Pine Crest Health Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Hazel Crest, Illinois.
- Location
- 3300 West 175th Street, Hazel Crest, Illinois 60429
- CMS Provider Number
- 145220
- Inspections on file
- 42
- Latest survey
- January 25, 2026
- Citations (last 12 mo.)
- 22 (1 serious)
Citation history
Health deficiencies cited at Pine Crest Health Care during CMS and state inspections, most recent first.
Surveyors found that common shower rooms on both floors were unsanitary, in disrepair, and lacked privacy, affecting all residents. One resident’s case manager reported a shower room with broken tiles, no curtains, and mold. On inspection, surveyors observed chipped and crumbling tiles, dark brown-stained toilets that discharged dark water when flushed, dark substances on floors and walls, bath blankets on the floor, unflushed urine, and shower rooms used for storage instead of bathing. Toilets in some shower rooms were visible from the hallway due to missing privacy curtains and lack of door locks, even though many residents bathed independently and one resident required ADL assistance. Staff provided inconsistent descriptions of cleaning practices, the IP reported no involvement with housekeeping policies, and the facility lacked a written housekeeping protocol, cleaning schedules, or logs, despite multiple resident council complaints about filthy shower rooms.
Two residents experienced verbal and physical abuse by staff, including the use of profane language and physical mistreatment during care. One resident, who was cognitively intact, was subjected to hostile and inappropriate language, while another resident with severe cognitive impairment was exposed to repeated verbal aggression and reported being hit and pushed by a CNA. Witnesses and documentation confirmed these incidents, indicating a failure to follow abuse prevention policies.
A resident with a history of alcohol and opioid abuse, bipolar and schizoaffective disorders, and other medical conditions was not effectively monitored or supervised, despite a care plan and house rules prohibiting alcohol use. On one occasion, staff found the resident drowsy and disoriented in a room in disarray, with an empty brandy bottle on the bed, after which the resident became verbally aggressive and was sent to the hospital for alcohol intoxication and aggressive behavior. On a later occasion, staff were informed the resident had alcohol hidden in the room; an LPN found a liquor bottle under the bed covers, and after its removal the resident argued and cursed at a roommate and again required hospital care for alcohol intoxication and aggressive behavior. Facility leadership later acknowledged they did not know how the resident obtained alcohol the first time and that a staff member had purchased the alcohol for the resident in the second incident, contrary to facility rules and the resident’s substance abuse care plan.
The facility failed to accurately and consistently post required daily nurse staffing information. A surveyor found that the staffing notice near the reception area had not been updated for several days and still displayed an earlier date, and the posted form lacked unit-specific staffing details. The DON acknowledged that daily nurse staffing information is required to be posted each day. Record review confirmed the form was incorrectly dated and incomplete, despite requirements that such information be available for residents and the public and that services support residents’ physical and mental health at their highest practical levels.
Surveyors found that insufficient dietary staffing led to unsanitary kitchen conditions, including debris on the floor from a frequently backing-up grease trap, a visibly dirty and overflowing ice machine with a broken cover resting on wet blankets, and a food mixer with accumulated food particles left uncleaned under plastic wrap. The Dietary Manager reported working in place of an absent staff member and stated the kitchen was running behind, while job descriptions and facility policy showed that dietary staff were responsible for cleaning equipment, maintaining ice machines to prevent contamination, and cleaning floor surfaces daily. A total of 159 residents were receiving oral nutrition from this kitchen at the time of the deficiency.
Surveyors found that the facility failed to maintain safe food storage temperatures and sanitary conditions in the kitchen. Debris from a grease trap backup remained on the kitchen floor, the air vent above a food prep table was covered with dust, the ice machine was visibly dirty and overflowing with ice while its broken cover lay on wet blankets on the floor, and a food mixer stored under plastic wrap had accumulated food particles. The milk cooler was reading above safe temperatures, and spot checks of whole milk cartons stored there for several days showed temperatures above 41°F, despite facility policy requiring dairy products to be held between 33°F and 41°F. Resident council minutes documented complaints about spoiled milk, and facility policies also required daily cleaning and sanitizing of food equipment, ice machines, and floor surfaces for all residents receiving oral nutrition.
Surveyors found that the facility did not maintain key kitchen equipment and food storage conditions in accordance with its own policies. The three-compartment sink drainage system caused frequent grease trap backups onto the kitchen floor, with debris observed on the floor and prior maintenance logs documenting unresolved leaks. The ice machine was overflowing, had a broken lid that had been reported multiple times, and the broken cover was placed on wet blankets used to catch dripping water. The milk cooler displayed elevated temperatures, and calibrated checks showed multiple cartons of milk stored for several days at 51°F, above the required 33–41°F range for dairy products. These deficiencies affected all residents receiving food from the kitchen.
Surveyors found that laundry staff did not adequately clean dryer lint screens and compartments, as three dryers were observed with lint screens fully covered in lint and lint scattered on compartment floors. The housekeeping supervisor stated that lint areas were supposed to be cleaned every shift and acknowledged that not removing lint can cause a fire, while the DON confirmed that lint should be cleaned after each load and that failure to do so poses a significant fire hazard. Facility policies assigned responsibility to laundry staff for maintaining laundry room and equipment cleanliness and required machines to be cleaned at least daily, as well as adherence to policies to support quality care and a safe environment for all individuals in the facility.
Surveyors found that staff failed to maintain resident dignity and privacy in several ways, including leaving urinary catheter drainage bags uncovered in resident rooms, not ensuring that a cognitively intact resident had clothing available and allowing that resident and a roommate to be visible from the hallway with only a blanket or an exposed incontinence brief, and providing feeding assistance to a visually impaired, cognitively impaired resident while standing over the resident instead of sitting at eye level. Staff and leadership acknowledged that these practices did not follow facility policies requiring catheter bags to be stored in privacy bags, residents to be treated with dignity and bodily privacy, and nursing personnel to be positioned at eye level when assisting with meals.
Multiple residents experienced failures in the implementation of physician orders and care plans, including a resident on G-tube feeding whose pump was found turned off despite an active order for continuous infusion, and a resident with diabetes and Parkinson’s disease who reported months of severe foot pain and was found to have overgrown, discolored toenails and calloused, scaly plantar skin without any prior podiatry consult or related care plan interventions. Additional residents with a post–hip fracture hip abductor order and a continuous oxygen order did not have these treatments consistently applied as prescribed. These deficiencies occurred despite existing facility policies on ADLs, grooming, and resident rights.
Surveyors found that medications were not properly refrigerated, labeled, or removed after discontinuation. Lorazepam injection and oral concentrate for two residents were stored unrefrigerated in a narcotics drawer despite manufacturer stickers requiring refrigeration, and both medications had been discontinued but remained in the cart. Opened multi-dose insulin vials for several residents lacked open and discard dates, and one insulin vial was labeled with a past discard date. An LPN confirmed that insulin vials and pens must be dated and are generally usable for 28–30 days after opening, and the DON confirmed that liquid lorazepam must be refrigerated, multi-use insulin must be labeled when opened, and discontinued medications must be removed from the cart, consistent with facility policy.
