Pleasant Meadows Senior Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Chrisman, Illinois.
- Location
- 400 West Washington, Chrisman, Illinois 61924
- CMS Provider Number
- 146037
- Inspections on file
- 65
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 13 (1 serious)
Citation history
Health deficiencies cited at Pleasant Meadows Senior Living during CMS and state inspections, most recent first.
A cognitively intact resident reported that a CNA spoke in a scolding and belittling manner while assisting with a bedpan, which the resident perceived as a dignity issue and abuse. The facility’s abuse policy requires that any employee accused of abuse be immediately removed from resident contact and not return to work until an investigation is completed and the allegation is found unsubstantiated. However, the allegation was not documented on the abuse log when first reported, and the accused CNA continued to work an overnight shift on the same hall, answering call lights and assisting the reporting resident and other residents, thereby remaining in contact with multiple residents while the allegation was unresolved.
Multiple residents experienced significant changes in condition and had physician/NP orders that were not properly implemented or monitored. One resident with CHF and respiratory issues had orders for chest x-ray, labs, and respiratory monitoring, but no vitals or assessments were documented and the ordered diagnostics were not completed before hospitalization for sepsis and pneumonia. Another resident with severe cognitive impairment had an elevated pulse and CNA-reported signs of decline, yet there was no documented reassessment, vital sign monitoring, or notification to family or providers before the resident was found unresponsive and later died. A third resident on diuretics had ordered CBC/CMP and a follow-up BMP that were never documented as completed, and the resident’s first medication refusal and expressed desire to die were not followed up with assessment or provider/family notification. A fourth resident with CKD and recent AKI had ordered CBC/CMP monitoring that was not carried out and received treatment for dental infection without documentation that the guardian was informed of the dental problems or need for a dentist.
The facility failed to accurately transcribe and follow hospital discharge and practitioner medication orders, resulting in significant med errors for two residents. One resident, recently hospitalized for acute kidney injury, continued to receive Bumex, Spironolactone, and a higher dose of Eliquis than ordered because the hospital discharge changes were not entered into the EHR, while the MAR showed ongoing administration of these meds and abnormal lab values were documented. Another resident’s Keflex was transcribed and given at a lower frequency and shorter duration than ordered, Losartan was never entered as an active order after discharge, and Midodrine was administered multiple times despite systolic BP readings above the ordered hold parameter. The NP and DON confirmed these discrepancies as nursing medication errors and verified that nurses are responsible for reviewing, verifying, and transcribing admission orders and that MAR check marks indicate administration.
A cognitively intact resident reported that a CNA made belittling, scolding remarks during nighttime toileting assistance, which the resident perceived as abusive and a violation of dignity. The resident believed this concern had been reported to a corporate staff member, but the allegation was not entered into the abuse log. The DON later learned of the allegation, but, after being told the resident did not recall the incident and concluding abuse was not suspected, did not report the allegation to the state survey agency as required by the facility’s abuse reporting policy.
Surveyors found that multiple medications on a main skilled medication cart were not labeled or discarded according to facility policy and professional standards. An LPN had insulin pens for a resident in active use without documented open dates, and another resident’s insulin pen showed an open date well beyond the expected discard timeframe while still being administered. Ear drops for one resident and eye drops for another lacked open dates, even though one order had already reached its documented completion date and the other remained active. In interviews, the LPN acknowledged the labeling and discard failures, and the DON confirmed that insulin, eye drops, and ear drops must be dated when opened and discarded within 28–30 days, consistent with the facility’s medication labeling policy requiring beyond-use dating on all medications.
An RN failed to follow the facility’s infection control and medication administration policies by not performing hand hygiene before, during, or after administering oral medications and inhaler treatments to multiple residents. The RN handled medication cups, water cups, a resident’s personal cup, and an ice chest without using handwashing or hand sanitizer between residents or tasks. The RN later reported being unsure of the facility’s expectations for hand hygiene during a med pass, while the DON confirmed that staff are expected to perform hand hygiene before preparing meds, after administration, and when hands are soiled, consistent with the facility’s written hand hygiene and medication administration policies.
Two cognitively intact residents experienced deficiencies in environmental cleanliness and equipment maintenance. One resident’s room had cracked, peeling paint, old ceiling tiles, dim lighting, dark debris in ceiling light covers, and visible dirt and rust-colored debris around the toilet, along with string-like material hanging from bathroom ceiling corners; the resident reported feeling embarrassed and ashamed about the room’s condition and had previously voiced concerns to staff. Another resident’s wheelchair, used for transport to dialysis, was found at the dialysis unit with a large, hardened, foul-smelling dark substance on the backrest that staff believed to be feces, prompting a call back to the facility; leadership acknowledged being notified of the condition of the wheelchair, which the facility is responsible for maintaining under its equipment policy.
A cognitively intact resident with multiple complex conditions, including sacral pressure ulcers and mobility issues, was placed in a geriatric chair that did not allow self-propulsion while her personal wheelchair remained across the room. The resident reported feeling restricted, unable to access personal items, and stated the chair worsened her back and pressure sores. The DON acknowledged the chair was used for safety and positioning, confirmed it prevented self-propulsion, and admitted no restraint assessment had been completed and the chair’s use was not included in the care plan, despite a facility policy defining such devices as physical restraints requiring assessment and least-restrictive use.
