Pearl Pointe Nursing Rehab & Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Freeport, Illinois.
- Location
- 900 South Kiwanis Drive, Freeport, Illinois 61032
- CMS Provider Number
- 145234
- Inspections on file
- 55
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Pearl Pointe Nursing Rehab & Care during CMS and state inspections, most recent first.
A resident with all four extremities amputated, experiencing phantom pain, neuropathy, and back pain, did not receive ordered Oxycodone 5 mg BID for several days, resulting in severe, uncontrolled pain rated 10/10 despite Tylenol administration. MAR review showed multiple missed doses, including one dose falsely documented as given when the medication was not available. Nursing staff reported that the medication supply had run out, pharmacy records showed that 60 tablets had been delivered, and facility leadership later identified that one card of Oxycodone was missing. This occurred despite an active pain management care plan and a facility policy requiring assessment and administration of pain medications as ordered.
A facility failed to safeguard and accurately document controlled narcotic medications for three residents, resulting in missing oxycodone for a resident with quadruple amputations who went several days without his ordered pain medication, unexplained hydromorphone administrations documented for a cognitively intact resident who reported not taking that drug during the period in question, and inconsistent morphine ER documentation and missing hydrocodone/APAP records for a resident with a stage 4 sacral pressure ulcer. MAR entries, narcotic count sheets, and pharmacy delivery records did not reconcile, controlled drug receipt forms were missing or incomplete, and nurses signed out doses when medications were unavailable or after orders were discontinued, while the facility’s abuse policy lacked a definition for misappropriation of resident property.
The facility failed to immediately report suspected misappropriation of a resident’s oxycodone to the state survey agency and local law enforcement. After being informed that the resident’s oxycodone refill was being denied as too early and that an entire card of oxycodone 5 mg tablets was unaccounted for, facility leadership initiated an internal investigation but did not promptly notify the Illinois Department of Public Health or the police, despite facility policy requiring immediate reporting of suspected crimes involving resident property.
The facility failed to maintain accurate receipt, documentation, and reconciliation of controlled substances for three residents. For one resident with multiple chronic conditions and an amputation, one entire card of Oxycontin and its corresponding narcotic sheet were missing, and numerous Oxycodone doses were subtracted on controlled drug forms but not documented on the MAR, while extra medications were stored in an uncounted cupboard. For a second resident receiving hydromorphone, several delivered cards lacked controlled drug forms, and multiple doses were signed out on narcotic sheets without matching MAR entries. For a third resident with a stage 4 sacral pressure ulcer, morphine ER 15 mg tablets were inconsistently signed out and destroyed around the time of a dose change to 30 mg, and two cards of Hydrocodone/APAP documented on the pharmacy manifest had no corresponding receipt or destruction records.
Two residents with histories of substance abuse and behavioral issues were not adequately protected from accident hazards related to illicit substance use. One resident with multiple psychiatric and seizure-related diagnoses, prior poisoning, and known THC positivity was able to obtain and ingest cannabis gummies, leading to confusion, lethargy, and hospital transfer, while her care plan did not reflect her substance abuse history and staff only reported rumors of drug use. Another resident with cirrhosis, alcohol abuse, insomnia, and depression was allowed to leave independently on community passes despite refusing a urine drug screen, admitting to drinking alcohol when out, staff reports that he "does his own thing" and goes to bars, and psych documentation of ongoing alcohol and possible cocaine use during passes. Although facility policy prohibited alcohol/illicit substances and allowed revocation of passes for violations, the resident’s outside pass privileges were not reassessed or restricted.
Two residents with significant mental health and medical histories did not receive adequate, documented discharge planning and social services support. One resident with complex psychiatric and seizure disorders repeatedly expressed a desire to move to a group-home-like setting, and clinical staff agreed she would benefit from a specialized mental health environment; however, social service notes over several months contained no documentation of discharge planning efforts or contacts with potential placements, despite a care plan directing ongoing discharge assessment. Another resident with cirrhosis, alcohol abuse, and depression, who was independent in ADLs and had an independent community pass, reported discussions about alternative placement, yet social service records over several months similarly lacked any discharge planning documentation, even though facility policy required social work to assess discharge potential and document related activities.
The facility did not consistently take or document cooking and serving temperatures for multiple meals over several days, leaving many meals without any recorded temperature checks. The dietary manager reported that temperatures should be taken at cooking and just before service, but also confirmed that meals are delivered on open carts covered only with cloths and without heated plates or warming equipment. Several residents reported that their food is often cold, sometimes leading them to obtain food from outside the facility, and that hot items such as coffee are sometimes served cold and condiments are not always included. Resident council minutes documented repeated complaints about cold food and beverages over multiple meetings.
Surveyors found that kitchen staff did not document required cooking and serving temperatures for multiple meals over several days, leaving both cooking and holding temperatures blank on the facility’s logs. The Dietary Manager reported that temperatures are supposed to be taken when food is done cooking and again before service, with results logged at those times, and facility policy requires hot foods to be maintained at or above 135°F and reheated to 165°F if below that threshold. This lapse in temperature monitoring and documentation had the potential to affect nearly all residents who consumed meals prepared by the facility kitchen.
Two cognitively intact residents experienced unresolved equipment issues affecting their bed and wheelchair. One resident with multiple chronic conditions and a stage 4 sacral pressure injury reported a loose bed siderail needed for repositioning, which was observed to move side to side despite the concern having been reported earlier. Another resident with type II DM, CKD, anemia, restless legs syndrome, glaucoma, and a right below-knee amputation reported a defective wheelchair armrest; observation showed a partially detached cushion exposing metal and a scrape on the resident’s forearm. The Maintenance Director stated the facility does not use work orders or track repair requests and acknowledged awareness of both issues, despite a written preventative maintenance policy requiring resident equipment, including bed rails, to be in working order.
A resident with a history of falls and balance issues tripped and fell in her cluttered room while using a walker, due to overcrowding caused by multiple visitors and chairs. The incident resulted in a left ankle and foot fracture. Staff interviews confirmed that the room was not free from accident hazards at the time of the fall, despite the resident's care plan identifying her fall risk and the need for a hazard-free environment.
Staff failed to follow proper hand hygiene and sanitation protocols during food preparation and service, including not changing gloves after handling raw chicken, not sanitizing a thermometer between use on different foods, and leaving a meat slicer uncovered and soiled with food debris. These lapses in food safety practices had the potential to affect all residents receiving meals from the kitchen, except for two on NPO orders.
The facility did not complete updated PASRR referrals for several residents who developed new mental health diagnoses after admission, including conditions such as schizophrenia and major depressive disorder. Despite changes in diagnoses and the initiation of psychiatric medications, required referrals to the state authority were not made, and the facility's policy lacked guidance on this process.
Staff did not consistently follow infection control protocols, including proper hand hygiene and use of PPE, when caring for residents on Enhanced Barrier Precautions. For example, a CNA failed to perform hand hygiene between resident care activities and handled meal trays without cleaning hands, while other staff exited rooms wearing PPE or provided care to residents with chronic wounds without required gowns. These actions were not in line with facility policies for infection prevention.
A resident's urinary catheter bag was observed without a privacy covering on two occasions, once in a public dining area and once in a location visible from the hallway. Staff and the DON confirmed that facility policy requires dignity bags for catheter bags in public or visible areas, but this was not followed.
A resident with multiple chronic conditions was found self-administering several medications and a supplement without a physician's order or documented assessment of their ability to do so. Staff confirmed that no assessment or physician authorization was in place, and the care plan did not address self-administration, contrary to facility policy.
A resident who had a completed POLST form indicating a preference for Do Not Resuscitate (DNR) did not have a corresponding physician's order entered into the medical record. A registered nurse confirmed that the resident's code status was not documented in the electronic system, contrary to facility policy requiring such information to be included in the Physician Order Sheet.
A resident with documented developmental delay and childlike behavior was admitted after a PASARR Level I screening indicated no intellectual disability, despite medical records and observations suggesting otherwise. The facility relied solely on the hospital's PASARR and did not further assess or question the findings, resulting in the resident's developmental disability not being properly identified in the screening.
A resident with significant medical conditions and limited mobility was not provided with weekly showers as scheduled. Despite being dependent on staff for assistance with activities of daily living, the resident was not offered a shower for 12 days after initially refusing one, resulting in poor personal hygiene. Staff and administrative interviews confirmed the lapse in care and lack of adherence to the facility's shower schedule.
Two residents at risk for pressure ulcers did not receive appropriate prevention interventions, including proper use of heel protectors and air mattresses. Observations showed inconsistent application of physician orders and care plan interventions, such as incorrect mattress settings and use of fitted sheets that interfere with mattress function. Staff interviews revealed confusion about proper procedures, resulting in inadequate pressure ulcer prevention.
A resident with an indwelling urinary catheter and a recent UTI was observed multiple times with catheter tubing and a drainage bag in contact with the floor beneath his wheelchair. Staff acknowledged that the drainage system should not touch the floor, and facility policy requires proper positioning to prevent this.
Two residents receiving oxygen therapy did not have proper physician orders for oxygen administration, and oxygen tubing was not changed as required. Additionally, humidifying jars on oxygen concentrators were not consistently filled with water, and a resident was observed with an improperly placed nasal cannula and shortness of breath. Staff interviews confirmed lapses in monitoring and maintaining respiratory equipment according to facility policy.
