Pearl Of St Charles, The
Inspection history, citations, penalties and survey trends for this long-term care facility in St Charles, Illinois.
- Location
- 850 Dunham Rd, St Charles, Illinois 60174
- CMS Provider Number
- 145980
- Inspections on file
- 36
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Pearl Of St Charles, The during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple comorbidities, fully dependent on staff for personal hygiene, was observed with extensive brown-orange waxy crust covering much of both feet, including between the toes, as well as on the ankles and shins. Despite physician and podiatry orders for regular skin checks, daily betadine to one foot, and daily moisturizing with clean feet, staff had documented no skin concerns, and a CNA reported not washing the resident’s feet or applying lotion during morning care. Nursing staff and the NP found that the thick, dry, waxy buildup had been present for some time and was easily removable with basic washing and moisturizing, demonstrating a failure to provide ordered and necessary daily foot care.
A resident with multiple fractures and other medical conditions, receiving IV antibiotics for a bacterial wound infection, was given the wrong IV medication when an RN administered Zosyn instead of the ordered Vancomycin. The resident, who was cognitively intact, noticed after the infusion that the IV bag bore another resident’s name and reported it immediately. Progress notes and RN interviews confirmed that Piperacillin/Tazobactam was administered in error, contrary to facility policy requiring verification of the five rights of medication administration and use of two resident identifiers.
The facility failed to maintain sanitary practices in the kitchen, affecting 74 residents. A scoop was found in pooled water, breaded items were improperly stored, and spices lacked proper labeling. The reach-in freezer malfunctioned, with temperatures rising to 30°F, causing defrosting of stored items. Facility policies on ice machine maintenance, food labeling, and freezer temperatures were not followed.
The facility failed to maintain a sanitary environment in both the dining room and a resident's room. During meal service, a Restorative Aide served meals on dirty tables, and the dining room floor was littered with debris. A resident's room was also found unclean for several days, with stains and garbage present. The Housekeeping Director cited staffing shortages as a reason for the oversight.
The facility failed to provide adequate grooming and hygiene assistance to residents requiring help with ADLs. Five residents were observed with unmet hygiene needs, including long, jagged fingernails, unkempt hair, and inadequate cleaning after an ileostomy leak. One resident reported not being offered showers as per the facility's policy, resulting in dry, flaky skin and greasy hair. Staff admitted to being overwhelmed and not adhering to the required care schedule.
The facility failed to provide nutritionally comparable meal options and accommodate dietary restrictions for several residents. A resident on a vegetarian diet received a grilled cheese sandwich daily, lacking protein compared to other meals. Two residents with no pork diets also received grilled cheese sandwiches with insufficient protein. Additionally, a resident on a gluten-restricted diet received a meal with gluten-containing items, causing distress and stomachaches. The facility did not adhere to its policy of providing nutritionally comparable and dietary-appropriate meals.
The facility failed to provide prescribed high-calorie nutrition supplements to four residents, despite physician orders. A resident with quadriplegia and dysphagia did not receive the supplement during meals, even though it was present in the room. Another resident with dementia and a third on a pureed diet also missed their supplements due to a recent change in the facility's supplement orders. Additionally, a resident with multiple diagnoses, including diabetes, did not receive a diabetic high-calorie drink due to the facility's lack of the product.
The facility failed to follow infection control policies, including Enhanced Barrier Precautions and hand hygiene. A resident with a history of drug-resistant infection was not placed on EBP, and staff did not wear isolation gowns during high-contact activities. Additionally, a resident on contact isolation for C-Diff received care without proper PPE, and hand hygiene lapses were observed during peri-care and incontinence care. The Director of Nursing acknowledged the need for adherence to PPE and hand hygiene protocols.
The facility failed to offer and provide education on influenza and pneumococcal vaccines to several residents, as required by policy. Documentation showed that only about 38% of residents were offered the influenza vaccine, and there was a lack of evidence that education was provided to those who did not receive it.
The facility failed to provide education and obtain consent or declination for the COVID-19 booster vaccine for the 2024-2025 period for five residents with various medical conditions. Despite a vaccine clinic being held, only 32% of the facility's residents received the vaccine, and there was no documentation of education or declination for the remaining residents, contrary to the facility's policy and CDC guidelines.
A resident with multiple health conditions was offered and assisted into slippers soiled with stool, which had not been cleaned for a week despite the resident's request. The facility's staff, including an LPN and a CNA, failed to address the issue, compromising the resident's dignity. The DON later acknowledged the oversight, recognizing it as a dignity issue.