A resident with macular degeneration, whose care plan required provision of functional eyeglasses as adaptive equipment, did not have usable glasses for an extended period. The resident reported that her glasses had been broken for a long time and had no good pair available, and no eyeglasses were observed with her. An LPN and a CNA confirmed the resident did not have corrective eyeglasses and continued daily activities without them. The Social Services Director stated she did not schedule eye appointments for the resident and that the resident’s daughter was responsible for arranging such appointments, resulting in the care-planned vision support not being carried out.
A resident with cognitive impairment and high care needs was subjected to repeated verbal threats and aggressive comments from a severely cognitively impaired roommate with a history of verbal and physical aggression. Staff and documentation confirmed the abusive behavior, which included threats to harm both the resident and staff, in violation of the facility's abuse prevention policy.
A resident with severe cognitive impairment and arterial wounds did not receive wound care as ordered, with improper technique observed and dressings left unchanged for extended periods. Contract nurses failed to perform or document wound care, and facility staff lacked systems to monitor or audit wound treatments, resulting in the resident being found with maggots in the wound and undated dressings.
A resident with cognitive impairment and a history of exit-seeking behaviors left the facility unsupervised in a wheelchair after staff disabled the door alarm, and the care plan did not include adequate interventions for elopement risk. The resident was found by a community member after traveling a significant distance from the facility, and staff were unaware of the resident's absence until notified by an outside party.
A resident with multiple medical and cognitive conditions, identified as high risk for elopement, left the facility without staff knowledge and was later found in the community. Although staff responded and notified appropriate parties, the incident and related notifications were not documented in the resident's medical record as required by facility policy.
A facility failed to protect a resident from physical abuse by another resident, resulting in a skin tear. The incident occurred when an LPN heard an argument between two residents and observed one pushing the other, causing an injury. Despite initial intervention, the altercation resumed, leading to a scratch on the resident's arm, which required daily medical treatment.
A resident with severe cognitive impairment suffered second-degree burns after spilling hot chocolate on her lap due to inadequate supervision during dining. The hot beverage was served at an unsafe temperature, and the facility's policy on handling hot beverages was not properly followed, leading to the incident.
A resident with dementia and Alzheimer's was found with bruises, but the facility failed to notify the family or document the incident. The DON confirmed that an agency nurse was responsible, but no notifications were made, violating the facility's abuse prevention policy.
Two residents reported missing personal belongings, including money and a necklace, which the facility failed to resolve. Despite investigations, the facility did not recover the missing items or reimburse the residents, citing corporate protocol. The facility lacked documentation of residents' belongings, hindering confirmation of the missing items.
A resident with severe cognitive impairment was found with a facial bruise of unknown origin, which was not reported to the Abuse Prevention Coordinator in a timely manner. The facility staff failed to document the incident, notify the family and physician, or report to the Department of Public Health as required by policy. The deficiency highlights a lapse in following the facility's abuse prevention and reporting protocols.
A resident with severe cognitive impairment and in-house acquired burns on both thighs did not receive proper wound care as per physician orders. An LPN used potentially contaminated gloves to apply silver sulfadiazine cream without cleaning the wounds first, leading to cross-contamination. The LPN also failed to cover the burns with the prescribed dressing. Both the LPN and a Nurse Practitioner acknowledged the importance of following proper wound care protocols.
A resident with dementia and Alzheimer's was found with a large bruise on the forehead, but the facility failed to document the bruise's measurement, cause, or any incident report. The DON was notified late, and a Nurse Practitioner added a progress note two weeks after the bruise was identified. An Agency RN forgot to document the bruise, leading to incomplete medical records.
The facility failed to monitor and address significant weight loss in four residents, leading to ongoing weight loss and pressure ulcers. The RD was not notified of these changes, resulting in a lack of nutritional evaluation and intervention. Facility policies requiring RD evaluation for significant weight loss or wounds were not followed, indicating a breakdown in communication and monitoring processes.
A facility failed to protect residents from theft, affecting four residents. One resident lost a commemorative coin set and $100, causing emotional distress. Another resident reported $140 missing from her purse, with confusion over reimbursement. Two more residents reported missing money, with delayed facility response. These incidents show inadequate protection and investigation of thefts.
The facility failed to provide adequate pressure ulcer care and prevention for four residents, leading to the development and worsening of pressure ulcers. The facility did not complete weekly assessments, implement treatment orders timely, or administer treatments as ordered. One resident developed a stage three pressure ulcer and another developed an unstageable pressure ulcer. The facility also failed to update care plans, implement physician recommendations, and notify the dietitian of residents' wounds.
The facility failed to report allegations of misappropriation of resident property to the administrator, State Agency, and law enforcement for four residents. Despite internal reports of thefts, including money and commemorative coins, no investigations were documented, and incidents were not reported as required by the facility's policy. This deficiency potentially affects all 73 residents in the facility.