Surveyors found that the facility did not ensure PPE availability for residents on Enhanced Barrier Precautions (EBP). Facility documents and policy identified several residents with wounds or a gastrostomy tube who required EBP, including gown and glove use during high-contact care. Signage on their room doors instructed staff to use gowns and gloves, but observation of the unit revealed only one isolation bin with no gowns and no other PPE available. A CNA assigned to that unit confirmed the absence of gowns and acknowledged that EBP care requires both gown and gloves, while the DON stated that PPE is expected to be readily available according to resident needs.
Surveyors found that call lights in 2 of 3 second-floor shower rooms were not working, even though any of these shower rooms could be used by any of the 91 residents on that floor. During an observation with an LPN, the nonfunctioning call lights were confirmed, and the LPN reported they had been out for several days while acknowledging their importance for patient safety. The Maintenance Director stated an outside company had been contacted but could not verify how long the lights had been inoperative, and the DON estimated they had been nonfunctional for a few days, affirming that call lights must be operable for immediate staff access. Facility policies required bathroom call lights to be treated as emergencies and defects to be promptly reported to Maintenance, yet the shower room call lights remained inoperative for multiple days.
Surveyors identified that a handrail near the elevator in the 2400 unit, where 21 residents reside, was detached from the wall, hanging down several inches, and moved noticeably when pressure was applied. The ADON confirmed the handrail was not secured, and the DON stated the facility’s expectation is that handrails be securely affixed to assist with ambulation. Facility policy on the Preventative Maintenance Program requires regular environmental tours and safety audits to ensure all areas are safe and that handrails are present and in working condition, but this was not achieved in the 2400 unit corridor.
Surveyors identified that an LPN did not follow physician orders and facility policy during medication administration, resulting in an 11% medication error rate. One resident with polyneuropathy was ordered gabapentin 600 mg plus 100 mg TID (total 700 mg), but only received 600 mg while the MAR was signed as if the 100 mg dose had been given. Another resident with essential hypertension had a BP of 101/63; the LPN held chlorthalidone despite an order to hold it only if SBP<120, and did not administer valsartan or amlodipine even though both were signed out as given on the MAR with the same BP documented. The DON reported expectations that nurses follow the five rights of medication administration and the facility’s policy requires medications to be administered and documented according to physician orders by the same licensed nurse.
A deficiency was cited when an area of the facility was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The environment and supervision protocols were found to be insufficient to minimize accident risks.
A resident with multiple diagnoses, including dementia and schizophrenia, eloped from the facility without staff awareness. The care plan addressing elopement risk was not revised promptly after the incident, and no new interventions were implemented until several days later, despite the resident's documented cognitive decline and history of expressing a desire to leave.
A resident with limited upper extremity mobility and a history of agitation suffered an arm fracture due to improper handling during ADL care. The CNAs assisting him were unfamiliar with his specific needs, and his care plan lacked interventions for managing agitation and safe dressing techniques. This deficiency highlights the facility's failure to provide adequate supervision and resident-centered care.
The facility failed to maintain a safe and comfortable environment by using unauthorized space heaters, not ensuring cleanliness and repair in shower rooms, and failing to maintain adequate temperatures in residents' rooms and the dining area. A resident was observed wearing a winter coat and using multiple blankets due to lack of heat. The Maintenance Director admitted to using space heaters temporarily, and the Administrator acknowledged ongoing heating issues. The facility's policies on electric appliances and cold weather were not followed, affecting all residents reviewed.
A resident experienced a 6% unplanned weight loss due to the facility's failure to follow its policy for weighing residents and physician orders for weekly weight checks. The resident's weight was not documented for two weeks, and the family was not informed of the weight loss. Staff acknowledged the oversight, and the issue was only brought to the attention of the Nurse Practitioner and Dietitian after the fact.
A resident with a history of aggressive behavior struck another resident in the face without provocation, despite the facility's interventions to manage such behavior. The incident occurred in the dining room, where staff intervened to separate the residents. The facility's abuse policy was not effectively implemented to prevent this occurrence.
A resident with severe cognitive impairment was punched by another resident, resulting in a facial fracture. The incident occurred after a verbal exchange when the aggressor became upset over coffee service. The facility failed to prevent the assault, highlighting a lapse in their abuse prevention policy.
A resident with multiple health conditions fell during a transfer when a CNA attempted to use a mechanical lift without a second staff member, contrary to the facility's policy. The resident sustained minor injuries and was sent to the hospital for evaluation.
A resident with a history of falls and dementia suffered an acute left femur fracture, which was discovered during an orthopedic appointment. The LTC facility failed to determine the cause of the injury, despite the resident's complaints of pain after a family outing and multiple falls in August. Staff interviews revealed a lack of understanding of protocols for injuries of unknown origin, and the facility's policy on abuse prevention was not effectively implemented.
The facility failed to maintain safe food temperatures, affecting 143 residents. A dietary cook recorded food temperatures below the required 135 degrees Fahrenheit, with ground turkey at 128.6 degrees and pasta at 126.5 degrees. The dietary supervisor confirmed the policy of holding food at 135 degrees before serving.
The facility failed to maintain cleanliness in the laundry room and did not conduct the required annual Legionella test. Observations revealed dirty washing machines, uncovered clean linens, and a lack of daily cleaning logs. The facility also lacked a policy for water testing for Legionella, potentially affecting all 146 residents.
The facility did not maintain a clean and safe environment, as brown spots from water leakage were found on ceiling tiles and dust buildup on vents in several rooms. The Maintenance Director confirmed the spots were due to leaks from air conditioners and toilets, acknowledging the failure to adhere to the facility's policy requiring ceilings to be free of watermarks and vents to be dust-free.
The facility failed to identify and address early signs of skin impairment in two high-risk residents. One resident developed a gangrenous sore that was not reported until it worsened, leading to hospitalization. Another resident was found with improper use of a low air loss mattress, and lacked a care plan for pressure ulcer prevention. The facility did not adhere to its policies on skin assessment and pressure ulcer prevention.
A facility failed to implement its abuse prevention policies for a resident at high risk for abuse. Despite being alert and oriented, the resident did not have a care plan for abuse prevention or identified offender care plan, as required by the facility's policies. The Social Service Director acknowledged the oversight, which violated the facility's procedures for creating a resident-sensitive environment.
A resident with multiple diagnoses, including dementia and a self-care deficit, was observed with long and dirty fingernails, indicating a failure in providing adequate nail care. Despite the resident's initial refusal, she agreed to nail care when asked by the Wound Care Nurse. The facility lacked a specific policy on nail care, as confirmed by the Director of Nursing.
The facility failed to implement effective fall prevention measures and update care plans for three residents at high risk for falls. One resident was found in bed not in the lowest position, another was ambulatory without a required safety helmet, and a third attempted to enter the shower room alone. The facility did not conduct fall investigations or change interventions after falls, indicating a deficiency in their fall prevention program.
The facility failed to maintain updated hospice records for two residents, affecting the coordination of care. Observations showed outdated hospice certifications and inconsistent provider information. Staff interviews confirmed a lack of communication and adherence to hospice documentation policies.
