. One resident, with ALS, was not assisted to use his wheelchair despite being capable, and was left soiled by CNAs. Another resident, the Resident Council President, was left without incontinence care for hours and not provided a shower for over a week. These incidents highlight a failure to adhere to the facility's policy on maintaining residents' dignity.
A resident with multiple diagnoses, including chronic kidney disease, experienced medication administration errors at a rate of 11.11%, exceeding the acceptable threshold. An RN failed to administer the correct doses of spironolactone and vitamin D3 and incorrectly applied a lidocaine patch, contrary to physician orders and facility policy.
A resident, who is cognitively intact, reported that a former employee exposed himself to her in her room. The employee, part of a community program for individuals with mild cognitive deficits, was terminated after video footage confirmed his presence in the room. The incident was reported immediately by the resident, who was in shock and fear, and corroborated by staff who witnessed her distress.
A resident reported that a CNA was rude and refused to assist with oral care. The complaint was made to the ADON and manager on duty, but no investigation was conducted, and the allegation was not reported to the abuse task coordinator, violating the facility's policy.
The facility failed to provide timely incontinence care to two residents with severe cognitive impairments, leaving them in heavily saturated briefs for extended periods. Despite the facility's policy requiring regular incontinence care, staff did not adhere to these guidelines, resulting in neglect of the residents' toileting and hygiene needs.
A resident with ALS and a history of significant weight loss did not receive a prescribed nutritional supplement for several days due to staff absence and ordering delays. The resident was intolerant to the regular High Calorie drink, necessitating a switch to a clear supplement, which was not ordered in time, leading to missed doses.
Two residents in the facility did not receive their prescribed medications as ordered by physicians, leading to significant medication errors. A resident with ALS missed eight doses of Riluzole, while another resident with diabetic neuropathy did not receive their scheduled morning dose of Gabapentin. These lapses were confirmed through EMAR reviews and staff interviews.
The facility failed to maintain kitchen cleanliness and proper food storage, affecting 85 residents. Observations revealed a soiled dish machine, wet-stacked buckets and pans, unlabeled food items, and improper storage of staff lunches. Facility policies on cleanliness, air drying, labeling, and staff food storage were not followed, leading to unsanitary conditions.
The facility failed to implement its water management plan for Legionella, affecting all 87 residents. The Maintenance Director did not perform required weekly checks of water temperatures and chlorine testing, nor did he properly maintain eye wash stations. The Administrator confirmed the lack of documentation for monitoring activities, and the facility had only recently received chlorine testing kits. The facility's policy required systematic water flushing and regular testing, but no documentation was available to show compliance.
The facility did not develop a comprehensive COVID-19 immunization policy, affecting all 87 residents. The policy lacked procedures for offering vaccines, educating on benefits and risks, and documenting vaccination status. Additionally, staff without health insurance were unable to receive the vaccine at the facility, as confirmed by the Assistant Director of Nursing and a CNA.
The facility failed to conduct timely PASARR re-screenings for residents with serious mental illness, as required by the Level I PASARR process. A resident with schizoaffective disorder was not re-screened until seven months after admission, despite a 30-day authorization. Another resident with depression and schizoaffective disorder was not re-screened after a 60-day approval. Two additional residents with mental health diagnoses also missed timely re-screenings. The Admissions Director admitted to missing alerts for re-screening, leading to non-compliance with the facility's policy.
The facility failed to assist residents with personal hygiene and grooming, as observed in four residents with significant medical conditions. One resident with Alzheimer's had unclean fingernails while eating, another with ALS requested nail trimming but was ignored, a third with dementia had long, dirty nails, and a fourth had debris on her clothing, indicating a lack of assistance with dressing. These deficiencies highlight the facility's failure to adhere to its policy of providing necessary ADL support.
A resident with multiple diagnoses, including atrial fibrillation, did not receive prescribed anticoagulant medication due to a need for prior authorization. The facility failed to notify a provider about this issue, as required by their policy. A nurse practitioner discovered the oversight during a chart review, and staff confirmed that the provider should have been notified and documentation should have been made.
The facility failed to issue correct Beneficiary Protection Notification forms to two residents receiving Medicare Part A services. One resident was not given a Notice of Medicare Non-Coverage when their coverage ended, and another resident's family was not informed about the transition to private pay. The Social Services Director was unaware of the requirement due to being new to the facility.
A resident with multiple diagnoses, including atrial fibrillation, did not receive prescribed anticoagulant medication due to a lack of prior authorization and communication failures. The facility did not administer Rivaroxaban or bridging therapy with Enoxaparin as ordered, and a warfarin dose was missed despite subtherapeutic lab results. The facility's policy required physician notification with lab results, but this was not documented.