The facility failed to investigate allegations of misappropriation of money and personal property for four residents, affecting all 73 residents. Despite the facility's policy requiring documentation and investigation of such incidents, no investigations were conducted. Residents reported missing money and personal items, but the facility treated these as grievances and handled them internally without involving external authorities.
The facility failed to investigate allegations of misappropriation affecting several residents, including missing cash and commemorative coins. Despite the facility's Abuse Prevention Program requiring documentation and investigation of such incidents, no documented investigations were conducted. The Administrator admitted to treating these incidents as grievances per corporate instructions, without reporting to the state agency or police.
The facility's QAPI program was ineffective, failing to identify and address issues such as misappropriation of money and significant weight loss among residents. The administrator did not investigate or report financial misappropriation incidents, and there was a lack of timely nutritional interventions due to miscommunication between the DON and RD.
The facility failed to implement actions for performance improvement and track success, affecting all 73 residents. Despite identifying issues with wounds and lab services, no steps were taken due to time constraints caused by frequent state surveyor presence.
The facility failed to ensure consistent attendance of required members at quarterly QAPI meetings, with the former DON/Infection Preventionist and the Medical Director frequently absent. This inconsistency was confirmed by the facility's administrator and medical records staff, potentially impacting all 73 residents.
The facility failed to develop a comprehensive water management plan to prevent Legionella and other pathogens, affecting all residents. Additionally, staff did not implement Enhanced Barrier Precautions (EBPs) or provide proper wound care for several residents, failing to wear appropriate PPE and change gloves during high-contact care. There was also a lack of staff training on EBPs.
The facility failed to follow its vaccination policy, not offering the 2024 influenza vaccine to residents and lacking documentation for pneumococcal vaccinations. The DON admitted the facility was still scheduling a flu clinic and had not ordered the vaccine. Three residents lacked documentation of pneumococcal vaccination history or offers. This deficiency potentially affects all residents, especially those at higher risk.
The facility did not maintain a compliance committee that meets quarterly, as required by its policies. Key staff, including the DON and SSD, were unaware of the Compliance and Ethics Program, and no committee meetings were held. Instead, compliance issues were mistakenly believed to be addressed in Quality Assurance meetings, affecting all 73 residents.
The facility failed to maintain laundry dryers in a safe condition, creating a potential fire hazard for all 73 residents. Lint accumulation was observed on dryers and surrounding areas, with surfaces hot to the touch. Staff interviews revealed uncertainty about cleaning schedules, with maintenance staff failing to clean the area despite management's request weeks prior.
The facility failed to provide adequate ADL care, including timely fingernail care, bathing, and toileting for several residents. Complaints were documented about delayed nursing care, with residents experiencing long waits for assistance. One resident reported discomfort due to delayed toileting help, while another went without a shower for 16 days. A third resident had infrequent bathing and poor fingernail hygiene. Staffing challenges and non-adherence to facility policies contributed to these deficiencies.
The facility failed to maintain a safe environment by leaving two weekly pill organizers with unidentified pills unattended on an entryway table accessible to residents. The Director of Nursing confirmed the pills belonged to a resident of the attached assisted living facility and should not have been left there. A CNA/Receptionist stated that the pharmacy usually dropped off the pills at that location. Seven residents were independently ambulatory in the area, indicating they had access to the medications.
The facility failed to regularly assess psychotropic medication use for several residents, as required by policy. One resident's records showed outdated assessments and missing informed consents for medications like Lorazepam and Quetiapine. Another resident had outdated assessments for Zyprexa and no assessments for other medications. A third resident's last assessment was from December 2023, and a fourth resident's records did not address Depakote's use. The facility's policy required quarterly assessments, which were not completed.
The facility failed to obtain informed consents for psychotropic medications for two residents. One resident was receiving Depakote for Bipolar Disorder and a seizure disorder without documented consent. Another resident was on trazodone and fluoxetine without documented consents. The facility's administrator was uncertain about the consents and could not provide documentation before the survey concluded.
A resident with multiple diagnoses, including Dementia and Bipolar Disorder, was observed with a lap cushion used as a restraint without a physician's order or a comprehensive care plan. The facility's policy requires such orders and care plans, but the resident's records lacked these, despite the cushion being used as a fall intervention. The DON confirmed the need for a physician's order for the restraint.
A facility failed to update a care plan for a resident with Alzheimer's Disease to address significant weight loss. Despite a 17.6% weight loss over three months and dietician recommendations to increase nutritional supplements, the care plan did not reflect these changes. The Care Plan Coordinator confirmed the omission.
A resident with multiple health issues, including cellulitis, did not receive wound dressing changes as ordered by the physician. The wound nurse forgot to enter the treatment order, resulting in a delay of three days before treatment began and a dressing that was not changed for at least nine days, contrary to daily care instructions.
A facility failed to provide safe respiratory care by not dating and securing oxygen and nebulizer equipment for a resident. The resident's care plan required nebulizer and oxygen therapies, but the oxygen tubing was repeatedly found uncovered and on the floor, with no dates on the tubing or humidification bottle. The resident confirmed that staff did not date the equipment when changed.