The facility failed to secure indwelling urinary catheters for three residents, leading to potential risks. One resident's catheter was not anchored, and the urinary bag was on the floor. Another resident's catheter was unsecured, causing pulling during care. A third resident's suprapubic catheter was detached from its anchor. The DON confirmed the importance of securing catheters and keeping bags off the floor, as per facility policy.
A facility failed to adhere to the physician's order for managing a resident's PICC line. A nurse administered an IV antibiotic to a resident with a PICC line, where the dressing was loose and dated from weeks prior. The dressing should have been changed weekly or as needed, per the care plan. Although the nurse changed the dressing, they did not measure the catheter length or arm circumference, which are necessary to check for migration and swelling. The DON confirmed these steps are required to prevent infection.
A facility failed to obtain a physician order and develop a care plan for a resident requiring continuous oxygen due to chronic respiratory conditions. The resident was observed receiving oxygen without a documented order, and their care plan lacked specific settings for oxygen use. The facility's policy mandates a physician's order for oxygen administration, which was not followed in this case.
The facility failed to provide timely access to medical records for two residents. One resident's spouse reported waiting over a month for records after a request was made, while another resident's power of attorney had not received records weeks after a request. The facility's policy and state regulations require records to be available within two working days, but the facility did not follow up on these requests.
A resident with a history of falls and high fall risk was lowered to the floor by a CNA during a transfer. Despite the incident, the facility did not perform a fall assessment or follow-up monitoring, as required by their policy. The DON acknowledged the oversight, noting that the incident was not initially considered a fall.
A resident with hemiplegia and hemiparesis fell out of bed and sustained fractures due to inadequate assistance during care. The resident required two-person assistance for bed mobility, but a new CNA, feeling rushed and untrained, assisted the resident alone. The care plan lacked clarity on the required assistance, and the facility's policies on fall prevention and ADL support were not effectively implemented.
A facility failed to prevent verbal abuse among residents, involving derogatory and racial slurs exchanged during smoking breaks. Despite being identified as vulnerable adults, three residents engaged in ongoing verbal altercations, with staff aware but unable to stop the abuse. The facility's policy defines such interactions as verbal abuse.
A resident with insulin-dependent diabetes and end-stage renal failure was involuntarily discharged to a homeless shelter without prior notification or acceptance, leading to hospitalization. The facility claimed the resident was a danger due to disruptive behavior and alcohol abuse but lacked documentation to support these claims. The discharge violated state and federal regulations, as the facility failed to ensure an appropriate alternative placement and did not involve the resident in the discharge planning process.
A facility failed to administer medications as ordered, affecting multiple residents due to a nurse's late arrival and inadequate documentation in the EMAR. This led to uneven spacing of medication doses, impacting residents' health conditions such as pain management and blood pressure control. The facility did not obtain necessary physician orders for resident-centered medication administration, contributing to the deficiencies.
A resident reported feeling undignified and uncomfortable when a CNA used a cell phone during a shower, violating the facility's policy on cell phone usage during caregiving. Despite the resident's expressed discomfort, the CNA continued the conversation, leading to a grievance being filed.
A resident with multiple severe diagnoses experienced a significant change in condition, but the facility failed to notify the resident's POA for approximately 12 hours. Despite medical interventions, the resident was later sent to the hospital for respiratory failure. Staff interviews confirmed that the notification should have been made promptly as per facility policy.
The facility failed to provide necessary ADLs for a resident dependent on staff for care. The resident, with multiple medical conditions, was not assisted to get dressed, get out of bed, or brush her teeth on a specific weekend due to staffing issues. Staff confirmed the failure to assist the resident as required, despite the facility's policy mandating such care.
The facility failed to use a gait belt while transferring a resident and did not re-evaluate interventions for a resident identified as an elopement risk. The resident, with severe cognitive impairment and dementia, frequently attempted to exit the facility and wandered into other residents' rooms, causing distress. Staff acknowledged the issue but did not implement effective monitoring or electronic alert systems. Additionally, a CNA assisted the resident with toileting without using a gait belt, contrary to facility policy.