A resident with multiple chronic conditions, including diabetes, became more lethargic than usual. An LPN attributed the lethargy to a urinary tract infection but did not document vital signs, blood sugar, or a full assessment at the time. The resident was sent to the hospital, but only outdated vital signs were recorded, and there was no recent blood sugar check. Staff interviews confirmed uncertainty about whether proper assessments were completed, and facility policy requiring assessment and documentation during a change in condition was not followed.
The facility failed to provide timely incontinence care for three residents dependent on staff assistance. One resident with diarrhea and a pressure ulcer waited nearly an hour for care after a bowel movement, while another with kidney failure experienced long delays in bathroom assistance, leading to urination in briefs. A third resident with a pressure ulcer reported waiting up to 11 hours for care. The facility's DON acknowledged the importance of timely care, but staff did not seek additional help during these incidents.
A resident with COPD did not have their albuterol nebulizer order transcribed into the MAR, and there was a discrepancy in the administration of Norco, with three doses dispensed within a 10-hour period instead of two. The DON confirmed the errors and noted that controlled substances should be documented on both the MAR and count sheet.
The facility did not follow its menu requirements by serving burgers that were smaller than the specified 2 ounces of protein. The Registered Dietitian and Certified Dietary Manager confirmed the deficiency, and residents expressed dissatisfaction with the portion size. The cook estimated the burger size instead of measuring it, leading to the deficiency.
The facility failed to serve the correct menu items and portion sizes for residents on mechanical soft and pureed diets, affecting nearly all residents. The dietary manager and cook did not adhere to the prescribed menu and portion sizes due to time constraints and lack of awareness, resulting in inconsistencies in meal service. The facility lacked a policy to ensure adherence to menu items and portion sizes.
The facility failed to maintain proper kitchen sanitation and food storage practices, potentially affecting 63 residents. Observations included improperly stored bulk food items, crusted substances on containers, and inadequate dishwasher sanitizer levels. The dietary aide was unable to check sanitizer levels, and the dietary manager acknowledged the lack of a cleaning schedule. These issues violated the facility's food storage policy.
The facility failed to provide a homelike dining environment by serving meals on trays without removing items onto the table, affecting several residents. Residents expressed feeling institutionalized, and staff confirmed that management did not allow them to make changes to improve the dining experience. The facility had considered offering a more homelike option but had not implemented any changes.
The facility failed to provide a mechanical soft diet to residents who required it, affecting several individuals. The cook did not prepare the food to the necessary consistency, opting to hand-shred turkey instead of grinding it, which was easier and saved time. The dietary manager was unaware of the medical necessity of the prescribed diet and attempted to accommodate residents' preferences without proper understanding. The interim administrator recognized the risk of choking due to this oversight.
The facility failed to implement proper infection control protocols, including contact isolation and enhanced barrier precautions, for residents with conditions like C-diff, urinary catheters, and gastrostomy tubes. Staff frequently entered rooms without PPE, and there was confusion about the required precautions, leading to a significant lapse in infection control practices.
The facility failed to provide appropriate wound care for a resident with an arterial wound, as the treatment plan was not updated in the TAR, resulting in missed daily dressing changes. Additionally, another resident was sent to the ER twice without proper documentation or notification to the physician and family, violating the facility's policy for change in condition documentation.
Two residents in an LTC facility were not provided with adequate supervision and safe transfer practices. One resident, with moderate cognitive impairment, was lifted unsafely by CNAs without using a gait belt, contrary to facility policy. Another resident, with a history of falls, was found walking unassisted without proper supervision or a gait belt, and her care plan was not updated after a previous fall. The facility failed to adhere to its policies on fall prevention and care plan updates.
A resident with a suprapubic catheter did not receive proper catheter care, as the dressing was changed only weekly, and the catheter tubing secure device was not used. Facility staff confirmed that catheter care should be performed daily, and the secure device should be applied to prevent trauma. The facility's policy and the resident's care plan required daily dressing changes and catheter care every shift, which were not followed.
A resident with significant weight loss did not receive prescribed dietary supplements, such as fortified potatoes, despite orders and available recipes. The dietary manager acknowledged the absence of these supplements, and the facility's policy for timely intervention was not followed, contributing to the resident's continued weight decline.
The facility failed to ensure proper respiratory care for two residents requiring oxygen therapy. One resident had tangled and kinked oxygen tubing, a dusty concentrator, and an empty humidification bubbler. Another resident's oxygen tubing was outdated, and the concentrator filter was found on the floor. Staff acknowledged that equipment checks and cleaning were not performed as required by facility policy.
A facility failed to establish policies and procedures for dialysis care for a resident with end-stage renal disease. The resident's dialysis access site was not regularly assessed, and inappropriate food items were provided, contrary to her renal diet. There was no communication with the dialysis center, and no emergency kit was available for potential hemorrhage events. The Director of Nursing admitted to inconsistencies in information exchange and training gaps among staff.
Two residents in an LTC facility were found with medications left at their bedside, contrary to facility policy. One resident had a cup of pills left due to nausea, while another had Norco tablets and an insulin pen from home. Staff confirmed that medications should not be left unattended and must be administered under supervision.
A medication error rate of 28.5% was identified when a new LPN, under the supervision of an RN, administered medications to a resident 1 hour and 20 minutes past the scheduled time. The facility's policy requires medications to be given within one hour of the prescribed times, which was not adhered to in this instance.
The facility failed to ensure safe storage and handling of medications, with an unlocked medication refrigerator and unmonitored temperature logs since April 2024. Liquid lorazepam was found in the unlocked fridge, and 36 unidentified pills were scattered in a medication cart. An LPN admitted the fridge was left unlocked due to key issues, and the Interim Administrator confirmed the need for locked storage and daily temperature checks.
A facility failed to provide adequate hygiene care for three residents, resulting in deficiencies in their activities of daily living. One resident was hospitalized with poor hygiene, including matted hair and a dirty catheter. Another resident, with multiple medical conditions, reported not receiving scheduled showers, confirmed by gaps in documentation. A third resident, dependent on staff for hygiene, received infrequent bed baths, with incomplete hair washing documentation. The facility's policy required weekly hygiene care, which was not consistently followed.
A resident's wound dressings were not changed as per physician orders, despite family requests. The LPN stated they were waiting for ordered supplies, and the DON assumed the LPN forgot to change the dressing. The TAR lacked documentation of the dressing change, and the care plan did not address the wound.
The facility failed to implement pressure ulcer prevention measures for two residents. One resident with a pressure ulcer on the left heel did not have an offloading boot, contrary to the care plan and physician's orders. Another resident with a deep tissue injury to the right heel had no offloading devices in place, and the care plan lacked interventions for the injury. The facility's policy on pressure ulcer prevention was not followed.
Two residents in an LTC facility received inadequate catheter care, leading to hygiene issues and potential infection risks. One resident's catheter tubing had sediment, and the drainage bag was improperly positioned on the floor. The resident reported not receiving catheter care from staff, and records showed missed care. Another resident was sent to the hospital with a clogged catheter bag and poor hygiene, requiring intervention by hospital staff. The facility failed to follow care plans and policies for catheter maintenance.
A resident with multiple diagnoses left the facility AMA and requested her funds, but the facility failed to refund her Social Security payment within 30 days of discharge. The Business Office Manager and Corporate Director of Accounts Receivable did not ensure the timely closure of the resident's account, leading to financial distress for the resident living in a women's shelter.
The facility failed to assess and document a resident's venous wounds and did not follow up with the resident's physician or adhere to physician orders. This resulted in no wound assessments since January 2024, exposed and bleeding wounds, and an 18-day delay in increasing pain medication. The resident refused prescribed treatments and used cornstarch on her wounds against medical advice.
A resident with multiple medical conditions was left on a bed pan unattended for approximately three hours, causing pain, frustration, and embarrassment. Despite being fully cognitively intact and needing substantial assistance, staff repeatedly turned off the resident's call light without providing help. The facility lacked a specific policy for bed pan use or ADL assistance, contributing to the incident.
The facility failed to develop and implement care plans and interventions to prevent and treat pressure ulcers for two residents. One resident did not have a dressing replaced on a stage 2 pressure wound, and another resident's care plan was not updated with necessary interventions after a new pressure wound was identified. The facility did not adhere to its wound policy and physician orders.
Failure to Provide Ordered Oxycodone Resulting in Uncontrolled Phantom Pain
Penalty
Summary
The facility failed to provide effective pain management to a cognitively intact resident with all four extremities amputated who experienced phantom pain, neuropathy, and back pain. The resident had an active care plan for pain and physician orders for scheduled and PRN pain medications, including Oxycodone 5 mg twice daily. Medication Administration Records (MARs) for January and February showed that the last documented dose of Oxycodone was given at bedtime on 1/31/26, with the next dose not administered until 2/6/26, resulting in 11 missed doses. During this period, the resident reported being without his pain medication for several days, stated he was in a lot of pain rated 10/10, and described his amputation sites as feeling like they were on fire. He reported that Tylenol was given but did not adequately relieve his pain. Record review and staff interviews revealed documentation and medication availability issues that contributed to the missed doses. The February MAR showed that on multiple days the resident did not receive Oxycodone, and one RN acknowledged signing for a dose on 2/2/26 in error when the medication was not actually available. An LPN reported that when she worked on 2/6/26, the resident did not have Oxycodone, and a prior nurse had documented a code indicating the medication was not given. When the LPN attempted to obtain a dose from the medication dispensing machine, pharmacy access was denied pending management notification, and pharmacy records indicated that 60 Oxycodone tablets had been delivered on 1/17/26, with one card of 30 tablets later reported missing by facility leadership. The facility’s pain management policy required assessment, monitoring, and administration of medications as ordered, but the resident did not receive his prescribed Oxycodone for several days, despite ongoing severe pain and the absence of any documented change in the physician’s order.