A facility failed to administer medications according to Physician's Orders, resulting in a 6.06% error rate. An LPN gave a resident Metoprolol 4 1/2 hours late and administered an incorrect dose of Vitamin D3, citing computer issues and a misreading of units as reasons for the errors.
A resident reported receiving cold meals in their room. During meal service, the resident's food was measured at 95°F, which was not warm enough. The cook indicated that the delay in serving meals might be due to the process of assembling trays in the main kitchen and preparing drinks in the dining room before serving, causing meals to arrive cooler.
The facility failed to conduct timely pressure ulcer risk assessments and obtain treatment orders for residents, leading to inadequate care and worsening conditions. Inconsistent documentation and reliance on telehealth for wound care assessments contributed to these deficiencies.
A resident with a history of sepsis and endocarditis was admitted to a facility with a plan for six weeks of IV Vancomycin. The facility failed to coordinate with the physician, leading to an incorrect change in the Vancomycin order. The resident received an inappropriate dosage, resulting in kidney failure and rehospitalization with sepsis. The lack of proper care contributed to the resident's death.
A facility failed to provide an effective infection control program, affecting all residents. A resident admitted with sepsis and endocarditis was prescribed Vancomycin, but the dosage was changed without proper rationale, leading to kidney failure. The resident was later rehospitalized and expired due to inadequate care and communication. The Infection Control Committee did not evaluate or make recommendations during the resident's stay.
The facility failed to provide proper IV therapy to three residents, lacking documentation and care plans for IV access devices, dressing changes, and monitoring for infection. A resident with a PICC line for Vancomycin had no documented care, while another's physician order summary lacked IV access details. A third resident's care plan was incomplete, missing IV site monitoring and care information.
Two residents in a shared room engaged in a verbal altercation involving threats and expletive language, despite the facility's Abuse Prevention Program. One resident, with anxiety and cognitive impairment, threatened violence, while the other, with Parkinson's and depression, responded with aggression. Staff confirmed the incident, indicating a failure to protect residents from verbal abuse.
A resident's prescribed Semaglutide medication went missing from the facility's refrigerator, leading to a failure in protecting the resident's right to be free from abuse. Despite an investigation, the facility could not determine who took the medication. The resident, diagnosed with Diabetes and at moderate risk for abuse, confirmed the facility replaced the missing medication at a significant cost.
The facility failed to protect the financial affairs of four residents, as former employees retained access to resident trust accounts. The current BOM was unaware of the authorized signatories, and the facility's policy was not adequately followed, leading to mismanagement of resident funds.
Failure to Remove Accused CNA From Resident Contact During Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow its Abuse Prevention Program by not immediately removing from resident contact an employee accused of verbal abuse and by not documenting or initiating an abuse investigation when first informed of the allegation. The facility’s October 2022 Abuse Prevention Program states that visitors are encouraged to report suspected abuse immediately to the administrator or an immediate supervisor, who must then report to the administrator, and that employees accused of abuse will be removed from resident contact immediately and not permitted to return to work until the administrator reviews the investigation results and determines the allegation is unsubstantiated. A cognitively intact resident (R6), per a recent Minimum Data Set, reported that about a week prior, a CNA (V41) assisted with a bedpan during the night and responded to the resident’s comments about being too hot or too cold by stating that the resident needed to make up their mind because the CNA was not going to keep coming into the room every five minutes and was only required to come every two hours. R6 described this interaction as scolding, belittling, and abusive, and stated they did not like being treated that way and believed it was a dignity issue and abuse. R6 believed this concern had been reported to a corporate marketer (V42) the previous Thursday, yet when surveyors reviewed the facility’s abuse log on 3/17/26, there were no documented allegations involving R6. The allegation was reported to the DON (V2) on 3/17/26 at 12:10 PM. V2 stated that V42 had spoken with R6 the day before and that R6 reportedly did not recall the incident, so abuse was not suspected, and V2 had not yet spoken with V41. Despite the facility policy requiring immediate removal of accused staff from resident contact pending investigation, V41 reported working the previous evening from 6:00 PM to 6:00 AM on Hall 1 of the 200 unit and answering call lights on other halls, including assisting R6 onto the bedpan that night. Timecard records confirmed V41 worked from 5:47 PM on 3/16/26 until 5:57 AM on 3/17/26. The Resident List Report for that date shows that residents R13–R21 reside on Hall 1 of the 200 unit, indicating that during the period when the allegation was known to at least one staff member, the accused CNA continued to have access to multiple residents.