The facility failed to provide adequate personal care to dependent residents, with six out of seven residents reviewed experiencing unmet needs. Observations revealed residents with soaked incontinent briefs and delays in care, attributed to staff shortages. The facility's policy requires regular incontinent care, which was not consistently provided.
The facility failed to provide adequate staffing, resulting in delayed care for residents. On the day of the survey, only four nurses and four CNAs were available for 80 residents, leading to several residents not receiving timely assistance with activities of daily living. Multiple residents were found in soiled conditions, and staff acknowledged the delay in care due to being shorthanded. The DON and Administrator recognized the staffing issues and mentioned efforts to contract with staffing agencies.
A resident with multiple health issues was found to have two Scopolamine patches applied simultaneously, contrary to the prescribed order. The incident was discovered by the resident's daughter and later addressed by an LPN, but there was a lack of communication and documentation among the staff. The facility's medication error report confirmed the error, and both the Nurse Practitioner and Pharmacist emphasized the importance of removing the old patch before applying a new one to prevent overdose.
A resident with end-stage renal disease and CHF received a one-time IV fluid administration, but the facility failed to remove the IV catheter afterward. The catheter remained in place without proper maintenance or documentation, despite the facility's policy requiring regular flushing and monitoring. The oversight was discovered when the resident's daughter reported it to hospice, leading to the catheter's eventual removal.
The facility failed to provide timely incontinent care to three residents, resulting in prolonged exposure to urine-soaked briefs. One resident with severely impaired cognition was found with a urine-soaked brief and discoloration from prolonged wetness. Another resident with moderate cognitive impairment reported being wet despite being changed the previous night, and a third resident with intact cognition had not been changed since the previous night. The facility's policy of providing incontinent care every two hours was not followed.
The facility failed to investigate and revise fall care plans for two residents according to their fall policy. One resident with moderate cognitive impairment experienced multiple falls without subsequent care plan updates. Another resident with severely impaired cognition also had falls without revisions to their care plan. The Director of Nursing confirmed the lack of required investigations and updates.
A resident with multiple diagnoses reported abuse by a CNA to another CNA, who informed an RN. The RN assessed the resident and administered anxiety medication but did not immediately report the abuse to the administrator or state agency, leading to a delay in compliance with the facility's policy and state regulations.
Failure to Provide Required Written Notice Prior to Resident Room Changes
Penalty
Summary
The deficiency involves the facility’s failure to provide residents or their representatives with written notice prior to room changes, affecting five residents reviewed for resident rights. One cognitively intact resident, admitted since 2021 and long residing in the same room, reported that on 1/28/2026 maintenance staff entered her room and began packing her belongings without prior explanation or notification of a room change. She became upset and questioned the reason for the move, later filing a grievance the same day stating she was not informed of the reason for the room change. The resident stated that management told her that her daughter had been notified, but she emphasized that she made her own decisions and remained unsure why she was moved. Interviews and record review showed that the Admissions Director was instructed to assist with the room move due to planned remodeling on the resident’s unit and acknowledged not knowing the facility’s process for notifying residents or representatives about room changes. The Maintenance Director confirmed he was told to assist with the move and stopped when the resident became upset, then notified the Social Worker Director (SWD) and Admissions Director. The SWD documented contacting the resident’s daughter to obtain consent and reported that the daughter agreed as long as the resident approved the move; the SWD and Admissions Director then explained the reason for the move to the resident, who verbally agreed but remained upset. The SWD stated she was unaware of the facility’s policy requiring written notice of room changes, relied only on verbal consents, and did not notify new roommates of room changes, despite acknowledging that residents have the right to be informed of room changes and the reasons for them.
Failure to Maintain Clean and Homelike Environment and Adhere to Deep Cleaning Policy
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for all 79 residents, as evidenced by persistent urine odors, dirty hallways, and debris in both resident rooms and common areas. Upon entrance and throughout the survey, strong urine odors were noted in the hallways, and multiple areas were observed to have dirty floors with black and brown marks, smudges, and food debris. Trash and soiled linen receptacles were full, and old meal trays were left on top of trash bins. Housekeeping staff were not observed cleaning the hallways during these times, and the facility was unable to provide documentation of regular or deep cleaning as required by their own policy. Several residents with significant cognitive and physical impairments were found in unclean environments. One resident, who is always incontinent and requires assistance with most activities of daily living, was found in a room with broken furniture pieces, plexiglass from a lighting fixture, and food and paper debris scattered on the floor. Another resident, with severe cognitive impairment and frequent incontinence, had a room and hallway cluttered with food debris, trash, and wheelchair parts, and reported that cleaning was only done when she left her room. Additional observations included overflowing garbage cans, medication cups and food wrappers on the floors, and residents having to step over debris to enter their rooms. One resident, who is dependent on staff for mobility and transfers, had a care plan specifically requiring clutter-free and clean environments, yet her room and hallway were not maintained accordingly. Interviews with staff revealed that the facility was not following its own policy for quarterly deep cleaning of resident rooms. The Housekeeping Director and Administrator confirmed that only one room was deep cleaned per week, resulting in each room being deep cleaned only once per year, rather than quarterly. There was no documentation of monthly cleaning schedules or audits to ensure compliance. Staffing shortages and changes were also noted, with key housekeeping staff absent or on leave, further impacting the cleanliness of the facility. Residents and staff both reported a decline in cleanliness and housekeeping services.