Misappropriation and Poor Control of Narcotic Medications for Three Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of narcotic medications and to accurately document and safeguard controlled drugs. For one resident with multiple serious diagnoses and quadruple amputations, the controlled drug record for oxycodone 5 mg showed a discrepancy between the documented count and the actual pills on hand, with two tablets unaccounted for and no administration entries explaining the reduction. Later, pharmacy records indicated that two full cards (60 tablets) of oxycodone had been delivered, but the resident had no oxycodone available for several days. The MAR showed doses signed out as given on days when the medication was not available, and one nurse acknowledged signing for a dose in error. The resident reported being without his prescribed pain medication for four days, experiencing severe pain rated 10/10, with amputation sites feeling like they were on fire, and stated he was only given Tylenol during this period. For a second resident, the January MAR documented several administrations of hydromorphone 4 mg by two nurses, but there was no corresponding controlled drug receipt/record/disposition form for reconciliation of these doses. Pharmacy delivery records showed that two cards of hydromorphone 4 mg (60 tablets total) had been delivered in early December, yet the narcotic count sheet for one of the cards was missing. The resident, who was cognitively intact and had multiple complex medical conditions including multiple myeloma and chronic kidney disease, stated he had stopped taking hydromorphone in December and confirmed he did not receive hydromorphone doses in January, despite the MAR entries indicating otherwise. For a third resident with a stage 4 sacral pressure ulcer and severe pain requiring morphine ER, the controlled drug record for morphine sulfate ER 15 mg showed that on one date a nurse signed out two tablets, noted an increased dose to 30 mg, then marked the entry as an error and crossed out the entire line, leaving the count unchanged. The same nurse then documented a single 15 mg tablet at an earlier time that same day, and the card was later destroyed with 19 tablets remaining. A separate controlled drug sheet for morphine ER 30 mg showed a 30 mg dose signed out that same day. Additionally, pharmacy records showed delivery of 60 tablets of hydrocodone/APAP 5-325 mg for this resident, but the facility could not produce any controlled drug receipt records documenting receipt or destruction of these tablets. The facility’s abuse policy defined abuse, including deprivation of necessary goods or services, but did not define misappropriation of resident property.
Failure to Immediately Report Suspected Misappropriation of Controlled Medication
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify the Illinois Department of Public Health (IDPH) and local law enforcement of suspected misappropriation of a resident’s controlled medication. Record review showed that on 2/2/26 the Administrator (V1) was notified that a resident’s oxycodone could not be refilled by the pharmacy because it would be refilled too soon, prompting concern for a potentially missing card of oxycodone. An internal investigation into unaccounted-for controlled medication was initiated on 2/6/26, and the Administrator was unable to locate the card. Despite this, the facility’s initial report to the IDPH Regional Office was not made until 2/10/26, and local law enforcement was also not notified until 2/10/26. Interviews confirmed that facility leadership recognized the missing oxycodone as misappropriation of resident property and acknowledged that it should have been reported immediately to IDPH and the police. The President of Operations (V5) stated that she was notified on 2/6/26 that the resident’s oxycodone was missing and that it was considered misappropriation, yet it was not reported at that time. The Administrator later stated that theft is to be reported immediately to IDPH and the police. The facility’s Abuse Prevention Program policy, dated 10/2023, requires contacting local law enforcement when there is reasonable suspicion that a crime has been committed in the facility by a person other than a resident. These findings show that, although there was reasonable suspicion of drug diversion and misappropriation of a resident’s oxycodone, the required immediate notifications to IDPH and law enforcement were delayed.
Failure to Accurately Account for and Document Controlled Substances
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate receipt, documentation, administration, and reconciliation of controlled substances for multiple residents. For one resident with extensive medical conditions including COPD, major depressive disorder, alcohol abuse, diabetes, traumatic lower leg amputation, and malnutrition, the pharmacy manifest showed two cards of Oxycontin 5 mg (30 tablets each) were delivered, but one card and its corresponding controlled drug receipt/record/disposition form were missing. The President of Operations confirmed that card one and sheet two for this Oxycontin order could not be located and acknowledged that extra medications from the cart had been stored in a medication cupboard that was not included in shift-change narcotic counts. For the same resident, controlled drug forms for Oxycodone 5 mg tablets showed numerous doses subtracted as given on specific dates and times, but these administrations were not documented on the resident’s MAR. For a second resident receiving hydromorphone HCL 4 mg tablets, the November controlled drug receipt/record/disposition form indicated two cards of 30 tablets each were delivered, but only one card’s form was present. On that form, six doses were signed out as administered on specific dates and times, yet these doses were not documented on the November MAR. Additional hydromorphone deliveries in December and January were documented on manifests, but the facility lacked controlled drug receipt/record/disposition forms for several of the cards delivered, and for some periods there were hydromorphone doses signed out on the controlled drug forms that were not recorded on the MAR. The President of Operations stated that pharmacy did not reconcile narcotics beyond current medications, that clinical managers such as the DON were expected to perform random monthly audits comparing manifests, narcotic sheets, and MARs, and that no records of such audits were available. For a third resident admitted with multiple diagnoses including a stage 4 sacral pressure ulcer, the December MAR showed an order for Morphine Sulfate ER 15 mg twice daily that was discontinued and later replaced with Morphine Sulfate ER 30 mg three times daily. The controlled drug receipt/record/disposition form for Morphine Sulfate ER 15 mg documented 30 tablets dispensed, and on one date a nurse signed out two tablets at 9:00 AM, noted an increase from 15 mg to 30 mg, and then crossed out the entire line as an error, leaving the count at 20, followed by signing out one tablet at 7:00 AM and ultimately destroying the card with 19 tablets. The 30 mg morphine controlled drug sheet showed an additional tablet signed out at 9:00 AM the same day. The President of Operations stated that controlled medications should not be signed out after discontinuation. Additionally, the manifest showed two cards (60 tablets total) of Hydrocodone/APAP 5-325 mg delivered for this resident, but the facility could not provide any controlled drug receipt records documenting receipt or destruction of these tablets.
Failure to Control Resident Substance Use and Reassess Community Pass Privileges
Penalty
Summary
The deficiency involves the facility’s failure to prevent and supervise a resident from ingesting cannabis and to reassess another resident’s community pass privileges for safety. A posted safety and security notice at the reception desk stated that personal items may be inspected when there is reasonable cause for concern about prohibited or unsafe items such as illegal substances and contraband. One resident (R1) had diagnoses including seizures, schizoaffective bipolar disorder, post-traumatic stress disorder, suicidal ideations, prior poisoning by unspecified drugs with intentional self-harm, unspecified mood disorder, and epilepsy, as well as a known history of substance abuse and prior positive THC screens. Hospital records from a recent transfer documented that R1 appeared more confused, was slurring her words, and had a urine toxicology screen positive for marijuana; R1 reported she may have taken “gummies or something” and later told surveyors she was getting gummies from another resident (R2). R1’s current care plan did not include her history of substance abuse. Staff interviews showed that CNAs were aware of rumors of residents using illegal substances in the facility but had not personally observed contraband, and management had not discussed the posted contraband sign with them. Nursing staff reported that on the day of R1’s hospital transfer, she was very lethargic and not acting like herself, leading to her being sent out and again testing positive for THC, with uncertainty about how she obtained the substance. The DON acknowledged R1’s history of substance abuse and prior positive THC tests but stated she was not sure how R1 was getting the substance and was not aware of residents using substances in the facility. The Administrator stated that R1 reported getting gummies from another resident, while that resident denied providing them. Staff also reported that R1 frequently attempted to go into R2’s room without a clinical reason, and nursing staff redirected her back to her own room. The facility also failed to reassess and manage community pass privileges for R2 despite documented concerns about substance use. R2 had diagnoses including unspecified cirrhosis of the liver, alcohol abuse, insomnia, and major depressive disorder, and his record showed an order for a urine drug screen that was never completed because he was either out of the building or unable to provide a specimen. R2’s community survival skills assessment indicated he was capable of outside pass privileges, and he reported going out independently, consuming alcohol on occasion when out, and being able to leave when he pleased. Staff, including a CNA and an RN, stated that R2 “does his own thing,” leaves the facility when he wants, and that they had heard he goes to bars and drinks. The DON stated R2 was independent and did not need supervision, and social services reported that residents who violate pass standards should lose independent pass privileges but was not aware of R2 using substances. A psych NP documented that R2 had a history of alcohol abuse, was currently using illicit substances such as alcohol and possibly cocaine, refused urine drug screening, was refusing antipsychotic medication, and might be using substances during community passes. The facility’s community pass policy stated that using alcohol or illicit substances or bringing them into the facility is prohibited and may result in forfeiture of pass privileges, and that the facility reserves the right to revoke passes if a resident is assessed as a threat to self or others.