Failure to Monitor, Implement Orders, and Notify Providers/Families for Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to monitor and report changes in condition and to follow physician and NP orders for multiple residents, despite policies requiring such actions. For one resident with CHF and respiratory issues, the NP assessed increased cough, congestion, wheezing, and fatigue and ordered a chest x-ray, CBC, CMP, use of spirometer, PRN nebulizer treatments, supplemental O2 if needed, and ongoing monitoring of respiratory status. The record shows PRN nebulizer treatments and oxygen use over several days, but there is no documentation of vital signs or respiratory assessments during that period and no evidence that the ordered chest x-ray and labs were completed. The resident was later sent to the hospital for shortness of breath and cough and was admitted with sepsis secondary to pneumonia and acute hypoxemic respiratory failure. The NP and MDS coordinator confirmed that no assessments or vital signs were documented between the NP visit and the hospitalization, and that the x-ray company only contacted the facility after the resident had already been transferred. Another resident with severe cognitive impairment and multiple cardiac and vascular diagnoses had a documented pulse increase to 106 after a period of pulses in the 60s–80s, with no subsequent blood pressures, pulses, assessments, or notifications to family or providers. Nursing notes later document that the resident was transferred to the ER for lack of response to stimuli, cold extremities, and gurgling, with EMS finding the resident unresponsive, flaccid, cold, mottled, and in respiratory distress with very low oxygen saturation and hypotension; the resident died at the hospital. The day-shift RN did not recall any changes or follow-up on the elevated pulse and stated that any reassessment or reporting would have been documented, which it was not. A CNA reported that the resident had been nonverbal, had purple, cold legs, and had not swallowed medications the evening before, and that these changes were reported to the RN, but there is no documentation of reassessment, monitoring, or provider/family notification in the record. A third resident with atrial fibrillation, COPD, hypertension, and diabetes had care plan interventions to monitor diuretic side effects and report pertinent lab findings. The NP ordered a CBC and CMP, and later the physician ordered spironolactone with a repeat BMP in one week, but there is no documentation that these lab orders were entered or completed. The resident had a recent elevated WBC and cellulitis with ongoing antibiotics, and the MAR shows the resident refused morning medications on one date with no documented reason or follow-up. The resident later died in the facility, and there is no documentation that the provider or family were notified of the medication refusal or the resident’s statements about wanting to die, which CNAs reported had been communicated to nurses. A fourth resident with CKD stage 4 and recent hospitalization for dehydration and acute kidney injury was receiving spironolactone, Bumex, and Eliquis. Lab results showed elevated BUN and creatinine with low eGFR, and the NP documented hyperkalemia likely due to CKD and dehydration, with IV fluids given and a CMP ordered. Subsequent CBC/CMP results showed continued renal impairment, and new orders were written for CBC and CMP over a defined period, but there is no documentation that these orders were implemented or that results were obtained. Nursing notes show the resident was treated with antibiotics and pain medications for broken teeth, bleeding gums, and infection, but there is no documentation that these dental problems and need for a dentist were reported to the resident’s guardian. The guardian later stated they were unaware of the dental issues or need for dental care until the day of a hospice referral, indicating that significant changes and conditions were not communicated as required by facility policy.
Failure to Accurately Transcribe and Follow Medication Orders Resulting in Significant Med Errors
Penalty
Summary
The deficiency involves the facility’s failure to accurately transcribe and follow physician and hospital discharge medication orders, resulting in multiple significant medication errors for two residents. For one resident with a recent hospitalization for acute kidney injury, the hospital discharge instructions directed that Bumex, Spironolactone, and Eliquis 5 mg be stopped and Eliquis 2.5 mg twice daily be started. These changes were not entered into the resident’s EHR upon readmission, and the MAR showed that the resident continued to receive Spironolactone 25 mg daily, Bumex 1 mg twice daily, and Eliquis 5 mg twice daily beginning the day after readmission, with later dose reductions not aligned with the original discharge orders. Laboratory results over the following days showed abnormal BUN, creatinine, eGFR, and potassium levels, and a nurse practitioner documented hyperkalemia likely due to chronic kidney disease and dehydration, with IV fluids administered. The nurse practitioner later confirmed that the hospital discharge orders and the MAR did not match and identified this as a nursing medication error, noting that the medications involved can affect blood pressure and kidney function. For another resident, the hospital discharge orders for Keflex 500 mg by mouth four times daily for four days were incorrectly transcribed and administered as twice daily for two days. A subsequent hospital discharge also ordered continuation of Losartan 12.5 mg daily, but this medication was never entered as an active order in the EHR after the resident’s return. Additionally, the MAR documented Midodrine 5 mg three times daily with instructions to hold the dose if systolic blood pressure was greater than 120, yet the resident received multiple doses in February and March when the documented systolic blood pressure exceeded that threshold. The nurse practitioner confirmed there were no ordered changes to the Keflex and Losartan orders and identified these as medication errors. The DON stated that nurses are responsible for reviewing, verifying, and transcribing admission orders, and confirmed that a check mark on the MAR indicates a medication was administered.
Failure to Report Resident’s Verbal Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of verbal abuse to the state survey agency as required by its Abuse Prevention Program. The written policy dated October 2022 states that visitors are encouraged to report suspected abuse to the administrator or an immediate supervisor, who must then report to the administrator, and that the facility will report allegations of abuse to the Illinois Department of Public Health (IDPH). A cognitively intact resident (R6), per a recent Minimum Data Set, reported that about a week prior, a CNA (V41) assisted with a bedpan during the night. During this interaction, when the resident stated they could not decide if they were too hot or too cold, the CNA responded that the resident had better make up their mind because the CNA was not going to keep coming into the room every five minutes and was only required to come in every two hours. The resident perceived this as scolding, belittling, and a violation of dignity, and characterized it as abuse. R6 stated they believed they had reported this concern to a corporate marketer (V42) the previous Thursday. When surveyors reviewed the facility’s abuse log on 3/17/26, there were no documented allegations involving this resident. The allegation was reported to the DON (V2) on 3/17/26 at 12:10 PM. Upon interview, the DON stated that V42 had spoken with the resident the day before and the resident reportedly did not recall the incident, and therefore the DON did not report the allegation to IDPH because abuse was not suspected. The DON stated the allegation was reported to the corporate administrator (V9), but no report was made to the state survey agency, resulting in a failure to follow the facility’s policy and regulatory requirements for reporting allegations of abuse.