Medication Administration Deficiency Due to Unavailability
Penalty
Summary
The facility failed to ensure that prescribed medications were available and administered according to its policy, affecting one of the three residents reviewed for medication administration. The resident, identified as R3, was admitted with multiple diagnoses, including interstitial pulmonary disease, pulmonary fibrosis, and essential hypertension, and was cognitively intact. The resident's electronic medical record (EMR) and electronic medication administration record (EMAR) revealed that several medications, including Pantoprazole sodium and Dorzolamide HCL ophthalmic solution, were not documented as administered on specific dates due to unavailability. Additionally, Mycophenolate mofetil was also unavailable and not administered as prescribed. R3 expressed frustration about not receiving medications as prescribed and reported that the facility often ran out of her medications, despite her providing some from her home supply. During a medication cart audit, it was confirmed that two of R3's ordered medications were missing, and the Licensed Practical Nurse (LPN) acknowledged that the medications were not administered due to their unavailability. The facility's medication administration policy requires documentation of medication preparation and reasons for non-administration, as well as contacting the pharmacy if medications are not present, which was not adhered to in this case.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for five out of eight residents reviewed, leading to a deficiency in accommodating the needs and preferences of residents. Observations revealed that several residents, including those with fall risks and cognitive impairments, did not have access to their call lights. For instance, one resident reported not having a call light for months, relying on staff rounds for assistance, while another resident's call light was found on the floor, out of reach. These residents were aware of the call light's function and expressed the need for it, especially in emergencies. The deficiency was further highlighted by staff interviews and policy reviews. Staff members, including the Director of Nursing and Certified Nursing Assistants, acknowledged that residents should have access to call lights. The facility's policy, revised in June 2024, mandates that residents capable of using call lights should have them accessible at all times, with regular checks by direct care staff and maintenance. Despite this policy, the facility did not ensure compliance, resulting in residents being unable to call for help when needed.
Deficiency in ADL Assistance and Bathing
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for four residents, specifically incontinence care and bathing, as per their needs and the facility's policy. Resident R6, who has multiple diagnoses including diabetes and peripheral vascular disease, was found with a saturated brief and reported not receiving a scheduled shower. The Director of Nursing was unaware of any schedule changes, and documentation confirmed the missed shower. Resident R1, diagnosed with ALS and other conditions, reported not receiving showers as scheduled and expressed dissatisfaction with bed baths. Documentation showed significant gaps between showers, contrary to the facility's schedule. Similarly, Resident R5, with acute kidney failure and other health issues, reported inadequate assistance with showers, with documentation indicating only one shower in a month. Resident R3, who is the Resident Council President and has multiple health conditions, reported delays in incontinence care and missed showers. Documentation showed a lack of recorded showers over a ten-day period. The facility's policy mandates that residents unable to perform ADLs independently should receive necessary services, including regular showers, which were not consistently provided as per the residents' care plans.
Inadequate Staffing Leads to Deficient Resident Care
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of residents, particularly during the evening and night shifts. The staffing pattern described by the staff scheduler was not consistently followed, resulting in insufficient numbers of CNAs on several shifts. This led to a high staff-to-resident ratio, which impacted the ability of staff to provide timely care, including bathing, incontinence care, and mobility assistance. Several residents reported not receiving necessary care due to staffing shortages. One resident, who was cognitively intact and required substantial assistance with ADLs, reported not being able to get out of bed or receive showers due to staff time constraints. Another resident, also cognitively intact, experienced delays in call light responses and did not receive incontinence care as needed. Additional residents reported similar issues with receiving scheduled showers and incontinence care. The facility's policy on Activities of Daily Living Support was not adhered to, as evidenced by the lack of documentation for showers and the inequitable distribution of shower assignments among staff. Staff members, including agency and PRN CNAs, expressed concerns about the workload and the difficulty in providing quality care due to the high number of residents assigned to each CNA. These staffing issues were corroborated by the facility's own records and staff interviews.