Failure to Provide and Document Discharge Planning Social Services
Penalty
Summary
The deficiency involves the facility’s failure to provide medically-related social services and discharge planning for two residents who expressed or required consideration for alternative placement. One resident with a history of seizures, schizoaffective bipolar disorder, PTSD, suicidal ideation, intentional self-harm, mood disorder, and epilepsy stated she wanted to be discharged to a setting similar to her prior residential group home. She reported that social services were trying to find a place for her but had not informed her of the status, and that social services staff told her no one would accept her if she was lying. The social services worker confirmed the resident had lost her apartment during the facility stay, that the prior group home refused readmission without giving a reason, and that developmental disability homes indicated they could accept the resident when she was able to walk, noting she had recently started walking. The psych NP and RN both stated the resident would benefit from a setting specializing in mental health services with peers her own age, and the RN noted staff were not trained to care for psychiatric residents. Despite a care plan stating that discharge planning should be continually assessed and that social services would assist in finding a group setting, social service notes from September through late January contained no documentation of discharge planning or contacts with group homes or facilities for placement. The second resident was admitted from an acute care hospital with cirrhosis, alcohol abuse, restless leg syndrome, insomnia, and major depressive disorder, and reported being independent with care and ambulation. He stated there had been discussion about finding alternative placement, while social services reported that the plan was for him to remain at the facility and that he became defensive when asked about discharge planning, confirming he was independent and not receiving therapy. The administrator described him as a young male resident who goes out on pass independently and stated he was at peace and complacent at the facility but had nowhere else to go. Social service documentation described him as alert, oriented, able to communicate needs, ambulating independently with a walker, a smoker, and having an independent community pass. However, social service notes from November through January contained no documentation of discharge planning, and the regional nurse consultant confirmed there was no documentation of discharge planning or attempts to find alternative placement for either resident, despite facility policy requiring social work involvement in assessing discharge potential, documenting significant discharge information, and coordinating community services.
Failure to Monitor and Maintain Food Temperatures Leading to Ongoing Resident Complaints
Penalty
Summary
The facility failed to ensure that food and drink were served at palatable and safe temperatures by not consistently taking and documenting cooking and serving temperatures for multiple meals. Review of kitchen food temperature logs on January 20, 2026 showed that no food temperatures were recorded for all three meals on January 8, for breakfast and lunch on January 9–11, for supper on January 12, for all three meals on January 13, for breakfast and lunch on January 14, for all three meals on January 15, and for breakfast and lunch on January 16–17. Both cooking and serving temperatures were missing on these dates. The facility census data indicated 65 residents, with corporate staff clarifying that one resident did not eat food from the facility kitchen, leaving 64 residents potentially affected. The Dietary Manager stated that food temperatures should be taken when food is cooked and again right before serving, and that staff should log these temperatures as they are taken. Residents reported concerns about food quality and temperature. One resident stated that the food is always cold when served. Another resident reported that the food is not good, orders out often because the food is bad, and that the food is cold most of the time, depending on when the meal is received. A third resident reported that some meals are good and some are not, and that hot food is sometimes served cold. The Dietary Manager described that food trays are delivered on an open metal cart covered with a cloth, without heated plates, closed carts, or any heating apparatus to keep food warm during delivery, and acknowledged that such equipment would be helpful to keep food warm. Resident Council minutes from October and December 2025 documented ongoing complaints under “Dietary old business,” including that residents wanted to keep the issue of cold food open, reported that coffee is cold at times, and that condiments are not always provided on meal trays.
Failure to Document Food Cooking and Serving Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to ensure that final cooking and serving temperatures of food were taken and documented in accordance with its own food safety policy. Review of kitchen food temperature logs on January 20, 2026 showed that no food temperatures were recorded for all three meals on multiple dates, including January 8, 13, and 15, and for breakfast and lunch on January 9–11, 14, 16, and 17, as well as supper on January 12. Both cooking temperatures and serving temperatures were missing for these meals. At the time of the survey, the facility census data sheet showed 65 residents in the facility, with corporate staff indicating that one resident did not eat food from the facility kitchen, leaving 64 residents potentially affected. During an interview, the Dietary Manager stated that food temperatures are supposed to be taken when food is finished cooking and again immediately before serving, and that these temperatures should be logged as they are taken. The facility’s written policy on Food Safety and Sanitation: General Preparation and Cooking Practices, revised September 18, 2023, states that the facility will follow sanitary practices in food preparation and cooking, including maintaining hot food at a minimum of 135°F on the steam table and prior to service, and reheating food to 165°F if it falls below 135°F. The absence of documented cooking and serving temperatures on the identified dates shows that these required practices were not followed or recorded as required by facility policy.
Failure to Maintain Safe Bed Rail and Wheelchair Equipment for Two Residents
Penalty
Summary
The facility failed to maintain resident equipment in safe working order for two cognitively intact residents. One resident, admitted with chronic respiratory failure, venous insufficiency, lymphedema, morbid obesity, fluid overload, cellulitis of the right lower limb, bed confinement, and a stage 4 sacral pressure injury, reported that the right siderail on his bed was loose. During observation, the siderail moved side to side when the resident manipulated it, and he stated he needed the siderails to roll from side to side. He reported having notified the facility about this problem about a week earlier, but it had not been fixed at the time of the surveyor’s observation. Another resident, admitted with type II DM, chronic kidney disease, anemia, restless legs syndrome, adjustment insomnia, glaucoma, and an acquired absence of the right leg below the knee, reported waiting for maintenance to fix the right armrest on his wheelchair. Observation showed the right armrest’s cushioned piece was hanging off the back by about 5–6 inches, exposing metal underneath, and the resident had a scrape on his right forearm, which he attributed to using his arms to propel the wheelchair. The left armrest lacked a cushioned piece. The resident stated he had reported this concern a couple of weeks earlier. The Maintenance Director stated the facility does not use work orders or track when repairs are requested or completed, acknowledged awareness of the loose siderail and the armrest concern, and indicated he was waiting for a replacement armrest. The facility’s Preventative Maintenance Program Policy requires that resident equipment, including bed rails, be in working order during environmental and safety audits.
Failure to Maintain Safe Walkway Results in Resident Fall and Fracture
Penalty
Summary
The facility failed to ensure that a resident's walkway path in her room was free from accident hazards, resulting in a fall and injury. One resident, who was at moderate risk for falls due to a history of falls, balance problems, and use of an assistive device, attempted to walk through her room using a walker. At the time, her roommate had several visitors, and the visitors were sitting in chairs across the roommate's bed, creating a crowded and cluttered environment with limited walking space. As the resident tried to navigate the narrow space, she tripped and fell. Following the fall, the resident sustained a left ankle and foot fracture, requiring her to be non-weight bearing on her left leg. Interviews with staff, including an LPN and the DON, confirmed that the room was overcrowded and did not provide enough space for safe ambulation. The resident's care plan identified her fall risk and included interventions such as proper footwear, use of a walker, and keeping the call light within reach, as well as ensuring her room was free from safety hazards and clutter. Despite these interventions, the environmental hazard of overcrowding was not addressed at the time of the incident.
Failure to Maintain Hand Hygiene and Sanitation in Food Service
Penalty
Summary
The facility failed to ensure proper hand hygiene and sanitation practices in the kitchen, as observed during food preparation and service. A cook was seen handling raw chicken with gloved hands and, without changing gloves or washing hands, proceeded to touch a seasoning container and a sheet pan, only removing the soiled gloves and washing hands after these tasks. The Food Service Director confirmed that gloves should be changed and hands washed when switching tasks or after handling raw meat, in accordance with the facility's handwashing policy. Additionally, another cook was observed using a thermometer to check food temperatures, rinsing it under water between different food items without using a sanitizing wipe or rag, as required by facility policy. Sanitizing wipes were not available at the prep table during this process. Further, the meat slicer on the prep counter was found uncovered and had caked-on food debris behind the blade and on the housing. The Food Service Director was unsure if the blade was removable for cleaning and stated that the machine did not come with a specific cover. The facility's policy requires all preparation and serving equipment to be cleaned and sanitized after contact with raw foods to prevent cross-contamination. These failures in hand hygiene, equipment cleaning, and sanitization have the potential to affect all residents receiving food from the kitchen, except for two residents on NPO orders.
Failure to Update PASRR Referrals for Residents with New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that residents with new diagnoses of mental health disorders were referred to the state-designated authority for Pre-admission Screening and Resident Review (PASRR) as required. Specifically, four residents were identified who had new or updated mental health diagnoses, such as schizophrenia, major depressive disorder, schizoaffective disorder, and insomnia, after their initial admission and original PASRR screenings. Despite these new diagnoses, there was no evidence that updated PASRR screenings or referrals were completed for these residents. Interviews with the facility liaison confirmed that these omissions were discovered during an audit, and the liaison was previously unaware that new diagnoses required updated PASRR referrals. Record reviews showed that the original PASRR or OBRA screens for these residents did not reflect their subsequent mental health diagnoses. For example, one resident was prescribed antipsychotic medication following reports of aggressive behavior and mood swings, and another had a diagnosis of schizophrenia added years after admission, yet neither had an updated PASRR. The facility's PASRR policy also lacked guidance on updating screenings when new qualifying diagnoses are identified.