A resident with a history of anxiety and other medical conditions accessed an unsupervised laundry room in an LTC facility, resulting in a chemical burn from spilled detergent. The laundry room door was propped open, and no staff were present, violating the facility's safety policy requiring locked doors and supervision. The incident highlighted a failure in maintaining a hazard-free environment and adequate resident supervision.
Unsanitary, Damaged, and Non-Private Shower Rooms Affecting All Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, functional, sanitary, and comfortable environment in the common shower rooms on both the first and second floors, affecting all residents. A resident, a 67-year-old female with multiple diagnoses including thyroid disorder, essential hypertension, paranoid schizophrenia, unspecified psychosis, thyrotoxicosis, mild dementia, mental disorder NOS, vitamin D deficiency, constipation, and spasmodic torticollis, was identified as the complainant through her Maximus case manager, but she was unavailable for interview. The case manager reported that during a visit in the fall, he observed the first-floor shower room next to the conference room and described it as horrible, with broken floor tiles, no privacy curtains, and mold throughout the bathroom. Surveyor observations on the first floor showed that the 400 hall shower room was locked and required the Maintenance Director to open it, as nursing and housekeeping staff did not have a key. Inside, the toilet bowl had dark brown stains and, when flushed, spewed dark brown water. Floor and wall tiles were chipped, some shower areas lacked curtains, assistive devices were stored in the room, and there were varying degrees of dark substance on the grout of walls and floors. The 200 hall shower room contained bath blankets on the floor, unflushed urine in the toilet, chipped 1x1 floor tiles and broken wall tiles, dark substances on floors and walls, and was also used for storage of assistive devices. There was no privacy curtain for the toilet, which was visible from the hallway when the door was open, and there was no lock on the door. The DON stated that most first-floor residents are more independent and shower without assistance, and the identified resident’s care plan indicated she requires assistance with ADLs. On the first floor, another shower room on the 500 hallway was entirely used for storage and not available for shower use. On the second floor, all shower rooms were observed to have crumbling tile, lack of privacy curtains, and varying levels of dark substances on floors and walls. A housekeeper reported that bathrooms are cleaned once per shift and upon request, while the Housekeeping Manager stated that she and housekeepers make rounds and clean when they determine it is needed. The Infection Preventionist stated she is mainly involved with antibiotics and not housekeeping and did not provide a policy for shower cleaning or remediation of the dark substance. There was no facility policy on housekeeping protocol for shower cleaning, no logs or scheduled cleaning records available for review, and resident council minutes documented at least three complaints about the shower rooms being filthy. Based on these observations, interviews, and record reviews, the facility did not provide a clean, safe, comfortable, and sanitary area for residents to shower, and a deficiency was cited.
Failure to Protect Residents from Verbal and Physical Abuse
Penalty
Summary
The facility failed to protect residents from verbal and physical abuse, as evidenced by two separate incidents involving two residents. In the first incident, a cognitively intact resident was subjected to inappropriate and profane language by a staff member during an argument about returning from a smoke break. Multiple interviews and documentation confirmed that the staff member used hostile and unprofessional language, including profanity, towards the resident. Witnesses described the staff member as agitated and hostile, and the resident reported feeling disrespected, childlike, and angry as a result of the interaction. The facility's abuse policy, which prohibits such behavior, was not followed in this case. In the second incident, a resident with severe cognitive impairment and a diagnosis of schizophrenia was reportedly subjected to both verbal and physical mistreatment by a certified nursing assistant (CNA). Multiple residents and a nurse reported that the CNA was verbally aggressive, used disparaging language, and was excessively loud when providing care. Witnesses also reported hearing the CNA give harsh commands and a thud against the wall, and the resident herself stated that the CNA hit her on the head and pushed her. The resident expressed a desire not to be cared for by this CNA and reported feeling mistreated on several occasions. The facility's investigation included multiple interviews and statements corroborating the resident's claims of mistreatment. Both incidents demonstrate a failure to ensure that residents were free from all forms of abuse, including verbal, mental, and physical abuse, as required by the facility's own policies and federal regulations. The actions of the staff members involved resulted in residents experiencing fear, intimidation, and emotional distress. The facility did not prevent or adequately address the abusive behaviors at the time they occurred, leading to substantiated findings of mistreatment and abuse.
Failure to Prevent Access to Alcohol for Resident With Known Alcohol Abuse History
Penalty
Summary
The deficiency involves the facility’s failure to monitor and supervise a resident with a known history of alcohol abuse, allowing the resident to obtain and consume alcohol on two separate occasions, resulting in hospitalizations. The resident was admitted with diagnoses including alcohol abuse, opioid abuse, bipolar disorder, schizoaffective disorder, hypertension, acute kidney failure, and acute respiratory failure. The resident’s care plan identified a history of substance abuse/chemical dependency, including opioid abuse and alcohol use, and included an intervention to establish a behavioral contract and ensure the resident was aware of rules prohibiting alcohol and illicit substances. The facility’s house rules also stated that drug and alcohol use were strictly prohibited and that illegal or non-prescribed drugs or alcohol may not be brought into the premises. On one occasion, a progress note documented that while an LPN was passing medications, a CNA called out after nearly finding the resident on the floor. The resident’s room was in disarray, and upon assessment, the resident was drowsy and disoriented, with vital signs within normal limits. As the LPN moved the call light closer to the resident, an empty bottle of brandy wine was found on the bed. When asked where the bottle came from, the resident became upset, used profanity, and later came to the nurse’s station and threw a shoe at staff. The resident was sent to the hospital, where records showed diagnoses of alcohol intoxication, aggressive behavior, and chronic tremor, and the hospital physician attributed the aggressive behavior to alcohol intoxication. On a later occasion, another progress note documented that staff were informed the resident had alcohol in his room under his pillow. An LPN went to the room and found a liquor bottle under the resident’s cover. After the bottle was removed, the resident noticed it was gone, went to the nurse’s station where his roommate was standing, and began arguing, shouting, and cursing at the roommate, refusing to calm down when asked. Hospital records from this second episode again documented admission for aggressive behavior, alcohol intoxication, chronic tremor, hypertension, hypothyroidism, and COPD. Interviews indicated that the facility did not know how the resident obtained alcohol in the first incident, and that in the second incident the alcohol had been purchased for the resident by a staff member, despite facility rules and the resident’s documented alcohol abuse and care plan interventions.
Failure to Accurately and Consistently Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that required daily nurse staffing information was accurately completed and consistently posted for public review. On 08/11/25 at 9:20 AM, a surveyor observed that the Daily Nurse Staffing information posted near the receptionist area was last dated 08/06/25, showing that current staffing data had not been posted for five consecutive days. The posted Daily Nursing Staffing form also lacked unit-specific information, meaning the required details for each unit were not provided. At 11:30 AM the same day, the DON confirmed that accurate and up-to-date daily staffing information is required to be posted each day. A record review of the form posted on 08/11/25 further confirmed it was incorrectly dated 08/06/25 and incomplete, lacking unit-specific data, despite the requirement that such information be available for residents and the public. The Illinois Long-Term Care Ombudsman Program Residents' Rights pamphlet cited in the report notes that facilities must provide services to keep residents’ physical and mental health at their highest practical levels and that the facility must be safe, clean, comfortable, and homelike. These failures had the potential to affect all 161 residents residing in the facility, as the required daily nurse staffing information was neither current nor complete for multiple days, and the posted documentation did not meet the specified content requirements.