Failure to Provide Dignified Care and Timely Assistance
Penalty
Summary
The facility failed to provide an environment where residents are treated with dignity and respect, as evidenced by the experiences of two residents. One resident, who was admitted with multiple diagnoses including ALS and anxiety disorder, reported not being assisted to get out of bed into his electric wheelchair since October 2024, despite being capable of sitting in it with assistance. The resident expressed frustration over being left in bed and not being offered help to get out of bed, even though there was no medical order for bedrest. Additionally, the resident reported an incident where CNAs left him soiled after providing incontinence care, stating their shift was over. Another resident, who is cognitively intact and serves as the Resident Council President, reported not receiving timely incontinence care and not being provided with a shower for over a week. The resident stated that after requesting assistance for incontinence care, staff did not respond promptly, and she was left unchanged for several hours. The resident expressed concern about complaining due to fear of staff retaliation, highlighting a lack of respect and dignity in care provision. The facility's policy on Activities of Daily Living emphasizes maintaining residents' dignity and ensuring they are clean and well-groomed. However, the incidents reported by the residents indicate a failure to adhere to these policies, resulting in residents feeling neglected and disrespected. The facility's maintenance staff confirmed that the resident's wheelchair was in good repair, yet the resident had not been assisted to use it, further underscoring the deficiency in providing dignified care.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to administer medications as ordered by the physician, resulting in a medication error rate of 11.11%, which exceeds the acceptable threshold of 5%. This deficiency was identified during the review of one resident's medication administration. The resident, who was admitted with multiple diagnoses including chronic kidney disease, pulmonary hypertension, and hypertension, was on a medication regimen that included diuretic therapy. The facility's medication care plan required the administration of diuretic medications as ordered and monitoring for side effects and effectiveness every shift. On the day of the observation, a registered nurse (RN) prepared and administered medications to the resident, including spironolactone and vitamin D3, but failed to administer the correct doses as per the physician's orders. Additionally, the RN applied a lidocaine patch to the resident's left lower back instead of the prescribed area on the left knee. The Director of Nursing (DON) confirmed that the RN did not follow the physician's orders, which is against the facility's medication administration policy. This policy mandates checking the medication administration record for the right medication, dose, route, patient, and time, and reading each order entirely before administration.
Resident Exposed to Sexual Abuse by Facility Employee
Penalty
Summary
The facility failed to protect a resident from sexual abuse, resulting in a significant deficiency. A resident, who is cognitively intact and has been diagnosed with major depressive disorder and dementia, reported an incident involving a former employee, a laundry aide, who exposed himself to her while she was in her room. The resident was asleep and awoke to find the employee standing with his genitals exposed. She immediately reported the incident to staff members in the hallway, expressing fear and shock. The employee, who was part of a community program for individuals with mild cognitive deficits, was terminated following the incident. Despite the employee's denial and confusion about the event, video footage confirmed his presence in the resident's room at the time of the alleged incident. The resident's account was corroborated by staff members who witnessed her distress and immediate report of the incident. The facility's abuse prevention policy emphasizes the residents' right to be free from abuse, yet this incident highlights a failure in ensuring that protection. The resident involved is known to be alert and oriented, with no history of fabrication, further supporting the credibility of her report. The incident was reported to the facility's administration, and the employee was subsequently removed from the facility.
Failure to Investigate and Report Allegation of Abuse/Neglect
Penalty
Summary
The facility failed to investigate and report an allegation of potential abuse/neglect involving a resident who was cognitively intact and required substantial assistance with activities of daily living. The resident reported that a CNA from a staffing agency was rude and refused to provide care, specifically assistance with brushing teeth. This complaint was made to the Assistant Director of Nursing and the manager on duty, but no investigation was conducted, and the allegation was not reported to the designated abuse task coordinator. The facility's policy requires that any allegations of abuse or neglect be reported immediately and investigated with a written report completed within 24 hours. However, the designated abuse task coordinator was not informed of the allegation, and no investigation was initiated. The failure to follow the facility's abuse policy resulted in a deficiency as the resident's complaint was not addressed appropriately, and the required procedures for handling such allegations were not followed.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide adequate incontinence care to two residents, R7 and R10, who were dependent on staff for assistance with activities of daily living, including toileting and hygiene. R7, an elderly resident with severe cognitive impairment and multiple health conditions, was observed on September 30, 2024, to have been left in a heavily saturated incontinence brief from 11:00 AM to 2:30 PM, despite being dependent on staff for toileting needs. Additionally, a complaint was made by R7's power of attorney on September 21, 2024, regarding R7 being found heavily saturated with urine, which was confirmed by the LPN on duty. This indicates a pattern of neglect in providing timely incontinence care to R7. Similarly, R10, another elderly resident with severe cognitive impairment, was found on October 1, 2024, to be wearing a heavily saturated incontinence brief that had not been changed since the start of the shift at 6:00 AM. The facility's policy requires incontinence care to be provided every shift based on the resident's needs, yet this was not adhered to, resulting in R10 being left in a saturated brief for an extended period. These incidents highlight a failure to meet the facility's policy for incontinence care, which aims to keep residents clean and dry and prevent urinary tract infections.