Failure to Label and Discard Insulin and Ophthalmic/Otic Medications per Policy
Penalty
Summary
Surveyors identified a failure to properly label and discard medications during an inspection of the main skilled medication cart on the 200 Hall. In the presence of an LPN, one resident’s Basaglar insulin pen and Adelong insulin pen were found without documented dates of opening, despite the resident having active physician orders and currently receiving both medications per the January 2026 MAR. Another resident’s Novolog FlexPen was labeled with an open date of November 26, 2025, while the January 2026 MAR showed an active order and current administration of Novolog. Additionally, one resident’s Ofloxacin ear drops and another resident’s Latanoprost eye drops were found without documented open dates; the MARs showed that the Ofloxacin order had a completion date of January 1, 2026, and that the Latanoprost order was active and currently being administered. During interviews, the LPN acknowledged that the insulin pens and Latanoprost eye drops should have been labeled with open dates and agreed that the Novolog FlexPen with the November 26, 2025 open date and the Ofloxacin without an open date should have been discarded. The DON stated that eye and ear drops are to be labeled with the date opened and discarded 28 days after opening, and that insulin vials and pens are to be labeled with the date opened and discarded within 28–30 days of opening. The facility’s Medication Labels Policy dated October 27, 2014, requires medications to be labeled in accordance with facility requirements and applicable laws, specifies that only the dispensing pharmacy or a registered pharmacist may modify or attach prescription labels, and requires every medication to be labeled with a beyond-use (expiration) date on the package.
Failure to Perform Hand Hygiene During Medication Pass
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to hand hygiene during medication administration. On 01/12/2026 at 8:57 AM, an RN (V5) prepared oral medications and an inhaler for resident R43, entered the resident’s room, handed the medications and water to the resident, and then provided an inhaler followed by water for swish and spit. The resident returned the cup and inhaler to the RN, and at no point before, during, or after this medication administration did the RN perform hand hygiene. At 9:10 AM the same day, the RN prepared oral medications for resident R40, entered the room, handed the medications and water to the resident, and disposed of the used cups before leaving the room, again without performing hand hygiene before or after medication administration. On 01/12/2026 at 9:25 AM, the RN prepared oral medications for resident R63, entered the room, handed the medications and water to the resident, and responded to the resident’s request for more water by taking the resident’s Styrofoam cup and stating she would refill it after the medications were taken. The RN then provided additional small cups of water as the resident continued taking medications and later filled the resident’s cup with ice from the 100 Hall ice chest, without performing hand hygiene at any point before, during, or after this process. On 01/13/2026 at 10:32 AM, the RN stated she was unsure of the facility’s expectations regarding hand hygiene during medication administration, although she agreed it should be performed between each resident. The DON (V2) later stated her expectation that nursing staff perform hand hygiene prior to preparing medications, after administering medications, and whenever hands are visibly soiled. The facility’s written Handwashing/Hand Hygiene and Medication Administration policies require adherence to recognized hand hygiene procedures, including washing hands before beginning a medication pass, prior to handling medications, after direct resident contact, and using approved hand sanitizer between handwashings when appropriate.
Failure to Maintain Clean, Homelike Resident Room and Wheelchair
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment in a resident room. One cognitively intact resident (R25) reported embarrassment and shame about the condition of her room, describing cracked, fading paint and large nails in the wall that she tried to cover with pictures and a tee shirt. She expressed concern about the age of the ceiling tiles and worry they might contain asbestos. Surveyor observation of R25’s room and bathroom, with the DON present, revealed cracked areas on the walls with peeling paint, visible dark debris in the ceiling light covers, very dim lighting, dark and rust-colored debris on the back of the toilet riser and along the back of the toilet seat, and a string-like substance hanging from the bathroom ceiling corners. The Plant Operations Manager stated she is responsible for painting rooms and supervising housekeeping but has been occupied with resident transportation duties and has not had time to verify that housekeeping is cleaning other areas, and confirmed there was no dated plan of action for interior repairs. The deficiency also includes failure to ensure resident equipment was clean and properly maintained. A cognitively intact resident (R8) used a wheelchair to attend dialysis. Dialysis staff observed an approximately six-inch area of a hard, dark substance on the backrest of the wheelchair that appeared to be feces and reported an odor consistent with feces when the resident stood to be weighed; the substance was not on the resident’s person. The Plant Operations Manager reported she was called by the facility to retrieve the wheelchair from the dialysis unit and observed the hardened dark substance on the backrest, which she believed to be feces. The DON acknowledged being notified by dialysis staff that there was feces on the backrest of the wheelchair and directed the Plant Operations Manager to pick up the wheelchair and have it cleaned off-site before returning it to the dialysis center. The facility’s equipment policy states that wheelchairs are maintained by the facility for general resident use.