Failure to Provide Adequate Daily Foot Care and Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate foot care and skin hygiene for a dependent resident with multiple comorbidities, including Type 2 hemiplegia/hemiparesis, epilepsy, and Parkinson’s disease. The resident’s MDS showed severely impaired cognition and dependence on staff for footwear, lower body dressing, bathing, and substantial/maximal assistance for personal hygiene. Physician orders included daily and weekly skin checks, daily betadine application to the right foot, and moisturizing lotion to both lower extremities as needed for dry skin. A podiatry note documented dry, thin skin on both feet and directed that the feet be kept clean with daily lotion use. Despite these orders and the resident’s dependence, staff reported no skin concerns prior to the surveyor’s observation. On observation, when the nurse removed the resident’s pressure-relieving boots and socks, a brownish-orange waxy crust was seen covering most of the bottoms of both feet, with additional crust on the sides, tops, ankles, and shins, and a large amount between all toes. As the nurse wiped the feet with a wet towel, chips of the substance fell off, revealing intact, pink, dry skin underneath, and only a small portion of the buildup was removed at that time. The DON stated the buildup was not typical and that the feet appeared very dry, and acknowledged the feet should not have had that extent of waxy buildup. The wound nurse stated she had applied cream earlier that morning, acknowledged the substance had been present for a long time, and indicated staff were expected to wash the resident’s feet during scheduled bed baths and apply cream/ointment daily. A CNA reported she had not washed the resident’s feet or applied lotion during morning care, and another CNA stated the brown-orange crust appeared intermittently. The nurse practitioner later described approximately 50% of the bottoms of both feet as covered with easily removable waxy, yellow/orange-brown dry skin and stated the condition was preventable with daily cleaning and moisturizing, noting that staff were expected to perform daily foot care to remove such buildup.
Significant IV Medication Error Due to Failure to Follow Five Rights
Penalty
Summary
A resident with multiple traumatic fractures (including left calcaneus with delayed healing, left first metatarsal, left tibia and fibula shafts, left acetabulum, left pubis, and left ileum) related to a motorcycle injury, and additional diagnoses of anemia, intestinal obstruction, and hypertension, had an active order for IV Vancomycin HCl in dextrose solution (1 g/200 ml, 1.75 mg three times daily) for a bacterial wound infection from 10/11/25 through 10/20/25. The resident’s MDS dated 12/28/25 documented intact cognitive function. On one night in October, around midnight, the resident reported that an RN administered an IV medication, and after the infusion was completed, the resident noticed the medication label showed another resident’s name and immediately informed the nurse. Subsequent interviews with two RNs, including a unit manager, confirmed that the nurse administered Zosyn (Piperacillin/Tazobactam 3.375 g/100 ml) instead of the ordered Vancomycin on that date. Progress notes documented that this medication error occurred, specifying that Piperacillin/Tazobactam was given in place of Vancomycin. The DON stated that nurses are expected to follow the facility’s medication administration policy, which requires verification of the “five rights” (right patient, right drug, right dose, right route, right time) and use of two resident identifiers before administering medications. The documented error shows that these required checks were not effectively carried out, resulting in the resident receiving the wrong IV medication.
Sanitary Practices and Freezer Malfunction in Facility Kitchen
Penalty
Summary
The facility failed to adhere to sanitary practices in the kitchen, affecting 74 residents who received food prepared there. During an inspection, a plastic scoop was found inverted in a holder with pooled water and blackish substances touching the scoop. Additionally, several cardboard boxes containing breaded items were improperly stored on a counter, with some hot dog buns showing a whitish substance. The delivery date on the box was January 15, 2025, and the Dietary Manager acknowledged that these products should have been refrigerated. Furthermore, opened containers of spices on the spice rack lacked proper labeling, with some dating back to May 31, 2021, without an open or use-by date. The reach-in freezer in the kitchen was found to be malfunctioning, with the thermometer reading 25 degrees Fahrenheit initially, and later dropping to 20 and then rising to 30 degrees Fahrenheit. This resulted in frozen vegetables, ice cream, gelato, and waffles being soft to the touch, indicating defrosting. The Regional Dietary Director confirmed that the freezer should maintain a temperature of 0 degrees Fahrenheit. The facility's policies on ice machine maintenance, food labeling, and freezer temperatures were not followed, contributing to the observed deficiencies.