Failure to Provide Nutritional Supplement to Resident
Penalty
Summary
The facility failed to provide a nutritional supplement to a resident with a history of significant weight loss, which was necessary to prevent further weight loss. The resident, who is cognitively intact and has a diagnosis of ALS, was prescribed a High Calorie drink twice daily. However, due to intolerance causing loose stools and abdominal pain, the dietitian changed the supplement to a clear type on September 18, 2024. Despite this change, the resident did not receive the supplement on several days in September, as confirmed by the Interim DON and a nurse. The failure to provide the supplement was attributed to the ancillary staff being off for 10 days, during which the clear supplement was not ordered. It was only ordered on September 24, 2024, arrived on the 26th, and was administered to the resident on the 27th. The resident confirmed the lack of supplement provision during this period, which was crucial for maintaining their nutritional status and preventing further weight loss, as outlined in the facility's Weight Management Policy.
Significant Medication Errors in Resident Care
Penalty
Summary
The facility failed to administer significant medications as per physician orders for two residents. The first resident, diagnosed with ALS, did not receive their prescribed Riluzole medication for several days in September 2024. The EMAR review confirmed that the resident missed eight doses of Riluzole, a medication critical for delaying the progression of ALS. The resident reported the missed doses to the Assistant Director of Nursing, who subsequently reordered the medication. The second resident, with a diagnosis of diabetic neuropathy, did not receive their scheduled morning dose of Gabapentin, a pain management medication, on the day of the survey. The EMAR review showed that the 9:00 A.M. dose was not administered, which was confirmed by the resident and a registered nurse. The Nurse Practitioner acknowledged that the failure to administer these medications constituted significant medication errors, as they are essential for managing the residents' conditions.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain cleanliness and proper food storage in the kitchen, affecting 85 residents who receive meals prepared there. During an inspection, it was observed that the dish machine was heavily soiled with lime debris, and the floor beneath it had a buildup of black debris resembling mud. The pipe leading to the sewer drain was rusted. Additionally, plastic buckets used for mixing beverages were stacked wet, and washed pans were stored without being air-dried, leading to water droplets inside them. The walk-in cooler contained unlabeled pitchers of orange beverage, and the freezer had an open, unlabeled bag of deli meat. Staff lunches were improperly stored next to residents' food, and the dry storage area had an open, undated bag of elbow macaroni. The facility's policies on kitchen cleanliness, air drying utensils, labeling, and staff food storage were not adhered to. The kitchen had not been deep cleaned for an unspecified period, contributing to the buildup of debris. The Food Service Dietary Manager acknowledged the issues but was unaware of the last deep cleaning. The facility's failure to follow its policies resulted in unsanitary conditions, with staff lunches stored in the wrong area and food items not properly labeled or dated. These deficiencies were observed over two days, with repeated issues noted during follow-up inspections.
Failure to Implement Water Management Plan for Legionella
Penalty
Summary
The facility failed to adhere to its water management plan for Legionella, affecting all 87 residents. The Maintenance Director, responsible for monitoring the water management plan, admitted to not having started the required weekly checks of water temperatures, including the hot water tank, and chlorine testing. Additionally, the Maintenance Director only cleaned and tested the eye wash stations twice in two months and did not perform the necessary flushing of the eye wash stations. During an interview, the Administrator confirmed that the Maintenance Director had been in charge of the water management plan for about two months but had not documented any monitoring activities, including temperature checks and chlorine testing. The facility had just received chlorine testing kits, indicating a lack of preparedness in implementing the water management plan. The facility's Water Management Plan outlined specific controls and monitoring frequencies, such as weekly chlorine testing and daily flushing of plumbing fixtures, which were not being followed. The facility's policy required systematic water flushing, emergency disinfection, and regular testing of chlorine levels at various points in the water system. However, there was no documentation to show that these procedures were being carried out. The policy also specified that the Maintenance Supervisor should fill out water management log sheets, but as of the survey date, no such documentation was available, indicating a significant lapse in the facility's infection prevention and control program.