Insufficient Dietary Staffing Leads to Unsanitary Kitchen Conditions
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient support personnel to safely and effectively carry out food and nutrition services in the kitchen, resulting in multiple unsanitary conditions. During an observation with the Dietary Manager, only two staff were working in the kitchen instead of the three scheduled, due to one staff member having a pre-approved sick day. The Dietary Manager reported she was covering the absent staff member’s position and that the kitchen was running behind. Surveyors observed debris on the kitchen floor near the wall from a grease trap backing up from under the kitchen floor, and the Dietary Manager stated this backup happened frequently and that Maintenance had been aware of it for a long time. The ice machine was observed with visible dirt on the left, right, and front sides, and it was overflowing with ice. The broken cover of the ice machine was seen lying on wet blankets placed on the floor to catch water dripping from the ice. The surveyor also observed that the food mixer, which was covered with transparent plastic wrap, had accumulated food particles, and the Dietary Manager acknowledged it should have been cleaned before being covered but was not, due to the kitchen running behind while she functioned in the absent staff member’s role. The facility census showed 161 residents, with 159 receiving oral foods from the kitchen. The facility’s dietary job descriptions indicated that the dietary aide working 6:30 a.m. to 3:00 p.m. was responsible for ensuring all hydration stations were filled, and the AM cook working 5:30 a.m. to 2:00 p.m. was responsible for cleaning the cook area. The facility’s dietary services policy required that all food equipment, utensils, dishes, and steam tables be cleaned and sanitized daily, that ice machines be used and maintained to eliminate contamination during ice manufacture, storage, and dispensing, and that all floor surfaces be cleaned daily and as appropriate using appropriate cleansers. These observed conditions and staffing issues occurred in the context of providing food to 159 residents who receive oral nutrition from the facility’s kitchen.
Improper Milk Storage Temperatures and Unsanitary Kitchen Conditions
Penalty
Summary
Surveyors identified multiple deficiencies in the facility’s dietary services related to food storage temperatures and sanitation practices in the kitchen. During a kitchen observation with the Dietary Manager, debris from a grease trap backup was seen on the kitchen floor near the wall; the Dietary Manager stated this backup happens frequently and that Maintenance had been aware of it for a long time. The air vent/vent return above the food preparation table was observed with accumulated dust. The ice machine had visible dirt on its left, right, and front sides, was overflowing with ice, and its broken cover was lying on wet blankets placed on the floor to catch dripping water. The food mixer, which was covered with transparent plastic wrap, had accumulated food particles on it, and the Dietary Manager acknowledged it should have been cleaned before being covered. The surveyors also found that milk was not being stored at appropriate refrigerated temperatures. The milk cooler thermometer read 55°F, and after calibrating a new thermometer, two of twelve 8‑oz whole milk cartons that had been in the cooler for four days were measured at 51°F; the Dietary Manager stated milk should be stored at less than 41°F. Facility resident council minutes from two separate monthly meetings documented resident complaints about spoiled milk. Facility policies on food storage and dietary services required perishable foods, including dairy products and eggs, to be stored between 33°F and 41°F, and required that food equipment, ice machines, and floor surfaces be cleaned and sanitized daily and maintained to prevent contamination. At the time of the survey, 159 residents were receiving oral nutrition from the facility’s kitchen, and the cited conditions were present in the kitchen and food service areas.
Failure to Maintain Kitchen Equipment, Drainage, and Milk Storage Temperatures
Penalty
Summary
Surveyors identified that the facility failed to maintain essential kitchen equipment in safe working order, affecting food service for 159 residents who receive oral nutrition from the kitchen. During a kitchen observation with the Dietary Manager, debris and residue from a grease trap backup were seen on the floor near the wall, and the Dietary Manager stated this backup from under the kitchen floor happens frequently and that Maintenance has been aware of it for a long time. The Administrator later explained that the three-compartment sink could cause the grease trap to overflow and back up onto the kitchen floor if all three compartments are emptied at the same time, indicating the drain system was not functioning properly. Maintenance logs for July and August documented repeated reports from dietary staff about the three-compartment sink leaking and the need to replace the ice machine lid, with no evidence on the logs that these issues were addressed or resolved, despite facility policies and the Maintenance Director job description requiring the building and drains to be kept in good repair, clean, and free of hazards. Surveyors also observed that the ice machine was overflowing with ice and that its cover was broken and could not fit properly, as confirmed by the Dietary Manager, who reported the broken cover had been reported several times and that the machine would need replacement. The broken cover was seen placed on wet blankets on the floor that were being used to catch water dripping from the ice. In addition, the milk cooler thermometer read 55°F, and after calibrating a new thermometer, two of twelve 8‑oz cartons of whole milk that had been stored in the cooler for four days were measured at 51°F. The Dietary Manager acknowledged that milk should be kept below 41°F and that the refrigerator should be cold enough to maintain that temperature. These conditions occurred despite facility dietary and food storage policies requiring that ice machines be maintained to eliminate contamination, floor surfaces be kept clean, and perishable foods such as dairy products be stored between 33°F and 41°F to protect against spoilage and prevent the spread of infections and communicable diseases.
Failure to Maintain Clean Dryer Lint Screens and Compartments
Penalty
Summary
The facility failed to adequately clean and maintain dryer lint screens and compartments in the laundry area, creating a deficiency in providing a safe, clean, and well-maintained environment for all 161 residents. During a tour of the laundry area with the housekeeping supervisor, three dryers were observed; in dryer #1 the lint compartment floor was clean but the lint screen was fully covered with lint, in dryer #2 the lint compartment floor had loose lint and the lint screen was fully covered with lint, and in dryer #3 the lint compartment floor had a large amount of loose lint and the lint screen was fully covered with lint. The housekeeping supervisor stated that the lint needed to be cleaned up right away, reported that lint screens and compartments were supposed to be cleaned every shift, and acknowledged that not cleaning the lint out can cause a fire. The DON also acknowledged that failure to regularly clean dryer lint compartments poses a significant fire hazard and stated that dryer lint should be cleaned out after each load. Facility policies on Laundry Services and Resident Rights documented that laundry staff are responsible for maintaining cleanliness of the laundry room and equipment, that machines should be cleaned and disinfected at least daily, and that staff must follow policies and rules to support quality care and a safe environment. No specific residents with individual medical histories or conditions were identified in the report; the deficiency was determined to have the potential to affect all 161 residents residing in the facility at the time of the survey.