Facility Fails to Maintain Sanitary Conditions in Dining Room and Resident Room
Penalty
Summary
The facility failed to maintain a sanitary dining environment during meal service, affecting eight residents. During an observation, a Restorative Aide was seen distributing breakfast trays on tables that were visibly dirty with smears and debris. The floor was also littered with straw covers, paper bits, and food crumbs. Despite being notified of the unsanitary conditions, the aide continued to serve meals. The Housekeeper later admitted that the dining room had not been cleaned the previous night due to a shortage of housekeeping staff. The Maintenance Director confirmed that the cleaning responsibilities were not clearly communicated to the staff. Additionally, the facility failed to maintain cleanliness in a resident's room. The resident, who was cognitively intact and had multiple medical conditions, reported that her room had not been cleaned for several days. Observations confirmed the presence of brown stains on a blanket, garbage, and sticky smears on the floor. Despite assurances from a housekeeper that the room would be cleaned, the conditions remained unchanged. The Housekeeping Director acknowledged the oversight and attributed it to staffing issues, as the housekeepers responsible for mopping were only available during the day shift.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate grooming and hygiene assistance to residents requiring help with Activities of Daily Living (ADL). Five residents were observed with unmet hygiene needs. One resident, who is legally blind and cognitively impaired, was found with long, jagged fingernails and a black/brown substance underneath them. Another resident, also cognitively impaired, was seen with unkempt hair and similar substances under his nails, despite being cooperative during care. A third resident, requiring assistance for grooming, was observed with drool on his beard and unkempt facial hair, yet staff did not offer to trim his beard or clean his nails after providing other care. A resident with multiple medical conditions, including an ileostomy, was not properly cleaned after a leak from her appliance. The staff changed her gown and sheets but did not clean her skin or change her soiled incontinence brief, leaving her visibly wet and uncomfortable. The resident expressed that staff typically do not wash her skin after such incidents, and she had to resort to using a garbage can when no one assisted her to the restroom. Another resident, cognitively intact, reported only being offered a shower once since admission, despite the facility's policy of offering showers twice a week. The resident's skin was dry and flaky, and his hair greasy, indicating a lack of proper hygiene care. Staff admitted to not offering him a shower due to being overwhelmed, and documentation did not support that showers were offered as required. The facility's policy mandates appropriate support for residents unable to perform ADLs independently, which was not adhered to in these cases.
Failure to Provide Nutritionally Comparable and Dietary-Appropriate Meals
Penalty
Summary
The facility failed to provide nutritionally comparable meal options and accommodate dietary restrictions for several residents. On February 24, 2025, a resident on a vegetarian diet received a grilled cheese sandwich with noodles, Brussels sprouts, and cake, which was a daily occurrence according to the cook. On February 25, 2025, two residents with no pork diets also received grilled cheese sandwiches, which contained significantly less protein compared to the pork fried rice served to other residents. The facility's policy requires nutritionally comparable menu items to accommodate resident preferences, but this was not adhered to. Additionally, a resident on a gluten-restricted diet did not receive a meal tray initially and was later given a tray with gluten-containing items such as noodles, dinner roll, and cake. The resident expressed distress and reported frequent stomachaches due to consuming foods not suitable for her diet. The dietary manager acknowledged the error, and the dietitian confirmed that the resident should have been served according to her diet order. This oversight highlights a failure to adhere to dietary restrictions and provide appropriate meal substitutions.
Failure to Provide Prescribed High-Calorie Supplements
Penalty
Summary
The facility failed to provide high-calorie nutrition supplements as ordered by the physician for four residents. Resident 19, who has quadriplegia and dysphagia, was supposed to receive a high-calorie drink four times a day but did not receive it during observed meals. Despite the presence of the supplement in the room, the resident reported not receiving it, and staff confirmed the absence of the supplement during meal times. Similarly, Resident 20, with dementia and other conditions, was ordered a high-calorie drink once a day but did not receive it during observed meals, with staff confirming the lack of the supplement. Resident 27, who was on a pureed diet, was also supposed to receive a high-calorie drink twice a day but did not receive it during observed meals. Staff confirmed the absence of the supplement, citing a recent change in the facility's supplement orders as the reason for the unavailability. Resident 326, with multiple diagnoses including stroke and diabetes, was ordered a diabetic high-calorie protein drink once a day but did not receive it due to the facility's lack of the supplement. The dietitian was aware of the switch in supplements but the facility had not yet acquired the new product, leading to the deficiency.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies, specifically regarding Enhanced Barrier Precautions (EBP), Transmission-Based Precautions (TBP), and hand hygiene. For instance, a resident with a history of Carbapenem-resistant Pseudomonas aeruginosa was not placed on EBP upon admission, and staff did not wear isolation gowns during high-contact activities such as repositioning the resident. Additionally, a resident on contact isolation for C-Diff did not receive care in accordance with the facility's policies, as a registered nurse administered IV antibiotics and performed a PICC line dressing change without wearing an isolation gown. Furthermore, the nurse used a pillow from another bed without sanitizing it afterward. The facility also demonstrated lapses in hand hygiene practices. Two CNAs assisted a resident with peri-care without changing gloves between tasks and failed to perform hand hygiene after removing gloves and handling soiled items. Another incident involved a CNA providing incontinence care to a resident while wearing the same gloves throughout the procedure, despite direct contact with fecal matter. The Director of Nursing acknowledged that staff must perform hand hygiene before, during, and after care, and wear complete PPE when providing care to residents on contact isolation or EBP. The facility's hand hygiene policy mandates the use of soap and water in specific situations, such as after caring for residents with diarrheal infections like C. difficile, but these protocols were not followed in the observed cases.