Failure to Implement COVID-19 Immunization Policy
Penalty
Summary
The facility failed to develop and implement a comprehensive COVID-19 immunization policy for both staff and residents. Despite multiple requests, the facility did not provide a COVID-19 immunization policy and procedure. The existing policy, dated May 25, 2023, lacked specific procedures for offering the COVID-19 vaccine to residents and staff, providing education on the vaccine's benefits, risks, and potential side effects, and documenting vaccination status in medical records. This deficiency affected all 87 residents in the facility. Additionally, the facility did not offer the COVID-19 vaccine to staff members without health insurance. The Assistant Director of Nursing/Infection Preventionist indicated that these staff members were expected to obtain the vaccine independently. During a vaccine clinic in January 2024, several staff members consented to receive the vaccine but were unable to do so at the facility due to lack of health insurance. This issue was confirmed by a CNA who had to pay for the vaccine at a pharmacy. A list provided by the facility showed that eight employees requested the vaccine but did not receive it at the facility due to insurance issues.
Failure to Conduct Timely PASARR Re-Screenings
Penalty
Summary
The facility failed to provide timely re-screening for residents with serious mental illness as required by the Level I PASARR (Preadmission Screening and Resident Review) process. This deficiency was identified in four residents who were reviewed for PASARR compliance. Resident R50 was admitted with multiple diagnoses, including schizoaffective disorder, and was initially screened for a 30-day stay. However, the re-screening was not conducted until more than seven months later, triggering a Level II PASARR assessment. Similarly, Resident R75, diagnosed with depression and schizoaffective disorder, was approved for a 60-day stay but did not receive the necessary re-screening before the expiration of this period. Additionally, Resident R6, with diagnoses including bipolar disorder and anxiety, was authorized for a 30-day stay but was not re-screened within the required timeframe. Resident R53, admitted with major depressive disorder and anxiety, also did not receive a timely re-screening after the initial 30-day authorization. The Admissions Director acknowledged the oversight, stating that the re-screening alerts were missed, leading to the failure in updating the PASARR screenings as required. The facility's policy mandates that all new admissions and readmissions undergo the PASARR process, but this was not adhered to in these cases.
Failure to Assist Residents with Personal Hygiene and Grooming
Penalty
Summary
The facility failed to provide necessary assistance with personal hygiene and grooming for residents who were unable to perform these activities independently. This deficiency was observed in four residents, each with significant medical conditions requiring staff support. Resident R23, with diagnoses including cerebral infarction and Alzheimer's disease, was observed with unclean fingernails containing black substances, despite needing staff assistance for personal hygiene. This was noted during meal times when R23 was eating with his fingers, and the issue persisted over multiple days without being addressed by the staff. Resident R77, diagnosed with ALS, was cognitively intact but had functional limitations in his upper extremity, requiring assistance with personal hygiene. Despite requesting help to trim his long and jagged fingernails, the staff did not fulfill this request over two consecutive days. Similarly, Resident R28, with severe cognitive impairment and multiple diagnoses, was observed with long, jagged fingernails with black substances underneath, indicating a lack of staff assistance with personal hygiene as outlined in her care plan. Resident R58, who was severely impaired cognitively and required maximum assistance with ADLs, was observed with white flaky debris on her clothing, indicating a lack of assistance with dressing. The facility's policy mandates that residents unable to perform ADLs independently should receive necessary services to maintain good hygiene and grooming. However, the observations and interviews revealed that the facility did not adhere to this policy, resulting in the identified deficiencies.
Failure to Notify Provider of Missed Anticoagulant Medication
Penalty
Summary
The facility failed to notify a provider about a resident not receiving prescribed anticoagulant medication. The resident, who had multiple diagnoses including cerebral infarction, atrial fibrillation, and peripheral vascular disease, was admitted to the facility with orders for anticoagulant therapy. The resident's care plan included administering anticoagulants as ordered and monitoring for side effects and effectiveness. However, the resident did not receive the prescribed rivaroxaban and enoxaparin due to a need for prior authorization from the insurance, and there was no documentation that a provider was notified of this issue. A nurse practitioner discovered the oversight during a chart review and noted that the resident had not received the anticoagulant medication since returning from the hospital. The facility's policy requires notifying a provider when there is a significant change in a resident's condition, but this was not done. Interviews with facility staff confirmed that the nurses should have notified the provider and documented the notification, but this did not occur. The facility lacked documentation to show that a provider was informed about the resident not receiving the anticoagulation medication.