Failure to Maintain Resident Dignity, Privacy, and Respectful Assistance
Penalty
Summary
The deficiency involves multiple failures to uphold resident dignity and privacy, including improper handling of urinary catheter drainage bags, lack of appropriate clothing, failure to use privacy curtains, and undignified feeding assistance. One resident with cognitive impairment and an indwelling urinary catheter was observed in bed with an uncovered urinary drainage bag hanging from the bed frame, containing approximately 1500 ml of dark amber urine with large sediment. The resident stated that staff only sometimes covered the bag. An LPN confirmed at the time of observation that the catheter bag was not covered and acknowledged that urinary catheter bags should be stored in a privacy bag or otherwise covered to maintain dignity, consistent with facility policy requiring drainage bags to be stored in a privacy bag. Another resident with cognitive impairment, an unhealed pressure ulcer, and an indwelling urinary catheter was also observed lying in bed with an uncovered urinary drainage bag hanging from the bed frame, containing approximately 300 ml of straw-colored urine. When asked about the uncovered bag, this resident was unable to provide an explanation. The DON later affirmed that urinary drainage bags must be stored in a manner that promotes resident dignity and privacy and that residents should have a privacy bag even when in their rooms. Additionally, a resident with legal blindness, cognitive impairment, and a care plan requiring substantial/maximal assistance with eating was observed being fed by a CNA who stood over the resident rather than sitting at eye level. The CNA acknowledged awareness that staff should be seated at eye level when assisting with meals, as required by facility policy, but stated they were also acting as a sitter for two other residents. Further dignity concerns were identified involving two roommates. One cognitively intact resident was observed from the hallway using only a thin blanket for coverage and reported having no clothes, stating that they had to go to the nurse’s station naked and walk around the facility without clothing because none were available. No clothing was observed in this resident’s room. At the same time, the roommate was seen from the hallway sitting in a wheelchair with no pants on and an incontinence brief fully exposed, with no privacy curtain drawn or other measures used to maintain bodily privacy. A CNA assisting the roommate with dressing confirmed assignment to both residents, acknowledged that the cognitively intact resident was naked under the blanket due to lack of clothes, and stated that when assigned to this resident they had to search laundry for spare clothing that might fit. The CNA then obtained pants, a shirt, and an incontinence brief from the linen cart and placed them on the resident’s bed. These observations conflicted with the facility’s dignity and resident rights policies, which require staff to promote bodily privacy, respect, and a positive self-image.
Failure to Follow Physician Orders and Care Plans for Enteral Feeding, Podiatry, Hip Abductor, and Oxygen
Penalty
Summary
The deficiency involves multiple failures to follow physician orders and care plans for several residents. One resident with a gastrostomy tube had an order for Glucerna 1.2 at 85 mL/hr for 20 hours, with the feeding to remain on until a specified time and serving as the resident’s only source of nutrition and hydration. During observation, the resident was in bed with the enteral feeding pump turned off, despite the order indicating it should have been running. The feeding bottle showed only about 250 mL infused when approximately 510 mL should have been administered based on the start time and ordered rate. The wound care nurse confirmed the pump was off without any reason documented and that the feeding should have been on according to the electronic health record and care plan. Another deficiency concerns a resident with diabetes mellitus, muscle weakness, and Parkinson’s disease whose care plan included monitoring for skin issues and need for assistance with ADLs. The resident reported ongoing severe foot pain, describing toenails digging into the skin and throbbing in the feet, and stated having repeatedly asked staff for three months to have a doctor examine the feet. On examination, an LPN found markedly overgrown, thickened, discolored toenails with sharp, irregular edges, and multiple areas of hard, dry, scaly skin on the plantar surfaces of both feet. There was no prior podiatry order in the EMR, and staff acknowledged that no podiatry consult had been placed until the surveyor raised the concern. The most recent MDS did not document the existing hard, dry, patchy areas on the feet, and the care plan did not reflect a need for skilled foot care or interventions related to the poor foot condition, despite facility policies on ADLs, grooming, and resident rights. Additional deficiencies include failure to follow physician orders and care plans for a resident with a right hip fracture and hip replacement, and a resident with an order for continuous oxygen. One resident had an active order and care plan requiring use of a hip abductor device while in bed, with specific instructions for placement from hip to ankle level and proper strap fit, but the report indicates the facility did not ensure the device was applied as ordered. Another resident with diagnoses including COPD, encephalopathy, obstructive sleep apnea, and hyperlipidemia had an active physician order for oxygen at 3 L via nasal cannula to be used continuously, and the facility failed to follow this order. These combined actions and inactions affected four residents reviewed for quality of care.
Improper Refrigeration, Labeling, and Disposal of Medications
Penalty
Summary
Surveyors identified that medications were not stored and labeled according to professional standards and facility policy. Lorazepam Injection Solution 2 mg/mL for resident R136 was found in the controlled substance narcotics drawer of the medication cart at 11:14 AM, unrefrigerated, despite a sticker on the packaging instructing that it be kept refrigerated. The LPN (V13) confirmed that the medication should be refrigerated per the manufacturer’s instructions to maintain patency. Physician orders showed that this lorazepam injection had been discontinued on a prior date, yet it remained in the cart. Similarly, at 11:21 AM, Lorazepam Oral Concentrate 2 mg/mL for resident R137 was observed unrefrigerated in the narcotics drawer, also labeled to be kept refrigerated, and the LPN (V23) confirmed it should be refrigerated. Physician orders documented that this lorazepam oral concentrate had also been discontinued on a prior date but was still present in the cart. At 11:25 AM, additional medication storage and labeling issues were observed in the medication cart with LPN V23. Opened multi-dose insulin vials for residents R70 (Humalin solution), R42 (Humalog), and R51 (insulin lispro) were found without an open date or expiration/discard date. Another opened vial of Insulin Aspart for resident R107 was labeled with a discard date of 7/23, which V23 acknowledged as expired and removed from the cart. V23 affirmed that all multi-dose insulin vials and pens are to be labeled with the open date and discard date and stated that insulin is generally good for 28 to 30 days after opening. The DON (V2) confirmed that facility expectations are that liquid lorazepam is stored in the refrigerator, all multi-use insulin containers are labeled and dated when opened, and discontinued medications are removed from the cart. Facility policies on labeling/dating medications and medication storage require dating of insulin when first opened, refrigeration of medications requiring 36–46°F, and immediate withdrawal and disposal of outdated or deteriorated drugs.
Failure to Provide PPE for Residents on Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified that the facility failed to provide sufficient personal protective equipment (PPE) for residents requiring Enhanced Barrier Precautions (EBP), specifically affecting four residents identified in facility documentation as needing EBP due to a gastrostomy tube or wounds. The facility’s EBP policy, revised in 9/2023, and an EBP document dated 8/2025 indicated that residents with multidrug-resistant organisms (MDRO) or at increased risk of acquiring MDRO require gown and glove use during high-contact resident care activities. On 8/11/2025, signage on the doors of the rooms for these residents indicated that gloves and gowns were required when performing resident care. However, during observation of the 2400 unit, only one isolation bin was present and it contained no gowns, and no other PPE was available on the unit. A CNA assigned to the 2400 unit confirmed that there were no gowns available for residents on EBP and stated they would not be able to care for the residents properly without a gown and gloves, which are required to provide care under EBP. The DON later affirmed that the facility’s expectation is that PPE be readily available for staff as indicated by resident needs.