Failure to Offer and Educate on Vaccinations
Penalty
Summary
The facility failed to offer and provide education regarding the seasonal influenza and pneumococcal vaccines to several residents. Specifically, four residents were identified as not having been offered or provided education about these vaccines. One resident, with a history of cerebral palsy, anemia, and essential hypertension, had no documentation indicating they were offered or educated about the influenza vaccine for the 2024-2025 season. Another resident, with diagnoses including hemiplegia and cardiac arrhythmia, also lacked documentation of being offered or educated about the influenza vaccine for the same season. Additionally, a resident with chronic obstructive pulmonary disease and chronic kidney disease had signed a consent for the pneumococcal vaccine, but there was no documentation of the vaccine being administered. Furthermore, this resident's family refused the pneumonia vaccine, yet no education was documented as being provided. Another resident, with conditions such as congestive heart failure and chronic kidney disease, had no documentation of being offered or educated about the pneumococcal vaccine, nor was there evidence of previous vaccination. The facility's policy requires offering these vaccines, but documentation showed only about 38% of residents were offered the influenza vaccine, indicating a significant gap in compliance with the policy.
Failure to Educate and Document COVID-19 Booster Vaccination
Penalty
Summary
The facility failed to provide education and obtain consent or declination for the COVID-19 booster vaccine for the 2024-2025 period for five residents. These residents, who have various medical conditions such as cerebral palsy, anemia, essential hypertension, HIV, anoxic brain damage, hemiplegia, asthma, cardiac arrhythmia, chronic obstructive pulmonary disease, and chronic kidney disease, were not documented as having been offered the COVID-19 booster vaccine or provided with education about it. This lack of documentation was noted despite the CDC guidelines emphasizing the importance of the COVID-19 vaccine for individuals in long-term care facilities. The facility's Infection Preventionist confirmed that a COVID-19 vaccine clinic was held, and only 25 residents received the vaccine, which is approximately 32% of the facility's census of 76 residents. The facility's policy states that it will encourage residents, staff, and families to stay up to date with COVID-19 vaccinations, including booster doses. However, there was no documentation provided regarding the education or declination of the COVID vaccine for the remaining residents, indicating a deficiency in the facility's adherence to its policy and CDC guidelines.
Failure to Maintain Resident Dignity with Soiled Slippers
Penalty
Summary
The facility failed to treat a resident with dignity by offering and assisting the resident into slippers that were soiled with stool and not ensuring they were cleaned. The resident, who was cognitively intact, had been admitted with multiple diagnoses including chronic obstructive pulmonary disease, abdominal aortic aneurysm, partial intestinal obstruction, ileostomy status, malignant neoplasm of overlapping sites of the colon, and reduced mobility. During an observation, a Licensed Practical Nurse (LPN) changed the resident's ileostomy dressing but left the resident with soiled clothing and bedding, instructing a Certified Nursing Assistant (CNA) to assist further. The CNA later helped the resident into a clean gown and changed the linens but offered the resident slippers that were visibly stained with stool. The resident confirmed that the slippers had been soiled the previous week and had not been cleaned since. Despite the resident's desire to have them washed, the slippers remained at the bedside, uncleaned, until the Director of Nursing (DON) noticed them and acknowledged the oversight. The facility's policy on resident rights emphasizes treating each resident with dignity and respect, which was not upheld in this instance.
Failure to Secure Indwelling Urinary Catheters
Penalty
Summary
The facility failed to ensure proper care for residents with indwelling urinary catheters, as observed in three residents. One resident, who is alert and oriented, had a catheter that was not secured to his thigh, and the urinary bag was resting on the floor. This resident reported that the catheter had been unsecured for an unspecified period. Another resident, who requires assistance for toileting, had a catheter that was not secured, causing the tubing to pull during repositioning and care. This resident has a history of hospitalizations due to urinary tract infections and other complications. A third resident, who has a suprapubic catheter due to sacral wounds and recurrent urinary tract infections, was found with the catheter tube detached from the anchor, leaving it unsecured. The Director of Nursing confirmed that catheters must be secured to prevent dislodgement and that catheter bags should not rest on the floor to prevent infection. The facility's policy mandates that Foley catheters be positioned correctly and secured, and that the bag should be off the floor.
Failure to Follow PICC Line Management Protocol
Penalty
Summary
The facility failed to follow the physician's order for the management of a Peripherally Inserted Central Catheter (PICC) line for a resident. On February 25, 2025, a registered nurse administered an IV antibiotic to a resident with a PICC line on the right upper arm. The dressing on the PICC line, dated February 3, 2025, was observed to be loose and halfway open. According to the Physician Order Summary, the dressing should be changed once a week and as needed to prevent infection. The resident's care plan also indicated that the dressing should be changed weekly or sooner if it became soiled, loose, or damp, using sterile aseptic technique. The registered nurse changed the dressing on February 25, 2025, but did not measure the length of the catheter or the arm circumference, which are necessary to check for catheter migration and swelling. The Director of Nursing confirmed that these measurements are required when changing the PICC line dressing and reiterated the importance of changing the dressing every 7 days and as needed to prevent infection.