Failure to Adhere to Infection Control and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to consistently follow infection prevention and control protocols for residents on Enhanced Barrier Precautions (EBP). In one instance, a CNA entered a resident's room, applied gloves, assisted the resident, removed gloves, and then transported the resident to the dining room without performing hand hygiene before or after glove use. The same CNA then handled another resident's meal tray and proceeded to provide care to a different resident, again without performing hand hygiene. Facility policy requires hand hygiene before and after glove use and after contact with inanimate objects in the resident's vicinity. Additionally, staff did not properly use or remove personal protective equipment (PPE) as required for residents on EBP. One CNA exited a resident's room while still wearing PPE, retrieved a blanket from the hallway, and re-entered the room, contrary to facility policy that mandates removal of PPE before exiting the room. In another case, two CNAs provided perineal care to a resident with multiple chronic wounds while only wearing gloves and not gowns, despite policy requiring both gown and gloves for high-contact care activities for residents on EBP. Interviews with staff and review of facility policies confirmed these practices were not in accordance with established infection control procedures.
Failure to Provide Privacy Covering for Urinary Catheter Bag
Penalty
Summary
The facility failed to maintain resident dignity by not providing a privacy covering for a urinary catheter bag for one resident. On two separate occasions, the resident's catheter bag was observed without a privacy covering: once when the resident was transferred to a wheelchair and brought into the dining room with other residents present, and again when the resident was lying in bed with the catheter bag visible from the hallway. Interviews with CNAs and the Director of Nursing confirmed that facility policy requires the use of dignity bags for urinary catheter bags, especially when residents are in public areas or when the bag is visible from the hallway. The facility's own dignity policy includes the use of privacy coverings for urinary catheter bags as an example of promoting dignity and respect.
Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was safe to self-administer medications, as required by policy and physician oversight. One resident, who had diagnoses including Alzheimer's disease, dementia, COPD, chronic respiratory failure, schizoaffective disorder, chronic hepatic failure, scoliosis, and pneumonia, was observed with multiple medications and supplements at his bedside. These included an albuterol inhaler, fluticasone inhaler, beet root supplement, and diclofenac cream. The resident reported self-administering these medications as needed or as part of his routine. However, the physician's order sheet did not include an order for the beet root supplement, nor did it document any authorization for the resident to self-administer any medications. Interviews with facility staff confirmed that there was no assessment conducted to determine the resident's ability to safely self-administer medications, and no physician order was obtained to permit self-administration. The resident's care plan also lacked documentation regarding self-administration. Facility policy requires an assessment and physician approval before a resident may self-administer medications, with appropriate documentation in the care plan and medication record. These steps were not followed for this resident, resulting in a deficiency.
Failure to Document DNR Order per Advanced Directives Policy
Penalty
Summary
The facility failed to follow its advanced directives policy by not obtaining a physician's order for Do Not Resuscitate (DNR) for one resident who had indicated a preference for DNR status. The resident's Do-Not Resuscitate/Practitioner Orders for Life-Sustaining Treatment (POLST) form, dated several years prior, clearly documented the resident's wish to not have cardiopulmonary resuscitation attempted. However, a review of the resident's current Physician's Order Sheet did not show any documentation of a DNR order. During an interview, a registered nurse explained that the standard procedure involves social services discussing code status with the resident upon admission, completing the necessary forms, and obtaining signatures from both the resident and physician before entering the order into the electronic medical record. Upon reviewing the resident's electronic record, the nurse confirmed that there was no DNR order present and nothing indicating the resident's code status in the system. The facility's policy requires that advance directive information be added to the Physician Order Sheet, but this was not done for the resident in question.
Failure to Accurately Reflect Developmental Disability in PASARR Screening
Penalty
Summary
The facility failed to ensure that the required Preadmission Screening and Resident Review (PASARR) Level I screening accurately reflected a resident's possible or suspected developmental disability. One resident, a 33-year-old female, was observed to be very childlike, expressed confusion about her placement, and had a documented history of developmental delay and mild cognitive impairment. Despite these observations and documentation from the emergency room physician indicating a developmental delay and behavior significantly younger than her stated age, the PASARR Level I screening completed at admission indicated that there was no diagnosis or suspicion of intellectual disability. The facility relied on the PASARR completed by the hospital and did not conduct further assessment or question the findings, even though the resident's records and observed behavior suggested otherwise. The facility's policy requires review of PASARR documents to assess resident needs, but in this case, the documentation and observations indicating a developmental disability were not reflected in the PASARR screening outcome.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
A resident admitted with a history of falls, pneumonia, myocardial infarction type 2, and nonrheumatic aortic valve stenosis was observed to have unkempt, oily hair and overgrown facial hair. The resident reported feeling weak, unable to walk or stand independently, and stated that he had not been offered a shower since admission. Staff interviews confirmed that residents are scheduled to receive weekly showers, with a shower schedule indicating the resident's designated shower day. Documentation showed the resident refused a shower on one occasion, but was not offered another shower until 12 days later. The facility's policy on activities of daily living did not specify shower frequency. The administrator confirmed the resident did not receive a weekly shower as required.
Failure to Implement Pressure Ulcer Prevention Interventions for At-Risk Residents
Penalty
Summary
The facility failed to implement and maintain appropriate pressure ulcer prevention interventions for residents identified as at risk for pressure ulcers. For one resident, the Braden Scale indicated risk, and physician orders required heel protectors on both feet while in bed. However, observations showed the resident only had a heel protector on the left foot and was placed on an air mattress with a fitted sheet, which is not recommended as it can interfere with the mattress's function. The air mattress was also set to 'firm, normal pressure' rather than being adjusted to the resident's weight as required. The care plan for this resident included repositioning every two hours, use of pillows, heel protectors, and a specialty mattress, but these interventions were not consistently implemented as observed by surveyors. For another resident at risk for pressure ulcers, physician orders specified the use of a pressure reduction mattress. Observations revealed the resident was on an air mattress with a fitted sheet and the mattress was set to the maximum weight setting, which did not correspond to the resident's actual weight. Staff interviews indicated a lack of understanding regarding proper mattress settings and sheet usage, with some staff believing fitted sheets were acceptable and that mattress settings did not need adjustment. The care plan for this resident included use of a pressure-reducing mattress and wheelchair cushion, but the interventions were not properly individualized or implemented according to the resident's needs and manufacturer guidelines.
Failure to Maintain Proper Positioning of Catheter Drainage Bag and Tubing
Penalty
Summary
A resident with multiple sclerosis, hypertension, neuromuscular dysfunction of the bladder, and emphysema, who has an indwelling urinary catheter and a recent history of urinary tract infection, was observed on multiple occasions with his catheter drainage tubing and urinary drainage bag either dragging on the floor or resting on the floor beneath his wheelchair. Staff interviews confirmed that the drainage bag and tubing should not be in contact with the floor, and that the dignity bag straps had to be re-secured because they were not properly attached. The facility's catheter care policy requires that urinary drainage bags and tubing be positioned to prevent them from touching the floor, but this was not followed in the resident's care.
Failure to Ensure Safe and Ordered Oxygen Administration and Equipment Maintenance
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for two residents requiring oxygen therapy. For one resident with chronic respiratory failure, COPD, and pneumonia, oxygen was administered via nasal cannula without a physician's order, and the oxygen tubing in use was not changed according to the facility's policy, as evidenced by tubing dated several weeks prior. The resident's medical record did not contain any physician's order for oxygen administration or tubing changes, contrary to facility policy requiring such orders and weekly tubing changes. For another resident, the oxygen nasal cannula was not properly in place, and the resident was observed to be out of breath and self-administered an inhaler. The oxygen concentrator's humidifying jar was found empty during one observation, and only later was it refilled. Staff interviews confirmed that nurses are responsible for checking and refilling humidifying jars, and that humidifying jars should not be empty while in use. Facility policy also requires that the humidifying jar contains enough water to bubble as oxygen flows through, which was not consistently maintained.
Failure to Assess and Document Change in Condition for Diabetic Resident
Penalty
Summary
A resident with multiple diagnoses, including COPD, dementia, atrial fibrillation, heart failure, and diabetes, experienced increased lethargy while admitted to the facility. On the day of the incident, a nurse documented the resident's lethargy and attributed it to a urinary tract infection for which the resident was being treated. However, the nurse did not document any vital signs, blood sugar checks, or a complete head-to-toe assessment at that time. The resident was subsequently sent to the hospital via 911, but the transfer assessment only included vital signs from the previous day, and there was no documentation of a current blood sugar measurement or comprehensive assessment. Interviews with staff revealed uncertainty about whether vital signs or blood sugar were checked at the time of the change in condition, with the last documented blood sugar recorded several days prior. The facility's policy requires appropriate assessment and documentation when a resident experiences a change in condition, but this was not followed. The Director of Nursing confirmed that lethargy in a diabetic resident should prompt a blood sugar check and a thorough assessment, neither of which were documented in the resident's electronic health record.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for residents who were dependent on staff assistance, as observed in three residents. One resident, admitted with conditions including diarrhea and a sacral pressure ulcer, required substantial assistance for toileting hygiene. Despite activating the call light after a bowel movement, the resident was left waiting for nearly an hour before being attended to, during which time they were served lunch while still soiled. The CNAs assigned to the resident's care were occupied with other tasks and did not prioritize the resident's hygiene needs, despite the resident's expressed discomfort and the facility's policy on maintaining personal hygiene. Another resident, with diagnoses including diabetes and kidney failure, reported frequent urination due to a medical condition requiring high fluid intake. This resident experienced delays in staff response to call lights, particularly during shift changes, resulting in the resident urinating in their brief instead of using the bathroom. The resident expressed frustration over the long wait times, which sometimes exceeded an hour, impacting their ability to maintain personal hygiene and dignity. A third resident, with a stage four pressure ulcer and bladder dysfunction, also experienced significant delays in receiving incontinence care. This resident reported waiting up to 11 hours for staff assistance after a bowel movement, with staff turning off the call light and failing to return. The resident expressed understanding of the staff's workload but noted the standard wait time for assistance was typically an hour. The facility's Director of Nursing acknowledged the importance of timely incontinence care, especially for residents with pressure sores, but no staff sought additional help during the observed incidents.