Nonfunctional Call Lights in Second-Floor Shower Rooms
Penalty
Summary
Surveyors identified that call lights in 2 of the 3 shower rooms on the second floor were nonfunctional, despite facility policy requiring operable call systems to allow residents to request assistance. During an observation of the second-floor shower rooms with an LPN, it was confirmed that the call lights in these two shower rooms did not work. The LPN stated that any of the shower rooms could be used by any of the 91 residents residing on that floor and reported that the call lights had not been working since a specific Friday. The LPN also acknowledged that call lights are important for patient safety. Further interviews showed that the Maintenance Director reported an external company had been contacted to repair the inoperative call lights but could not confirm how long they had been nonfunctional. The DON stated that the call lights in the second-floor shower rooms had been out for about two or three days and confirmed that call lights must be operable and functioning properly in case a resident requires immediate staff accessibility. Facility policies titled "Call Light" and "Resident Rights" documented that bathroom call lights should be treated as emergencies requiring immediate attention and that call bell system defects must be promptly reported to Maintenance, as well as the requirement to follow policies and rules that support quality care and a safe environment. Despite these policies, the call lights in two second-floor shower rooms remained nonfunctional for multiple days while still available for use by residents.
Unsecured Corridor Handrail in Resident Unit
Penalty
Summary
The deficiency involves the facility’s failure to ensure that handrails were securely affixed along resident corridors in the 2400 unit. Census documentation showed that 21 residents resided on this unit. During observation on 8/12/2025 at 9:39 AM, the handrail near the elevator in the 2400 unit was found detached from the wall and hanging down approximately 6 inches, with a hole about 4 inches long visible where the handrail had been anchored. When pressure was applied to the top and bottom of the handrail, it was loose and able to move approximately 6 inches. The Assistant DON observed the condition of the handrail and confirmed it was not secured to the wall. On 8/13/2025 at 10:33 AM, the DON affirmed that the facility’s expectation is that handrails are securely affixed to the walls in case a resident needs assistance with ambulation. The facility’s written policy titled “Preventative Maintenance Program” dated 4/21/21 states that the purpose is to conduct regular environmental tours and safety audits to identify areas of concern within the facility, including that all facility areas are kept in safe condition and that handrails are present and in working condition. The observed loose and detached handrail in the 2400 unit corridor demonstrates that this policy was not effectively implemented, resulting in unsecured handrails in an area where 21 residents reside.
Medication Administration Errors Resulting in Elevated Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 25 medication opportunities, resulting in an 11% error rate. During a medication pass observed with an LPN on the first floor, a female resident with a diagnosis of polyneuropathy received only part of her ordered gabapentin regimen. The active physician orders directed that she receive gabapentin 600 mg plus an additional 100 mg tablet three times daily (total 700 mg TID) for neuropathy. However, the nurse administered only the 600 mg tablet and did not give the 100 mg tablet, yet documented in the MAR that the 100 mg dose had been given. In a separate observation with the same LPN, another resident with essential primary hypertension had a blood pressure of 101/63 and heart rate of 97 prior to medication administration. The nurse administered five medications and held chlorthalidone 25 mg due to the systolic blood pressure of 101. The physician’s orders specified that chlorthalidone should be held if SBP was less than 120, and that valsartan (80 mg total) and amlodipine 5 mg should be held if SBP was less than 110. Observation showed that valsartan and amlodipine were not administered, but the MAR reflected that both medications were signed out as given with the documented blood pressure of 101/63, and chlorthalidone was not given despite the order parameters. The DON stated that her expectations for nurses during medication administration include following the five rights of medication administration, proper hand hygiene, and maintaining resident privacy, and the facility’s medication administration policy requires medications to be administered in accordance with physician orders and documented by the same licensed nurse who administers them.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Revise Care Plan After Resident Elopement
Penalty
Summary
The facility failed to revise a comprehensive care plan and did not develop a care plan with measurable goals, objectives, and individualized interventions to address the need for increased supervision and preventive interventions for a resident at risk for elopement. The resident, who had diagnoses including schizophrenia, hyperlipidemia, cerebral infarction, bilateral primary osteoarthritis of the knee, dementia, and PTSD, was admitted with a history of expressing a desire to leave the facility and demonstrated cognitive decline as evidenced by a decrease in BIMS scores. Despite being identified as an elopement risk and placed on elopement protocol upon admission, the care plan was not updated in a timely manner following a significant incident. The resident eloped from the facility without staff knowledge, and the absence was only discovered after a family member notified the facility. The care plan addressing elopement risk was not revised until several days after the incident, and no new interventions were implemented until even later. Documentation and interviews confirmed that the care plan was not promptly updated after the elopement, and the facility's own policy required reassessment and care plan revision following such events. The lack of timely revision and individualized interventions contributed to the deficiency.
Failure to Implement Resident-Centered Interventions Leads to Injury
Penalty
Summary
The facility failed to implement resident-centered interventions for a resident, R3, who had a behavior of agitation and limited mobility in the upper extremities, leading to an injury. R3, a male resident with diagnoses including Bipolar Disorder and reduced mobility, required substantial assistance for upper body dressing due to impairments in both upper extremities. During an incident, while being assisted by CNAs with activities of daily living, a pop sound was heard from R3's left shoulder, which was initially assessed with no fracture. However, days later, R3 was found to have an oblique displaced fracture in the left humerus after being transferred to the hospital due to swelling and pain. Interviews with staff revealed that during the incident, R3 became agitated when a CNA attempted to remove his shirt by pulling it from the back and then from the sleeve, which led to the pop sound. The CNAs involved were not familiar with R3's specific needs and limitations, as it was their first time working with him. R3's care plan did not include specific interventions for managing his agitation during ADL care or instructions on how to safely perform dressing tasks given his limited mobility and tendency to become agitated. The facility's policies on behavioral management and ADL care emphasized the need for individualized care plans and special instructions, but these were not adequately implemented for R3. Staff interviews indicated a lack of consistent understanding and application of appropriate techniques for dressing R3, which contributed to the incident. The absence of clear guidelines and interventions in R3's care plan for handling his agitation and mobility limitations during ADL care was a significant factor in the occurrence of the injury.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to provide a safe and comfortable environment for its residents by using unauthorized space heaters in residents' rooms, failing to maintain cleanliness and repair in shower rooms, and not ensuring adequate temperature in residents' rooms and the dining area. A resident, who has been at the facility since 2024, was observed wearing a winter coat and using multiple blankets to keep warm due to the lack of heat in his room. The Maintenance Director admitted to using space heaters temporarily in certain rooms due to heating issues, which were removed when state inspectors arrived, acknowledging that space heaters are a fire hazard. The facility's shower rooms on the first floor were found to be in poor condition, with dirty walls, peeled-off base wall trims, and brownish stains. The Maintenance Director confirmed the need for cleaning and repairs, noting that the facility has many repairs pending and that decisions on when to perform them are not within his control. Additionally, the dining room was observed to be very cold, with temperatures ranging from 50 to 69 degrees, indicating inadequate heating. The facility's policies on electric appliances and cold weather were not adhered to, as space heaters were used without proper authorization, and residents were not moved to adequately heated areas as required. The Administrator acknowledged the heating issues and mentioned ongoing efforts to address them, but the deficiencies remained unaddressed at the time of the survey. The facility's failure to maintain a safe and comfortable environment affected all five residents reviewed for environmental conditions.