Failure to Obtain Physician Order for Oxygen Administration
Penalty
Summary
The facility failed to obtain a physician order and develop a care plan for oxygen administration for a resident with chronic respiratory conditions. The resident, who was admitted with diagnoses including chronic obstructive pulmonary disease, dependence on oxygen, and chronic respiratory failure with hypoxia, was observed receiving oxygen via nasal cannula at 3 liters per minute. Despite the resident's need for continuous oxygen, there was no physician order for oxygen administration documented in the resident's records from February 23 to February 25, 2025. Additionally, the resident's care plan, initiated on February 26, 2025, for shortness of breath, did not specify the settings for oxygen use. The Director of Nursing confirmed that the facility's policy requires a physician's order for oxygen administration, including the amount of liter flow and method of delivery. However, the resident was not listed among those utilizing oxygen in the facility, indicating a lapse in documentation and adherence to the facility's policy on oxygen use.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide medical records to two residents within the required timeframe. The first resident, who was admitted with conditions such as spinal stenosis and low back pain, was discharged in January 2025. Her spouse reported that they had been waiting for over a month to receive her medical records, which were requested on January 25, 2025. The medical records staff member, V8, acknowledged receiving the request and forwarding it to the legal team but did not follow up to ensure the records were provided. The facility's policy allows 30 days for processing requests for discharged residents, but the Illinois Long-Term Care Residents' Right booklet requires records to be available within two working days. The second resident's power of attorney requested medical records on January 27, 2025, but had not received them by February 20, 2025. The request was initially sent to the wrong facility, but the correct facility received it on January 27, 2025. The medical records staff member admitted to not following up on this request either. The facility's failure to provide timely access to medical records for these residents is a violation of both their internal policy and state regulations.
Failure to Perform Fall Assessment and Monitoring
Penalty
Summary
The facility failed to perform a fall assessment and monitor a resident after a fall incident. A resident, identified as R1, was admitted with diagnoses including spinal stenosis, low back pain, history of falling, muscle wasting, urinary retention, abnormalities of gait and mobility, and lack of coordination. R1 was assessed as high risk for falls. On January 13, 2025, R1 was reported to have been lowered to the floor by a CNA during a transfer from a chair to a bed when R1's legs gave out. Despite R1 denying any pain or discomfort, the facility did not complete a fall report, fall assessment, or follow-up assessment. The Director of Nursing acknowledged that a fall assessment, pain assessment, and change in condition forms should have been completed, but were not, as the facility did not consider the incident a fall. The facility's Fall Prevention and Management policy requires a fall risk screening and post-fall management procedures, which were not followed in this case.
Failure to Provide Adequate Assistance Leads to Resident Fall
Penalty
Summary
The facility failed to safely assist and position a resident in bed, resulting in the resident falling out of bed and sustaining left tibial and ankle fractures. The resident, who had multiple diagnoses including hemiplegia and hemiparesis following a cerebral infarction, required substantial to maximal assistance from two staff members for bed mobility. However, the comprehensive care plan did not specify the number of staff required for bed mobility, leading to a lack of clarity in the care provided. On the day of the incident, a CNA, who was new and felt rushed, assisted the resident alone during incontinence care. The CNA was unaware of the resident's specific care needs and did not have another staff member assist her, despite the resident's known requirement for two-person assistance. The CNA noticed a sticker indicating a two-person total mechanical lift transfer but was unsure about the assistance needed for bed mobility, highlighting a gap in training and communication regarding the resident's care plan. Interviews with facility staff, including the LPN, Restorative Nurse, and Therapy Rehab Director, confirmed that the resident required two-person assistance for bed mobility due to chronic left-side weakness. The Director of Nursing acknowledged that new CNAs should be trained on bed mobility during orientation, but the CNA involved in the incident had not received adequate training. The facility's policies on fall prevention and ADL support emphasized the need for appropriate interventions based on assessed risk factors, but these were not effectively implemented in this case.