Use of Geriatric Chair as Undocumented Physical Restraint
Penalty
Summary
Surveyors identified that a cognitively intact resident with multiple diagnoses, including osteomyelitis, sacral pressure ulcers, neoplasm of the spinal cord, type II diabetes, polyneuropathy, unsteady gait, and neurofibromatosis, was being kept in a geriatric chair that did not allow self-propulsion. On observation, the resident was seated in this chair in her room while her personal wheelchair, labeled with her name, was placed across the room. The resident stated she wanted to sit in her own wheelchair, expressed that she could not move around her room in the geriatric chair, and reported she could not independently access personal items such as her hairbrush or soda. She further stated that the chair made her back and existing Stage IV pressure ulcers hurt and that staff told her the chair was used because she attempted to transfer from bed to chair and had experienced falls, leading her to feel restricted. The DON stated that the geriatric chair was used for the resident’s safety and positioning and confirmed that the chair did not allow the resident to self-propel. The DON also acknowledged that no restraint assessment had been completed because staff did not consider the geriatric chair to be a restraint, and that the use of the geriatric chair was not addressed in the resident’s care plan. The facility’s own physical restraint policy defines physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement, and states that restraints are not to be used for punishment or staff convenience and require periodic assessment to reduce or eliminate their use. Despite this policy, the geriatric chair, which limited the resident’s freedom of movement and was not easily removable by the resident, was used without restraint assessment or care plan inclusion.
Failure to Provide and Maintain Prescribed Eyeglasses for a Resident With Macular Degeneration
Penalty
Summary
The facility failed to ensure a resident received proper treatment and assistive devices to maintain vision, as care-planned. The resident, admitted with diagnoses including essential hypertension, hyperlipidemia, fibromyalgia, lumbago with sciatica, and diaphragmatic hernia, had a care plan dated 12/16/2025 documenting macular degeneration and the use of reading glasses, with an intervention to ensure needed adaptive equipment, including eyeglasses, was provided, present, and functional. Despite this, the resident reported on multiple occasions that her glasses had been broken for a long time and that she did not have a good pair of glasses due to a broken frame, and no eyeglasses were observed on or with her during interview. Staff interviews confirmed that the resident did not currently have eyeglasses and continued daily activities without them, and the Social Services Director stated she did not schedule eye appointments for the resident, indicating that the resident’s daughter was responsible for arranging eye appointments. These observations, interviews, and record reviews demonstrate that the facility did not implement the care plan intervention to ensure the resident’s eyeglasses were provided and functional, resulting in the resident being without necessary corrective lenses for an extended period.
Failure to Prevent Verbal Abuse Between Residents
Penalty
Summary
The facility failed to protect a resident from verbal abuse by another resident. One resident, who is legally blind, has dementia, anxiety, and requires maximum assistance with daily activities, was subjected to repeated verbal threats and aggressive comments from his roommate, who is severely cognitively impaired. The roommate had a documented history of verbal and physical aggression, including a psychiatric evaluation following threats to kill his roommate and staff. The roommate stated he would act on his threats due to his military training and continued to make threatening and aggressive statements toward both the resident and staff, as witnessed by a CNA and documented in the facility's report to the state agency. Staff interviews and record reviews revealed that the verbally aggressive resident had previously been sent to a psychiatric facility for homicidal ideations and had a pattern of outbursts toward other residents and staff. Despite these known behaviors, the resident was returned to the facility after medication changes, and there were no further incidents reported after his return. The facility's abuse prevention policy defines verbal abuse as the use of threatening or frightening language, which was consistent with the behaviors observed and documented in this case.
Failure to Prevent Cross-Contamination and Ensure Wound Care Compliance
Penalty
Summary
The facility failed to prevent cross-contamination during wound care for a resident with severe cognitive impairment and significant mobility limitations. The resident had physician orders for daily wound care to the right ankle arterial wounds, including specific instructions for cleaning and dressing the wounds. Observations revealed that a nurse used the same piece of gauze to cleanse multiple open wounds on the resident's ankle, wiping both the wounds and surrounding skin, which constitutes improper wound care technique and risk of cross-contamination. Additionally, the resident's dressings were not labeled or dated as required. Record review and staff interviews indicated that contract nurses were assigned to the resident for several days, during which time wound care was not consistently performed as ordered. The resident was later found in a hospital with maggots present in the wound, and the dressing was adhered to the skin, suggesting it had not been changed for an extended period. Facility staff confirmed that wound care documentation was signed off as completed, even when the dressing had not been changed, and that there was no system in place to ensure treatments were actually performed or monitored. Further interviews with facility staff, including the DON and wound care nurses, revealed a lack of oversight and auditing of wound care practices, especially during the absence of the primary wound nurse. Staff reported that contract nurses often did not perform wound care, and there was no process to verify that dressings were changed or that physician orders were followed. The facility relied on reviewing treatment records for compliance but did not visually inspect wounds or dressings to confirm care was provided as ordered.