Failure to Monitor Resident's Weight Leads to Significant Weight Loss
Penalty
Summary
The facility failed to adhere to its policy for weighing residents and did not follow physician orders for weekly weight checks, resulting in a 6% unplanned weight loss for a resident. The resident, an elderly male with multiple medical conditions including chronic obstructive pulmonary disease, dementia, and hypertension, was admitted to the facility and had documented weights only on three occasions within a month. Despite physician orders for weekly weights, there were no recorded weights for a two-week period, leading to a significant weight loss that went unnoticed by the staff. The resident's family was not informed of the weight loss, and the facility's staff, including a Licensed Practical Nurse and a Wound Nurse, acknowledged the oversight in weight documentation. The Assistant Administrator provided records showing the weight loss, and both the Nurse Practitioner and Consultant Dietitian were only made aware of the issue after the fact. The facility's policy required notification of the physician and family for significant weight changes, which was not followed in this case.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by an incident involving two residents. One resident, with a history of disorganized schizophrenia and bipolar disorder, was struck in the face by another resident without provocation. The aggressor, who has a history of Alzheimer's disease, paranoid schizophrenia, and schizoaffective disorder, was known to display conflictual and aggressive behavior when agitated. Despite this, the facility's interventions to manage such behavior were not effectively implemented on the day of the incident. On the day of the altercation, the aggressive resident was already agitated, and although a CNA attempted to calm him, he was not moved to a different location as per usual practice. The incident occurred in the dining room, where the aggressor walked up to the victim and hit him in the eye. Staff intervened to separate the residents, but the aggressor continued to display aggressive behavior. The facility's abuse policy affirms the right of residents to be free from abuse, yet the measures in place failed to prevent this occurrence.
Failure to Prevent Resident-to-Resident Physical Assault
Penalty
Summary
The facility failed to prevent a resident-to-resident physical assault, resulting in a deficiency related to abuse prevention. Two residents were involved in the incident, where one resident, diagnosed with schizoaffective disorder and dementia, was punched in the face by another resident. This assault led to the victim falling backward and sustaining a right frontal maxillary process fracture. The incident occurred when the aggressor became upset after being instructed by staff to wait for coffee service, leading to a verbal exchange with the victim, who mistakenly believed the aggressor was swearing at him. The facility's abuse prevention program, which aims to protect residents from mistreatment and abuse, was not effectively implemented in this case. The aggressor's actions were substantiated as abuse, and the facility's failure to intervene before the physical assault occurred highlights a lapse in following their abuse policy. The victim's severe cognitive impairment and high risk for abuse, as documented in their records, further emphasize the need for vigilant supervision and intervention to prevent such incidents.
Failure to Follow Mechanical Lift Transfer Protocol
Penalty
Summary
The facility failed to adhere to its policy and procedure for mechanical lift transfers by not ensuring two staff members were present during the transfer of a resident using a mechanical lift. This deficiency was identified in the case of a male resident with a history of COPD, dysphagia, partial paralysis following a stroke, morbid obesity, seizures, weakness, anxiety disorder, and mild recurrent major depressive disorder. The resident, who was at risk for falls, experienced a fall during a transfer from his bed to his wheelchair when a certified nursing assistant attempted the transfer alone, resulting in the mechanical lift tipping over and causing the resident to fall and sustain injuries. The resident's care plan required a two-person transfer when using a mechanical lift, as per the facility's policy and procedure. However, on the day of the incident, the certified nursing assistant did not have a second staff member present, leading to the resident falling and sustaining a small abrasion and hematoma to his elbow. The resident was subsequently sent to the hospital for evaluation due to being on blood thinners. The incident was documented in the resident's progress notes and fall risk management report, confirming the failure to follow the established transfer protocol.
Failure to Determine Cause of Resident's Fracture
Penalty
Summary
The facility failed to prevent or determine the cause of an injury of unknown origin for a resident, resulting in an acute left femur fracture. The resident, who had a history of falls and was a high fall risk due to dementia and an unsteady gait, was discovered to have the fracture during an orthopedic appointment. Despite multiple falls in August, the facility did not identify any injuries at the time, and the fracture was not discovered until late September. Interviews with staff revealed a lack of awareness and understanding of protocols for injuries of unknown origin. Nurses and other staff members were unable to explain how the fracture occurred, and there was no documentation of any falls or incidents in September that could have led to the injury. The resident had previously been sent out on a pass with family and returned with complaints of pain, but this was not further assessed or reported to a physician. The facility's policy on abuse prevention states that an injury should be classified as of unknown source when the cause is not observed or explained and is suspicious due to its extent or location. The facility's inability to determine the cause of the fracture, despite the resident's history of falls and new onset of pain, indicates a deficiency in their ability to protect residents from injuries of unknown origin.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to ensure that food was held at a safe and proper temperature before serving, affecting 143 out of 146 residents observed for food temperatures. On the specified date, a dietary cook was observed taking food temperatures, with the ground turkey for upstairs recorded at 128.6 degrees Fahrenheit, which was then reheated to 131.0 degrees. The turkey patties were at 131.2 degrees, whipped potatoes at 128.0 degrees, and pasta at 126.5 degrees. The dietary cook acknowledged that the food temperature should be holding at 160-170 degrees Fahrenheit and planned to reheat the food and retake the temperatures. Later, the dietary supervisor stated that all food should be held at 135 degrees Fahrenheit before serving, and committed to ensuring the food was at the correct temperature before serving. The facility's policy mandates that hot food is cooked to a minimum safe temperature and held no lower than 135 degrees Fahrenheit, with specific guidelines for different food types.
Infection Control and Water Testing Deficiencies
Penalty
Summary
The facility failed to ensure the cleanliness of washing machines and to keep clean linens covered, as well as to conduct an annual test to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water system. During an inspection, it was observed that three washing machines in the laundry room were dirty, with detergent residues and accumulated dirt inside and outside, including the rim of the door. One machine was out of order, and the floor in front of the machines had missing and broken tiles. Additionally, the eye wash sink was dirty, and there was an overflow of unfolded, uncovered clean linens and clothes from containers. The laundry staff did not maintain a daily cleaning log for the washing machines, which should be cleaned and disinfected daily after each use, according to the facility's policy. Furthermore, the facility did not conduct the required annual Legionella test for 2024, as confirmed by the Maintenance Director, who stated that they were only performing daily water temperature checks. The facility's administrator acknowledged the absence of a policy on water testing for Legionella and other opportunistic waterborne pathogens. The facility's policy on laundry service mandates that all clean linen be stored covered and that the laundry room and its equipment be maintained clean, with spills cleaned immediately. However, the facility was unable to provide a policy on water testing for Legionella and other pathogens, which could potentially affect all 146 residents using the facility's linens and water.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to adhere to its policy of maintaining a safe, clean, comfortable, and homelike environment for residents, as evidenced by the presence of brown spots on ceiling tiles and dust buildup on vents in several rooms. During observations conducted on September 17, 2024, rooms 205, 211, 2210, and another unspecified room were found to have brown spots on the ceilings and dust accumulation on the vents. Interviews with the Maintenance Director (V11) revealed that the brown spots were due to water leakage from various sources, including air conditioners and toilets from rooms above. Both V11 and another staff member (V2) acknowledged that the facility's policy requires ceilings to be free of watermarks or spots and vents to be free of dust buildup, which was not the case in the observed rooms.