Medication Transcription and Administration Errors
Penalty
Summary
The facility failed to accurately transcribe a resident's hospital discharge medication list and did not follow a physician's medication order for narcotics, as well as their policy for controlled substances. A resident, who was admitted with chronic obstructive pulmonary disease (COPD), did not have an order for albuterol nebulizer transcribed into their Medication Administration Record (MAR) despite it being listed on the hospital discharge medication list. The Director of Nursing acknowledged that the albuterol nebulizer was likely overlooked and not entered into the resident's medications for the facility, which is used to treat shortness of breath and wheezing. Additionally, there was a discrepancy in the administration of hydrocodone/acetaminophen (Norco) for the same resident. The Controlled Drug Receipt/Record/Disposition Form showed that three doses of Norco were dispensed within a 10-hour period, while only two doses should have been given according to the physician's orders. The Director of Nursing confirmed that the 8:00 AM dose on 3/6/25 was administered too soon and that controlled substances should be documented on both the MAR and the count sheet, as per the facility's policy.
Facility Fails to Provide Correct Portion Size for Burgers
Penalty
Summary
The facility failed to adhere to its menu requirements by serving hamburgers that did not meet the specified portion size of 2 ounces of protein. This deficiency was observed during a lunch meal where the burgers appeared small and shrunken. The Registered Dietitian (V5) and Certified Dietary Manager (V4) both confirmed that the burgers should be 2 ounces, and it was noted that the cook (V6) estimated the size of the burgers rather than measuring them. A test patty was weighed and found to be less than 2 ounces, confirming the deficiency. Residents expressed dissatisfaction with the portion size, with one resident sarcastically commenting on the size of the burger and others noting that the burgers were small. The facility's menu for the day specified a cheeseburger with 2 ounces of protein, and the Tray Accuracy Policy and Procedure required adherence to specified portions. The failure to follow the menu and provide the correct portion size affected the majority of residents receiving a regular diet, as 83.8% of the facility's residents were on a regular diet texture.
Failure to Serve Correct Menu Items and Portion Sizes
Penalty
Summary
The facility failed to serve the correct menu items and portion sizes for residents on mechanical soft and pureed diets, potentially affecting 63 of the 64 residents. The dietary manager, V4, was observed slicing turkey in random portions without knowledge of the required portion sizes. Additionally, the cook, V6, prepared instant mashed potatoes instead of the prescribed mashed sweet potatoes due to time constraints and did not measure the portions for pureed meals, instead splitting them between the two residents receiving pureed diets. This resulted in all residents on mechanical soft diets receiving mashed potatoes instead of skinned sweet potatoes. The facility's daily spreadsheet outlined specific portion sizes and menu items, which were not adhered to during meal preparation and service. V4 and V6 admitted to not following the menu due to time constraints and a lack of awareness regarding portion sizes, leading to inconsistencies in the meals served. The facility was unable to provide a policy regarding adherence to menu items and portion sizes, further contributing to the deficiency.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to maintain proper sanitation and food storage practices in the kitchen, which could potentially affect 63 of the 64 residents. During an initial tour, surveyors observed several issues, including a split-open bulk bag of sugar, crusted substances on beef and chicken base containers, and scoops improperly stored inside these containers. The floors beneath the dry storage area were littered with crumbs and cereal, and several bulk food items, such as pinto beans and bread crumbs, were found opened. Additionally, cooler doors had dried, crusted substances, and the walk-in freezer contained small puddles of dried, melted ice cream. Further inspection revealed that the dishwasher was cluttered with a screwdriver, random parts, dust, and crumbs, and the sanitizer levels were below the required 50ppm. A dietary aide was unable to check the sanitizer levels despite having documented them as correct earlier. The dietary manager admitted to not having a set cleaning schedule and was unaware of the issues with open bags and containers, which could attract pests. The facility's policy on food storage emphasized the need to protect food from contamination and maintain cleanliness, but these standards were not met.
Failure to Provide Homelike Dining Environment
Penalty
Summary
The facility failed to provide a homelike dining environment for residents during meal times. On November 13, 2024, it was observed that residents were served their meals on trays in the dining room, without the items being removed and placed on the table. This practice was noted for five residents within the sample and five residents outside the sample. Residents expressed dissatisfaction, stating that being served on trays made them feel like they were in an institution rather than a home. One resident specifically mentioned that while they did not mind meals being brought on trays, they preferred the items to be placed on the table to create a more homelike atmosphere. Interviews with staff revealed that the practice of serving meals on trays without removing items was due to management's instructions. A Certified Nursing Assistant acknowledged that removing items from trays would create a more homelike environment but stated that they were not allowed to make such decisions. The Interim Administrator confirmed that the facility had considered changing this practice and offering residents the option to have their meals served in a more homelike manner, but no changes had been implemented yet. The facility's policy on dignity emphasized caring for residents in a manner that promotes quality of life, dignity, respect, and individuality.
Failure to Provide Prescribed Mechanical Soft Diet
Penalty
Summary
The facility failed to prepare and serve a mechanical soft diet to residents who required it, affecting three residents within the sample and seven additional residents outside the sample. The facility's documentation indicated that these residents were prescribed a mechanical soft diet, which requires food to be ground or chopped to a specific consistency to accommodate individuals with limited or difficulty in chewing regular textured foods. However, during an observation, it was noted that the cook did not prepare the mechanical soft food as required. Instead, the cook shredded turkey by hand, believing it was already soft enough, and served it with mashed potatoes and gravy. The dietary manager admitted to not following the prescribed diet preparation, stating that hand-shredding the turkey was easier and saved time. The manager also expressed uncertainty about the impact of not providing the correct diet, as they were not part of the nursing department. Additionally, the manager mentioned that residents sometimes complained about the ground diet, so they attempted to accommodate their preferences without understanding the medical necessity of the prescribed diet. The interim administrator acknowledged the risk of choking if residents received the incorrect diet, highlighting the potential danger of the facility's failure to adhere to dietary prescriptions.
Infection Control Deficiencies in PPE and Precaution Protocols
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, specifically regarding contact isolation and enhanced barrier precautions for several residents. Resident R214 was admitted with a diagnosis of enterocolitis due to Clostridium difficile (C-diff) and had orders for contact precautions. However, staff frequently entered R214's room without wearing personal protective equipment (PPE), and the signage on the door incorrectly indicated enhanced barrier precautions instead of contact isolation. Despite the facility's policy requiring gowns and gloves for contact precautions, staff were observed not following these protocols, and there was confusion among staff about R214's C-diff status. Resident R57, who had a urinary drainage catheter, was supposed to be on enhanced barrier precautions, which require gown and gloves during high-contact care activities. However, staff were observed providing care without wearing the necessary PPE. Similarly, Resident R38, who had a suprapubic catheter, did not have enhanced barrier precautions in place, and staff were unaware of the need for such precautions. The facility's policy clearly outlines the need for gown and gloves during high-contact activities, but this was not implemented for R38. Additionally, Resident R52, who had a dressing on her ankle, and Resident R17, who had a gastrostomy tube, were also not provided with the required enhanced barrier precautions. Staff were observed providing care without the necessary PPE, and there was a lack of signage and PPE availability outside their rooms. The facility's failure to implement these precautions as per their policy indicates a significant lapse in infection control practices, potentially putting residents and staff at risk of infection transmission.
Deficiencies in Wound Care and Change of Condition Documentation
Penalty
Summary
The facility failed to provide appropriate wound care for a resident, R52, who had an arterial wound on the right medial ankle. The wound care physician's note dated 11/11/24 indicated a treatment plan requiring daily application of santyl ointment and dressing changes. However, the Treatment Administration Record (TAR) was not updated to reflect these new orders, and the resident did not receive the necessary daily dressing change on 11/12/24. The error was only corrected after facility staff were notified. The resident's care plan also lacked documentation for the vascular wound, despite the resident's history of venous ulcers and other comorbidities. Another deficiency involved resident R23, who was sent to the emergency room on two occasions without proper documentation or notification of the physician and family. On 8/6/24, there were no nursing notes or assessments recorded when the resident was sent out. Similarly, on 10/29/24, the resident was sent to the ER for severe pain without any documented assessment or notification to the physician and family. The facility's policy requires thorough documentation of any change in condition, including vital signs, symptoms, and notifications, which was not followed in these instances. The facility's failure to adhere to its own policies and procedures for wound care and change in condition documentation resulted in deficiencies in the quality of care provided to the residents. The lack of proper documentation and communication with the physician and family could have impacted the continuity of care and the residents' overall well-being.