Failure to Provide Beneficiary Protection Notification Forms
Penalty
Summary
The facility failed to provide the correct and complete Beneficiary Protection Notification forms to residents receiving Medicare Part A services. This deficiency was identified in two residents. The first resident was admitted with multiple diagnoses, including disorders of the nervous system and cellulitis. The resident's Medicare Part A services ended when the covered days were exhausted, but the facility did not issue a Notice of Medicare Non-Coverage (NOMNC). Instead, they documented on the SNF Beneficiary Notification Review form, which was not appropriate. The Social Services Director admitted to not issuing the required form due to being new to the facility and unaware of the requirement. The second resident was admitted with diagnoses including multiple rib fractures and muscle weakness. The resident was discharged from the facility when the family initiated the discharge, but there was no documentation to support this claim. A progress note indicated that the resident's family was not informed about the transition to private pay. The facility's process involves weekly Medicare meetings to discuss residents' remaining Medicare Part A coverage days, but the necessary notifications were not provided to the resident's family, leading to confusion about payment responsibilities.
Failure to Administer Anticoagulant Medication as Ordered
Penalty
Summary
The facility failed to administer anticoagulant medication as ordered for a resident with multiple diagnoses, including cerebral infarction, atrial fibrillation, and peripheral vascular disease. The resident was admitted with orders for Rivaroxaban, but the medication was not administered due to a lack of prior authorization from the resident's insurance. This oversight was not communicated to the provider, resulting in the resident not receiving the necessary anticoagulant therapy. Additionally, the resident's care plan indicated the use of aspirin and warfarin, but there was no documentation of the administration of Rivaroxaban or the bridging therapy with Enoxaparin as ordered. Further issues were identified when the resident was not administered warfarin on a specific date, despite a new order following lab results indicating subtherapeutic levels. The facility's policy on anticoagulant therapy required notification of the physician with lab results before administering medication, but there was no documentation of such communication. The failure to administer the prescribed anticoagulant medications and the lack of communication with the provider contributed to the deficiency, as confirmed by interviews with the nurse practitioner and the acting director of nursing.
Inadequate Personal Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate personal care to dependent residents, as evidenced by observations, interviews, and record reviews. Six out of seven residents reviewed for activities of daily living (ADL) care were found to have unmet needs. For instance, a male resident with intact cognition, who is deaf and blind, was observed with a soaked incontinent brief containing urine and feces. The staff, including the Manager on Duty, acknowledged being shorthanded, which contributed to the lack of timely care. Another resident with mild cognitive impairment reported waiting for 30 minutes to be changed, and was found with a urine-soaked brief. The care plans for these residents documented the need for regular checks and cleaning after each incontinent episode, which were not adhered to. Additional cases included a male resident with moderate cognitive impairment who was found with a soaked brief containing stool, and a female resident whose feeding pump was beeping for a while without staff response. Her husband reported that she had not been changed since his arrival. Other residents with intact cognition also reported delays in receiving care, with staff citing understaffing as a reason for the delays. The Director of Nursing confirmed that the facility's policy requires incontinent care every two hours and as requested by residents, which was not consistently provided.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide adequate staffing to meet the care needs of residents, as evidenced by observations, interviews, and record reviews. On the day of the survey, there were only four nurses and four CNAs available for 80 residents, which was insufficient to meet the residents' needs. The LPN on duty acknowledged the shortage and mentioned that an additional CNA was expected to arrive late. This staffing inadequacy resulted in several residents not receiving timely assistance with activities of daily living, such as toileting and changing of incontinent briefs. Multiple residents were observed in soiled conditions due to the lack of staff availability. For instance, a resident who is deaf and blind was found with a soaked incontinent brief, and another resident with mild cognitive impairment reported waiting for 30 minutes to be changed. Other residents were also found in similar situations, with staff acknowledging the delay in care due to being shorthanded. The Director of Nursing and the Administrator both recognized the staffing issues, citing call-offs and no-shows as contributing factors, and mentioned efforts to contract with staffing agencies to address the problem.
Failure to Remove Old Medicated Patch Before Applying New One
Penalty
Summary
The facility failed to ensure proper administration of a medicated patch for a resident, leading to a potential overdose. The resident, who had multiple diagnoses including end-stage renal disease, type 2 diabetes mellitus, and dementia, was prescribed a Scopolamine transdermal patch to be applied every three days. However, it was discovered that two patches were applied simultaneously behind the resident's ears, which was against the prescribed order. This incident was brought to attention by the resident's daughter, who noticed the two patches and took pictures. The Licensed Practical Nurse (LPN) on duty at the time of the discovery removed both patches and applied a new one, but there was confusion and lack of communication among the staff regarding the incident. The Director of Nursing was not informed until later, and the nurses involved could not recall the exact date of the incident. The facility's medication error report confirmed the occurrence of the error but lacked specific details about the timing. The Nurse Practitioner and Pharmacist both stated that the old patch should be removed before applying a new one to prevent an overdose, highlighting the deficiency in following proper medication administration procedures.