Failure to Prevent Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to protect residents from verbal abuse, specifically resident-to-resident verbal abuse, involving three residents. Resident 1 reported being verbally abused by Residents 2 and 3, who made derogatory comments about his ethnicity. Resident 1's care plan indicated he is a vulnerable adult with a susceptibility to abuse, yet he was involved in multiple incidents of verbal altercations with other residents. Despite being cognitively intact, Resident 1 exhibited behaviors such as aggression, antagonizing, and using racial slurs, as noted in his progress notes. Resident 2 was not present during the investigation, but his care plan also identified him as a vulnerable adult. Resident 3, who has hemiplegia and hemiparesis, was involved in the verbal exchanges and was also identified as a vulnerable adult in his care plan. Staff members, including a CNA and the Unit Manager, reported ongoing verbal altercations among the residents, particularly during smoking breaks. The CNA stated that she had informed the Administrator and the DON about the incidents, but the verbal abuse persisted. The Unit Manager acknowledged that name-calling among residents constitutes abuse. The DON and Administrator were aware of the situation, with the Administrator noting that Resident 1 often reported being bothered by others but was vague about specifics. The facility's Abuse Prevention Program-Policy defines verbal abuse as the use of disparaging and derogatory language, which was evident in the interactions among the residents.
Unsafe Discharge of Resident with Complex Medical Needs
Penalty
Summary
The facility failed to provide a safe discharge for a resident with insulin-dependent diabetes and end-stage renal failure, requiring hemodialysis. The resident was involuntarily discharged to a homeless shelter without prior notification or acceptance from the shelter. This resulted in the resident being transported to a local hospital, where he remained awaiting placement in another long-term care facility. The resident had multiple diagnoses, including diabetes, end-stage renal disease, acute pulmonary edema, heart failure, acute respiratory failure, anxiety disorder, anemia, alcohol abuse, and glaucoma. The facility's decision to discharge the resident was based on claims that he was a danger to himself and others, citing disruptive behavior and alcohol abuse. However, the facility did not have documentation to support these claims, such as positive alcohol or drug tests. The resident was cognitively intact and able to perform all activities of daily living independently. Despite this, the facility proceeded with the discharge without ensuring an appropriate alternative placement, violating state and federal regulations. The facility's discharge planning policy required the involvement of the resident and their representative in the development of the discharge plan, which was not followed in this case. The facility also failed to coordinate with the receiving facility, resulting in the resident being left without proper care. The facility's actions led to an immediate jeopardy situation, as the resident was left without a safe and appropriate discharge plan.
Removal Plan
- The Social Service Director audited and identified residents with similar challenging behaviors. The residents were assessed via observation and review of clinical documentation, care plan, appropriateness of discharge location related to resident's needs and discharge criteria. All identified residents remain at facility.
- The facility initiated and completed education for the clinical staff and IDT regarding the discharge process which includes discharge address, necessary equipment, medications and/or prescriptions, transportation, community services, physician notification, discharge orders, and reason for discharge. Education of agency staff, PRN and vacationing staff will be completed prior to the start of their next shift.
- New hires will receive discharge education in orientation.
- Education was completed with the Social Service Director on appropriateness of discharge location related to the resident's needs.
- The facility reviewed and updated the policy and procedure regarding involuntary discharge and transfer.
- The facility Administrator and/or designee will monitor all discharges, using the discharge tool, to ensure appropriateness to include accurate discharge address, necessary equipment, medications, transportation, community services, physician notification with orders and reason for discharge, prior to actual discharge.
- The administrator and/or designee will review the discharge tool prior to each discharge to ensure a safe discharge.
- The Administrator and/or designee will bring the discharge tool to Quality Assurance meeting for review and recommendations for the duration of the audit.
- An ad hoc QAPI was completed with the Medical Director to review the removal plan.
Medication Administration Deficiencies Due to Late Nurse Arrival and Inadequate Documentation
Penalty
Summary
The facility failed to administer medications as ordered by physicians, affecting 12 out of 19 residents reviewed. The medications involved included antipsychotic drugs, sleeping pills, nicotine patches, and pain medications. The issue was exacerbated by the late arrival of an agency registered nurse, which led to delays in medication administration. The facility's electronic medication administration record (EMAR) did not document the specific times medications were administered, only indicating general time frames such as morning, afternoon, evening, and night. This lack of precise documentation resulted in uneven spacing of medication doses, which could potentially affect the efficacy of the medications. Several residents reported receiving their medications late, which they felt impacted their health conditions, such as pain management, blood pressure control, and anxiety. For instance, one resident mentioned that their blood pressure became unstable due to the delayed administration of their medication. Another resident expressed frustration over the long gaps between doses, which they believed affected their pain management. The facility's Director of Nursing acknowledged the issue, noting that the EMAR system's lack of specific time documentation allowed for uneven spacing of medication doses. The facility's policy on resident-centered medication administration was not followed, as there were no physician orders obtained for such administration for the affected residents. The Medical Director and a Nurse Practitioner highlighted the importance of timely and evenly spaced medication administration to prevent adverse effects and ensure optimal therapeutic outcomes. The facility's failure to adhere to these standards and obtain necessary physician orders contributed to the medication administration deficiencies observed during the survey.