Inadequate Supervision and Unsafe Transfer Practices
Penalty
Summary
The facility failed to transfer a resident, identified as R25, in a safe manner. R25, who has moderate cognitive impairment and requires substantial assistance with transfers, was observed being lifted by two CNAs, V14 and V15, without proper use of a gait belt. Instead, they lifted R25 under her arms and by her pants, which is against the facility's policy and could potentially cause injury. The CNAs admitted that R25 dislikes the gait belt, leading them to use her pants for support. The Director of Nursing confirmed that lifting residents under their arms is not safe and that therapy staff should be consulted for safer transfer methods. Another deficiency involved a resident, R52, who was not adequately supervised while ambulating. R52, who has a history of falls and requires extensive assistance, was found walking unassisted to the nurse's station and later in the common area without a gait belt. The CNAs involved, V10 and V11, acknowledged that R52 should not be walking alone and requires assistance. Despite this, R52's care plan was not updated following a fall on 9/27/24, and the necessary precautions were not implemented to prevent further incidents. The facility's policies on fall prevention and care plan updates were not adhered to, as evidenced by the lack of updated interventions in R52's care plan after her fall. The Director of Nursing acknowledged the oversight and the need for increased supervision and appropriate use of assistive devices for R52. The facility's failure to follow its own policies and provide adequate supervision and safe transfer methods contributed to the deficiencies identified in the report.
Inadequate Catheter Care for Resident
Penalty
Summary
The facility failed to provide adequate catheter care for a resident with a suprapubic catheter. Observations revealed that the resident had a thin, improperly cut 4 x 4 dressing around the catheter, which was not secured with tape. The resident reported that the dressing was changed only once a week, and the catheter tubing was cleaned with the same frequency. Additionally, the catheter tubing secure device was not in use, despite being available in the resident's room. The resident expressed willingness to have the secure device applied, but it was not being utilized. Interviews with facility staff, including an LPN and the DON, confirmed that catheter care should be performed daily, and the secure device should be used to prevent trauma and tension. The facility's catheter care policy also mandates daily dressing changes and securing of the catheter. The resident's care plan and medication review report indicated a need for daily dressing application and catheter care every shift, which was not being adhered to, leading to the deficiency.
Failure to Implement Dietary Interventions for Resident with Weight Loss
Penalty
Summary
The facility failed to implement dietary interventions for a resident, identified as R3, who experienced significant weight loss. R3 was admitted with multiple diagnoses, including paranoid schizophrenia and mood disorder, and was on a weekly weight monitoring plan. Despite having dietary supplements ordered, such as fortified potatoes and ready care shakes, these were not provided during meals. Observations on two consecutive days showed that R3's lunch trays did not include the prescribed fortified potatoes, and the dietary manager admitted that they do not serve them, despite knowing residents are supposed to receive them. The facility's policy requires monitoring for undesirable weight changes and implementing timely interventions, which was not adhered to in R3's case. The registered dietician confirmed that the kitchen has recipes for fortified potatoes, and the Director of Nursing expected the kitchen to serve dietary supplements as ordered. However, the failure to provide these supplements contributed to R3's continued weight loss, as evidenced by a 42-pound decrease over 11 months.
Deficiencies in Oxygen Therapy Management
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required oxygen therapy. For one resident, the oxygen tubing was excessively long, tangled, and kinked, which could impede the flow of oxygen. The oxygen concentrator was covered in a thick layer of dust, and the humidification bubbler was empty, which could lead to nasal dryness. The Licensed Practical Nurse (LPN) acknowledged that the equipment should be checked and cleaned weekly, but it was evident that this had not been done. The Director of Nursing (DON) confirmed that there was no regular cleaning schedule for the oxygen concentrators. For the second resident, the oxygen tubing had not been changed since the previous month, and the concentrator filter was found on the floor. The Maintenance Director stated that he only replaced the filter when informed by staff and did not regularly check the concentrators. The DON confirmed that the tubing and filters should be checked and changed weekly. The facility's policy required weekly cleaning and changing of oxygen equipment, but these procedures were not followed, leading to deficiencies in the care provided to the residents.
Lack of Dialysis Care Policies and Procedures
Penalty
Summary
The facility failed to have policies and procedures in place for the care of a dialysis resident, specifically for one resident (R13) who was dependent on renal dialysis and had end-stage renal disease. The resident's admission records indicated that she required dialysis three times a week, with an access site in her right arm that needed daily assessment for bruit and thrill. However, the Medication Administration Record (MAR) lacked orders for these assessments, and there was no Treatment Administration Record (TAR) for the resident. Additionally, the resident reported receiving inappropriate food items that did not align with her renal diet, such as potatoes and regular milk, and the facility did not provide lactose-free milk. The facility also lacked communication with the dialysis center, as no information was sent with the resident, and there was no documentation of dialysis-related information in her records. Nurses were not consistently checking the dialysis shunt for patency, and there was no emergency kit available in the resident's room for potential hemorrhage events. The Director of Nursing acknowledged the inconsistency in information exchange with the dialysis center and noted that not all nurses were trained in the care and treatment of dialysis patients. The Interim Administrator confirmed the absence of a facility policy and procedures for dialysis care.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were taken by residents at the time of administration for two residents. Resident R18, who has multiple diagnoses including osteomyelitis, diabetes, congestive heart failure, pressure ulcers, and gastroparesis, was observed with a medication cup half full of pills on her bedside table. The resident reported that the nurse left the medications because she was nauseous, and she could not identify the medications. The nurse confirmed that no pills should be left at the bedside and that residents must be observed taking their medications. The Medication Administration Record indicated that R18 had multiple morning medications scheduled, including antibiotics and blood pressure medications. The Director of Nursing acknowledged that R18 is known for not taking her medications as ordered. Resident R13 was found to have a glucometer, blood pressure cuff, and a cup with an insulin pen and multiple medication cups on her bedside table, including two Norco tablets. The LPN stated that R13 was not a resident who self-medicates and was unaware of the insulin pen's origin. The RN confirmed that R13 should not have these items by her bedside and that the insulin pen, which was brought from home, had no identifying information and would need to be discarded. R13 admitted to saving the Norco for after dialysis. The facility's policy requires documentation and physician notification if medication is withheld or refused, which was not adhered to in these cases.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to administer medications at the ordered times, resulting in a 28.5% medication error rate. This deficiency was observed in one of three residents during a medication pass. The resident, identified as R16, had physician's orders to receive apixaban 5mg at 9am and 5pm, and baclofen 10mg at 9am, 1pm, and 5pm. On November 12, 2024, at 10:20 AM, a Licensed Practical Nurse (V7) administered both medications 1 hour and 20 minutes past the scheduled time. V7, a new nurse, was being trained by a Registered Nurse (V8), who admitted she should have intervened but was allowing V7 to learn her routine. Both nurses acknowledged that medications should be administered within one hour before or after the scheduled time. The Director of Nursing (V2) confirmed that medications should adhere to this timing policy, as outlined in the facility's medication administration policy dated March 2024.
Medication Storage and Handling Deficiencies
Penalty
Summary
The facility failed to ensure the safe storage and handling of medications, particularly narcotics, as observed in one of the medication rooms and carts. During an inspection, it was found that the medication refrigerator was not locked, and the temperature log had not been updated since April 2024, despite the presence of liquid lorazepam inside. A Licensed Practical Nurse (LPN) admitted that the refrigerator was usually locked, but due to the presence of two nurses and only one set of keys, it was left unlocked. Additionally, the temperature of the medication refrigerator had not been monitored as required, which is crucial for maintaining the efficacy of the medications stored within. Furthermore, a review of one of the medication carts revealed 36 unidentified pills scattered throughout the cart, indicating a lack of proper medication handling and storage practices. An LPN acknowledged that these pills might have been dropped during medication passes or inadvertently popped out of medication cards. The Interim Administrator confirmed that the medication room and refrigerator should be locked to prevent diversion and that the temperature should be checked daily. The facility's policy on medication storage emphasized the importance of maintaining proper temperatures and keeping medication carts clean, which was not adhered to in this instance.
Deficiency in Resident Hygiene Care
Penalty
Summary
The facility failed to provide adequate hygiene care for three residents, resulting in deficiencies in their activities of daily living. Resident 1 was admitted to the hospital with poor hygiene, including matted hair with food, a clogged and dirty urinary catheter, and a pungent smell. The facility's records showed that Resident 1 did not receive a shower or bed bath for extended periods, with the last documented hygiene care occurring 34 days before hospital admission. The Director of Nursing acknowledged the protocol for handling shower refusals but admitted to not monitoring the shower tracking, and no issues were reported for Resident 1. Resident 2, who has multiple medical conditions and an amputation, reported not receiving weekly showers as scheduled. Observations confirmed greasy hair and facial hair growth, which the resident preferred to be clean-shaven. The facility's records indicated gaps in shower documentation, with a 20-day period without a shower. The care plan for Resident 2 lacked specific details on the assistance required for showers, contributing to the deficiency. Resident 6, who is dependent on staff for hygiene care, reported receiving bed baths only every couple of weeks and expressed dissatisfaction with the infrequency. Observations noted greasy hair, and records showed incomplete documentation of hair washing during bed baths. The facility's policy required weekly showers or bed baths, but the records for Resident 6 indicated non-compliance with this policy, leading to inadequate hygiene care.