Failure to Identify and Address Skin Impairments in High-Risk Residents
Penalty
Summary
The facility failed to identify early signs of skin impairment and provide timely treatment for a resident, R103, who was at high risk for skin issues. R103 developed a gangrenous sore on her foot, which was not reported or documented until it had significantly worsened. Despite being admitted with intact skin and a high risk for skin impairment, the facility did not conduct adequate skin assessments or follow up on early signs of skin issues. The resident's family member had informed a CNA about the sore months prior, but no action was taken until the condition had deteriorated, leading to hospitalization and potential amputation. Additionally, the facility did not adhere to the manufacturer's recommendations for the use of a low air loss mattress for another resident, R88. The resident was found with multiple layers of linens on the mattress, contrary to the policy that allows only one pad or sheet. This oversight was attributed to a hospice CNA, and the assigned CNA had not checked on the resident. Furthermore, R88, who was also at high risk for skin impairment, did not have a care plan developed for the prevention of pressure ulcers or skin injuries. The facility's policies on skin assessment and pressure ulcer prevention were not followed, as evidenced by the lack of timely reporting and documentation of skin impairments and the absence of appropriate care plans for high-risk residents. The failure to implement these policies contributed to the deficiencies observed in the care of residents R103 and R88.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written policies and procedures to prevent abuse, neglect, and theft, affecting one resident (R19) out of a sample of 29 reviewed for the abuse prevention program. On observation, R19 was found to be alert, oriented, and able to propel himself in a wheelchair. However, upon review of R19's medical records, it was discovered that there was no care plan for abuse prevention or identified offender care plan, despite his admission assessment indicating a high risk for abuse. The Social Service Director (V5) acknowledged that R19 should have had these care plans in place upon admission. The facility's policies on abuse prevention and identified offenders require the establishment of a resident-sensitive environment and the development of individualized care plans for residents at risk of abuse or identified as offenders. These policies include conducting criminal history background checks and consulting with the medical director and law enforcement to address the resident's needs. However, the facility did not adhere to these procedures for R19, as there was no documented care plan addressing his high-risk status, which is a clear violation of the facility's own policies.
Failure to Provide Adequate Nail Care for Dependent Resident
Penalty
Summary
The facility failed to provide adequate nail care to a resident who was dependent on assistance for Activities of Daily Living (ADLs). During an observation on September 17, 2024, a resident was noted to have long and dirty fingernails with black or dark-colored dirt underneath. This observation was confirmed by both the Wound Care Nurse and a Certified Nurse Assistant, who acknowledged that nail care should be provided during personal hygiene or shower routines. Despite the resident initially refusing nail care, she agreed to have her fingernails trimmed and cleaned when asked directly by the Wound Care Nurse. The resident in question was admitted with multiple diagnoses, including cerebral infarction, encephalopathy, dementia, and other conditions that contribute to a self-care deficit. The comprehensive care plan for this resident indicated a need for assistance with all ADLs, including personal hygiene. However, the facility was unable to provide a specific policy on nail care, and the Director of Nursing confirmed the absence of such a policy. This deficiency affected the resident's ability to maintain personal hygiene and dignity, as outlined in the facility's general ADL policy.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement effective fall preventive measures and update fall care plans after each fall occurrence, affecting three residents. One resident, identified as R88, was observed lying in bed not in the lowest position, despite being at high risk for falls due to multiple incidents. The facility did not conduct fall investigations or root cause analyses for R88's falls, and interventions were not changed after each occurrence. The resident's care plan indicated the need for the bed to be in the lowest position, which was not consistently followed. Another resident, R146, was observed ambulatory without wearing a soft Velcro safety helmet, which was part of his fall prevention care plan. Despite being at high risk for falls, the facility did not conduct fall investigations or change interventions after each fall. The resident's protective helmet was not found in his room, and he was seen in the dining room without it, indicating a lack of adherence to the care plan. A third resident, R13, was observed attempting to enter the shower room alone, despite being a high fall risk. The resident's care plan was not updated after a fall in the shower room, and the facility failed to ensure staff were aware of necessary interventions. The resident had a history of falls and was identified as high risk, yet the care plan was not revised following the most recent fall, highlighting a deficiency in the facility's fall prevention program.
Deficiency in Hospice Documentation and Coordination
Penalty
Summary
The facility failed to ensure that updated medical records for residents receiving hospice care were available and accessible to the interdisciplinary team (IDT). This deficiency was identified during a survey involving two residents, R88 and R113, who were part of a sample reviewed for hospice services. Observations revealed that both residents were totally dependent on activities of daily living (ADLs) and had been admitted to hospice care. However, their hospice records lacked updated certifications and plans of care, which are essential for coordinated care. For resident R88, the hospice records indicated an admission to hospice care on 6/18/21, but there were no updated hospice certifications or plans of care available. The hospice visit logs and progress notes were outdated, with the most recent entries dating back several months. Similarly, resident R113's records showed inconsistencies, such as a different hospice provider in the agreement contract compared to the one ordered by the physician. The hospice records for R113 also lacked admission orders and updated certifications, with the most recent progress notes being several weeks old. Interviews with facility staff, including the Director of Nursing and the Social Service Director, confirmed that there was a lack of coordination and communication regarding hospice documentation. The facility's policy on hospice services emphasized the need for complete and accessible clinical records, yet this was not adhered to in practice. The Administrator was unable to provide the correct hospice agreement contract for R113, highlighting further discrepancies in the documentation process.
Resident Access to Unsupervised Laundry Room Results in Chemical Burn
Penalty
Summary
The facility failed to provide adequate supervision to a resident, identified as R4, which resulted in R4 gaining access to a laundry room that should have been locked. Once inside, R4 accessed a laundry detergent that spilled on his right foot, causing a chemical burn that required treatment at a local hospital. The incident occurred when R4 entered the laundry room unsupervised, despite the facility's policy that no resident is allowed in the laundry room without supervision and that the door should be locked when no staff is present. R4's medical history includes bipolar type schizoaffective disorder, depression, anxiety, and age-related physical debility. On the day of the incident, R4 was participating in a vocational training program designed to help manage his anxiety through simple tasks. However, the program did not include working in the laundry room, and R4 was not supposed to be there. The laundry room door was found to be propped open, and no staff were present at the time, allowing R4 to enter and access the detergent. Interviews with facility staff revealed that the laundry department was closed during the time of the incident, and no staff were scheduled to work in the laundry room. The facility's safety policy requires that the environment be free from hazards and that residents be supervised, but these measures were not effectively implemented. The lock on the laundry room door was not functioning properly, which contributed to R4's ability to enter the room unsupervised.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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