Failure to Discontinue and Maintain IV Catheter
Penalty
Summary
The facility failed to properly manage the intravenous (IV) catheter care for a resident with multiple diagnoses, including end-stage renal disease and congestive heart failure, who was on hospice care. The resident was ordered to receive a one-time administration of 1000 ml of 0.9% Sodium Chloride for hydration, which was completed as per the order. However, the facility did not remove the IV catheter after the infusion was completed, as was required by the order. The oversight was discovered when the resident's daughter reported to hospice that the catheter was still in place despite the completion of the IV fluid administration. The hospice nurse contacted the facility, and the catheter was eventually removed by a registered nurse, but there was no documentation of the removal in the resident's records. Additionally, the facility failed to perform and document the necessary maintenance care for the catheter while it remained in place, such as flushing the catheter, measuring arm circumference, and monitoring the insertion site. The Director of Nursing acknowledged the failure to remove the catheter and the lack of documentation regarding its maintenance. The facility's policy required regular flushing of midline catheters to maintain patency and documentation of the insertion site appearance every shift, which was not adhered to in this case. This lack of adherence to the facility's standard IV infusion orders and pharmacy policy contributed to the deficiency.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care to dependent residents, as observed in three out of four residents reviewed for activities of daily living (ADL) care. Resident 2, a female with severely impaired cognition, was found in bed with a urine-soaked incontinent brief and discoloration from prolonged wetness. The assigned Certified Nursing Assistant (CNA) was unaware of their responsibility for Resident 2's care, leading to delayed intervention. Resident 2's care plan required peri care after each incontinent episode, which was not followed in this instance. Resident 3, a female with moderate cognitive impairment, reported being wet despite being changed the previous night. Upon inspection, her incontinent brief was found to be dirty and urine-soaked. The CNA responsible for her care acknowledged that Resident 3 should be checked every two hours but had not done so since 6:45 AM. Similarly, Resident 4, a male with intact cognition, was found with a urine-soaked incontinent brief after reporting that he had not been changed since the previous night. The facility's policy mandates incontinent care every two hours and as requested by residents, which was not adhered to in these cases.
Failure to Investigate and Revise Fall Care Plans
Penalty
Summary
The facility failed to investigate and revise fall care plans according to their fall policy and procedure for two residents. One resident, a [AGE] year-old male with moderate cognitive impairment, experienced multiple falls on 3/30/2024, 4/12/2024, and 4/22/2024. Despite being sent to the hospital for evaluation after the fall on 4/12/2024, the facility did not conduct a post-fall investigation or update the fall care plan with new interventions after the falls on 4/12/2024 and 4/22/2024. This was confirmed by the Director of Nursing, who could not find any documentation of the required investigations and updates to the care plan. Another resident, a [AGE] year-old female with severely impaired cognition and dependent on toileting hygiene, fell on [DATE] and 3/9/2024. The facility's fall care plan for this resident also lacked any revisions following the fall on 2/19/2024. The Director of Nursing confirmed the absence of updates to the fall care plan. The facility's Fall Prevention and Management Policy mandates that fall interventions be reviewed, revised, and updated based on the results of fall assessments and investigations, which was not adhered to in these cases.
Failure to Immediately Report Allegation of Abuse
Penalty
Summary
The facility failed to follow their policy and immediately report an allegation of abuse to the administrator and the state agency. A resident (R2) with multiple diagnoses, including heart failure, bipolar disorder, anxiety, schizoaffective disorder, and major depressive disorder, reported to a CNA (V6) that another CNA (V3) had abused her. This report was made on March 24, 2024, around 11:00 AM. V6 informed an RN (V4) about the allegation, who then assessed R2 and administered medication for anxiety but did not report the abuse immediately to the administrator or the state agency. Instead, V4 waited until the morning of March 25, 2024, to report the incident to the ADON (V8), who then reported it to the DON (V2) and the administrator (V1). The initial report to the state agency was submitted on March 25, 2024, at 9:38 AM, well beyond the required immediate reporting timeframe. The facility's policy mandates that any allegation of abuse must be reported to the administrator immediately and to the state agency within two hours. The failure to adhere to this policy was evident as V4 did not report the allegation immediately, leading to a delay in notifying the appropriate authorities. The facility's undated policy on abuse prevention clearly outlines the steps for internal reporting and the necessity for immediate action, which was not followed in this case. The delay in reporting the abuse allegation compromised the facility's compliance with its own policies and state regulations.
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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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