Failure to Change Wound Dressings as Ordered
Penalty
Summary
The facility failed to ensure that a resident's wound dressings were changed as per the physician's orders and the resident's needs. The resident, who had been admitted to the facility with a wound on the right elbow, was observed with an undated dressing that had not been changed despite requests from the family. The resident's daughter and son reported that the dressing was not changed even after multiple requests, and the dressing was found to have dirty, crusty drainage. The Licensed Practical Nurse (LPN) responsible for wound care stated that the facility was waiting for the ordered silver rope packing to arrive and had received an order to use iodoform packing in the meantime. However, the Treatment Administration Record (TAR) did not document the dressing change on the specified date. The Director of Nursing (DON) acknowledged that the family had reported the dressing was not changed, but assumed the LPN had forgotten to do it. The Physician Order Summary Report indicated specific orders for wound care, which were not followed as documented in the TAR. Additionally, the resident's care plan did not include interventions related to the wound on the right elbow. The facility's policy required daily checks of dressings for cleanliness and signs of infection, which were not adhered to in this case.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers had appropriate pressure-reducing measures in place. For one resident, who had an amputation of the right lower leg and multiple health conditions including diabetes and heart disease, the left heel was observed lying directly on the bed without any offloading device. Despite the presence of a small black area on the heel, indicating a pressure ulcer, the resident did not have an offloading boot, and the care plan required offloading the heel. The wound care physician's orders also specified offloading the heel, but these were not followed, as the resident's heel was not properly offloaded during the surveyor's visit. Another resident was observed sitting in a chair with heels resting on the floor and later in bed with heels on the mattress, without any offloading devices. This resident had a deep tissue injury to the right heel upon admission, but the care plan did not include interventions for this pressure injury. The physician's orders required offloading the heel while in bed, but this was not implemented, as observed by the surveyor. The facility's pressure ulcer prevention policy mandates the use of positioning devices to relieve pressure, which was not adhered to in these cases.
Inadequate Catheter Care and Hygiene in LTC Facility
Penalty
Summary
The facility failed to provide adequate catheter care for two residents, leading to deficiencies in maintaining hygiene and preventing infection. For one resident, the catheter tubing was observed with sediment, and the drainage bag was improperly positioned on the floor, which is against the facility's policy. The resident's catheter dressing was not secured properly, and the catheter site was not cleaned, resulting in encrustation around the tubing. Despite the care plan indicating that catheter care should be provided every shift, the resident reported that staff had not performed catheter care for a long time, and records showed missed catheter care on several dates. Another resident was sent to the hospital with poor hygiene, including a clogged catheter bag with large sediment and a visibly dirty exterior catheter. The resident had a pungent smell, indicating a lack of proper hygiene care. The hospital nurse had to change the catheter and bathe the resident. The facility's Director of Nursing acknowledged that there was an order for the catheter to be changed due to obstruction, but there was no record of when the catheter was last changed at the facility. Both residents had care plans and physician orders that outlined the need for regular catheter care and monitoring for signs of infection. However, the facility's failure to adhere to these plans and policies resulted in inadequate care, as evidenced by the observations and reports from the hospital. The facility's catheter care policy emphasized the importance of maintaining downhill flow of urine and preventing the drainage bag from touching the floor, which was not followed in these cases.
Failure to Refund Resident's Funds Timely
Penalty
Summary
The facility failed to refund a resident's funds within 30 days of discharge. The resident, who had multiple diagnoses including chronic obstructive pulmonary disease, diabetes, and bipolar disorder, left the facility against medical advice (AMA) and requested her money. Despite the resident's repeated calls to the facility, her account was not closed until over a month after her discharge, resulting in her Social Security payment being sent to the facility instead of to her directly. The Business Office Manager (BOM) and Corporate Director of Accounts Receivable were both involved but did not ensure the timely closure of the resident's account. The resident's account showed a Social Security deposit and care cost withdrawal on the day of her discharge, leaving a balance that was not refunded promptly. The BOM admitted to not knowing the process for handling funds after a resident's discharge and relied on corporate to manage it. The Corporate Director of Accounts Receivable acknowledged that the account should have been closed earlier to prevent the Social Security payment from being sent to the facility. The delay was partly attributed to a religious holiday that affected the office's operations. The facility's policy requires the safeguarding and management of resident funds, but the process was not followed correctly in this case. The Administrator in Training and other staff members were unclear about the procedures for closing accounts upon discharge, leading to the resident's financial distress. The resident, who was living in a women's shelter, repeatedly contacted the facility about her funds, highlighting the urgency of the situation. The facility eventually issued checks to the Social Security Administration to rectify the issue, but the delay caused significant inconvenience to the resident.
Failure to Assess and Document Venous Wounds and Follow Physician Orders
Penalty
Summary
The facility failed to assess and document a resident's non-pressure (venous) wounds and did not follow up with the resident's physician after a visit to his office. Additionally, the facility did not adhere to physician orders written during that visit. This resulted in the resident having no wound assessments since January 2024 for four venous wounds on her legs, exposed open and bleeding wounds to the backs of her thighs, and an 18-day delay in increasing her pain medication. The resident's electronic medical record shows that she was admitted with diagnoses including morbid obesity, mood disorder, chronic kidney disease stage 4, and non-pressure chronic ulcers of the left and right leg. The last wound assessment was dated January 15, 2024, indicating four venous wounds with varying degrees of serous drainage. Despite this, the facility's non-pressure injury list was undated and showed only two venous wounds, with incorrect treatment and physician information. The treatment administration record for April and May 2024 showed that the resident allowed dressing changes only 10 times in 37 days, missing opportunities for wound assessments. Observations and interviews revealed that the resident had a strong ammonia odor, open and bleeding wounds, and was using cornstarch on her wounds against medical advice. The resident refused the facility's prescribed treatment, preferring her own methods, and had limited interaction with facility physicians. Staff reported difficulties in providing care due to the resident's refusals and non-compliance. The facility's policies required weekly assessments and clear documentation of physician orders, which were not followed in this case.
Failure to Provide Assistance with ADLs
Penalty
Summary
The facility failed to provide assistance with Activities of Daily Living (ADLs) for a resident (R1) who was left on a bed pan unattended. R1, who has diagnoses including acute respiratory failure with double lung transplant, protein-calorie malnutrition, pneumonia, and type 2 diabetes mellitus, was placed on a bed pan and left there for an extended period. Despite being fully cognitively intact and needing substantial assistance, R1's call light was repeatedly turned off by staff who did not return to assist him. This led to R1 experiencing pain, frustration, panic, and embarrassment, ultimately resulting in him calling 911 for help after being left on the bed pan for approximately three hours. The incident was confirmed by multiple staff members, including the CNA who placed R1 on the bed pan and the Director of Nursing who reviewed video footage and assessed R1's condition when EMS arrived. Staff interviews revealed that the CNA responsible for R1 on the day of the incident admitted to placing him on the bed pan but did not remove him due to being busy and assuming someone else would do it. Other staff members, including CNAs and the Wound Nurse, acknowledged that leaving a resident on a bed pan for more than 30 minutes to an hour is too long and could cause skin breakdown. The facility did not have a specific policy and procedure for bed pan use or assistance with ADLs, as confirmed by the Administrator. This lack of protocol contributed to the failure in providing necessary care and assistance to R1, leading to significant distress and discomfort for the resident.
Failure to Implement and Update Pressure Ulcer Care Plans
Penalty
Summary
The facility failed to ensure a care plan and interventions were developed and implemented to prevent pressure ulcers, provide pressure ulcer treatment, and update interventions to the care plan and skin risk assessment once pressure ulcers developed for two residents. For Resident 1, who had diagnoses including acute respiratory failure with double lung transplant, protein-calorie malnutrition, pneumonia, and type 2 diabetes mellitus, the facility did not replace a hydrocolloid thin dressing on a stage 2 pressure wound on the buttocks when it was observed to be missing. The CNAs did not inform the floor nurse about the missing dressing, which posed an infection risk as the wound was exposed to stool. The wound nurse confirmed that the dressing should be replaced if it falls off or gets soiled, and the physician's order indicated the dressing should be applied on specific days and as needed. However, this was not followed through properly by the staff involved. Additionally, the progress notes and physician order sheet confirmed the presence of the pressure wound and the required dressing application schedule, which was not adhered to by the facility staff. This led to a failure in providing appropriate pressure ulcer care for Resident 1. For Resident 3, who was admitted without any skin abnormalities, the facility did not implement any prevention interventions despite the resident being at increased risk for skin integrity issues. When a new stage 2 pressure wound was identified on the left buttock, the care plan was not updated to reflect the wound physician's recommendations, which included limiting sitting time, turning side to side in bed, and off-loading the wound. The most recent pressure injury risk assessment was outdated, and the Director of Nursing acknowledged that the interdisciplinary team discusses new wounds and determines interventions, but the care plan was not updated accordingly. The facility's wound policy indicates that a pressure injury risk assessment should be completed when a significant change of condition occurs, but this was not followed for Resident 3.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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