Failure to Ensure Resident Dignity During Care
Penalty
Summary
The facility failed to ensure a resident was cared for in a dignified manner. A resident, who was dependent on staff for showers and had no cognitive impairment, reported that a CNA assisting her in the shower was using ear buds and having a conversation with a male voice on the phone. The resident felt uncomfortable and worried about her privacy, especially since she was naked and could not be sure if the phone was lying flat or propped up. Despite expressing her discomfort, the CNA continued the conversation, making the resident feel undignified and exposed. The resident filed a grievance about the incident, which was documented in the facility's grievance binder. The facility's policies, as outlined in the employee handbook, explicitly prohibit cell phone usage during caregiving and in resident care areas. Interviews with the facility's administrator, another CNA, and the Restorative Nurse/Nurse Manager confirmed that staff are not allowed to use cell phones while providing care due to privacy and dignity concerns. The facility's failure to enforce this policy led to the resident's experience of indignity and discomfort during a vulnerable moment.
Failure to Notify POA of Change in Resident's Condition
Penalty
Summary
The facility failed to notify a resident's Power of Attorney (POA) of a significant change in the resident's medical condition in a timely manner. The resident, who had diagnoses including acute on chronic congestive heart failure, chronic respiratory failure with hypoxia, end-stage renal disease, and pleural effusion, experienced shortness of breath around 1 AM. Despite receiving medical interventions such as increased oxygen and medication, the resident's POA was not informed of the change in condition until approximately 1:30 PM, about 12 hours later. The resident was eventually sent to the hospital for respiratory failure at approximately 3:45 PM on the same day. Interviews with staff revealed that the Registered Nurse on duty did not notify the POA because they believed the resident was stabilized. However, the facility's policy mandates immediate notification of the resident's representative in the event of any condition or treatment change. The Restorative Nurse-Manager confirmed that the notification should have been made promptly, especially given the severity of the situation. The failure to notify the POA in a timely manner was a clear deviation from the facility's policy and standard practice.
Failure to Provide ADLs for Dependent Resident
Penalty
Summary
The facility failed to ensure activities of daily living (ADLs) were provided for a resident (R6) who was dependent on staff for care. R6, who has diagnoses including epilepsy, malignant neoplasm of the brain, hemiplegia, and hemiparesis following cerebral infarction, was not assisted to get dressed, get out of bed, or brush her teeth on a specific Saturday and was not assisted to get out of bed on the following Sunday. R6 requires a mechanical lift for transfers and is dependent on staff for showers and other ADLs. The resident reported that staff informed her they were short-staffed and could not assist her without two people. Interviews with staff confirmed that there were staffing issues on the mentioned weekend, leading to the resident not receiving the necessary assistance. Certified Nursing Assistants (CNAs) and a Registered Nurse (RN) acknowledged the staffing challenges and the failure to assist R6 as required. One CNA mentioned that an agency CNA left mid-shift, causing a shift in assignments, and another CNA admitted to not getting R6 out of bed due to other tasks. The RN stated that it was brought to his attention that R6 wanted to get out of bed, but it was later in the day, and R6 decided she no longer wanted to get up. The Restorative Nurse emphasized that it is unacceptable to leave R6 in bed and that there is always someone available to help with transfers. The facility's policy mandates that residents unable to carry out ADLs independently will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene, which was not adhered to in this case.
Failure to Prevent Elopement and Use Gait Belt During Transfer
Penalty
Summary
The facility failed to use a gait belt while transferring a resident and did not re-evaluate interventions for a resident identified as an elopement risk. One resident, diagnosed with severe cognitive impairment and dementia, was noted to have multiple instances of attempting to exit the facility and wandering into other residents' rooms. Despite being identified as a high risk for elopement, the only intervention in place was staff redirection, which was inconsistently applied. The resident's family was aware of the situation but was not informed of any additional measures that could be taken to prevent elopement. On multiple occasions, the resident was found in other residents' rooms, causing distress to those residents. Staff members, including CNAs and nurses, acknowledged the resident's frequent wandering and attempts to exit the facility but did not implement more effective monitoring or electronic alert systems as outlined in the facility's policy. The facility's policy on elopement risk reduction was not followed, leading to repeated incidents of the resident being found in unauthorized areas. Additionally, the facility failed to use a gait belt during the transfer of the same resident, who was identified as a moderate fall risk. A CNA assisted the resident with toileting without using a gait belt, contrary to the facility's policy that mandates the use of gait belts for all residents requiring assistance with transfers. The Restorative Nurse confirmed that gait belts should be used to ensure the safety of both residents and staff during transfers.
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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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