Failure to Prevent Elopement Due to Disabled Door Alarm and Inadequate Care Planning
Penalty
Summary
A deficiency occurred when a cognitively impaired resident, identified as being at risk for elopement and falls, was able to leave the facility unsupervised in a wheelchair during nighttime hours. The exit door used by the resident was not properly alarmed or monitored, as staff had disabled the door alarm due to multiple visitors and insufficient staff to monitor the front area. The resident exited the facility unnoticed and traveled approximately three-tenths of a mile down a country road, crossing uneven terrain and railroad tracks, before being found by a local citizen who notified facility staff. The resident had a documented history of cognitive decline, major depressive disorder, Parkinson's disease, and other significant medical conditions, including recent episodes of unresponsiveness and ongoing suicidal ideations. The care plan for this resident noted confusion, high fall risk, and a history of turning off safety alarms, but failed to include adequate interventions to address the risk of elopement. Staff interviews revealed that the resident had been exhibiting exit-seeking behaviors and had previously expressed a desire to leave the facility, yet the care plan was not updated in a timely manner to reflect these behaviors or to implement necessary safety measures. At the time of the incident, staffing levels were low, with only one CNA and one nurse present for 37 residents on the unit. Staff did not hear any alarms when the resident exited, and the exit code had been posted on the door for years, making it accessible to residents. There was no physician order permitting the resident to leave the facility unattended, and the facility's policy required staff to know the whereabouts of all residents and to respond promptly to door alarms. The failure to ensure the exit door was alarmed and monitored, combined with the lack of an effective care plan for a resident at risk for elopement, directly led to the resident leaving the facility unsupervised.
Removal Plan
- Placed an alert band on R1 to ensure his safety.
- Completed a new elopement evaluation for R1 and placed R1 on monitoring checks to monitor exit-seeking behavior.
- Completed an audit of all wandering residents by the Social Service Director.
- Initiated training for all staff on identifying exit-seeking behaviors, placing wander alert bands immediately when identified at risk, physician orders, and where to locate the wander guard bands.
- Included training on the location of wander guard exit doors, alarm panels, immediate response to a door alarm or wander guard alarm, and completing safety checks indoors and outdoors.
- Reviewed and trained staff on the Door Alarm and Missing Person and Elopement Policy and Procedures.
- Reviewed the Missing Person and Elopement Policy and Procedures by the Corporate Clinical Director.
- Reviewed and revised Care Plans as necessary by the Social Services Director to update interventions as appropriate.
- Began audits of all exit doors by the Maintenance Director to ensure proper function of all door alarms.
- Started audits of all residents at risk for wandering by the Director of Nursing to ensure Elopement Assessments and Care Plans are up to date with accurate information and interventions.
- Planned to bring the audits to the Quality Assurance meetings to be reviewed by the interdisciplinary team.
Failure to Document Resident Elopement Event in Medical Record
Penalty
Summary
The facility failed to ensure that a resident's medical record included documentation of an elopement event. The resident, who had multiple medical diagnoses including congestive heart failure, cognitive decline, major depressive disorder, and Parkinson's disease, was identified as high risk for falls and elopement, with a history of confusion and exit-seeking behaviors. On the night in question, the resident left the facility in a wheelchair and was later found in the community by a local resident, after which a head count confirmed the resident was missing. Upon return, the resident was assessed and a wander guard was applied. The facility's investigation file included staff statements and noted that notifications were made to the administrator, supervisor, and the resident's representative. However, a review of the resident's medical record revealed that there was no documentation of the elopement incident, including the event itself or the notification to the resident's representative. The facility's policies require timely and accurate documentation of incidents, including notifications and interventions, in the clinical record. The Director of Nursing was unaware of the lack of documentation until it was brought to her attention. The absence of this documentation constitutes a failure to maintain medical records in accordance with accepted professional standards.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident, affecting two residents. The incident involved a resident with dementia, depression, and muscle weakness, who was completely dependent on staff for daily activities and used a wheelchair for mobility. During a medication pass, a Licensed Practical Nurse (LPN) heard an argument between two residents in their shared room. Upon entering, the LPN observed one resident pushing the other, resulting in a skin tear on the arm of the resident in the wheelchair. The incident report and investigation revealed that the LPN initially separated the residents after observing them arguing and attempting to push each other. However, the altercation resumed, leading to one resident scratching the other's arm, causing a wound. A Certified Nurse Aide (CNA) later found the injured resident holding their bleeding arm, and the resident admitted to causing the injury. The injured resident's skin tear required ongoing medical treatment, including cleaning and dressing the wound daily.
Resident Burned by Hot Beverage Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate assistance and supervision during dining, resulting in a preventable incident where a resident, identified as R1, suffered second-degree burns. R1, who has severe cognitive impairment and requires substantial assistance during meals, was left unsupervised and managed to take another resident's hot chocolate, spilling it onto her lap. The hot chocolate was served at an unsafe temperature, leading to burns on R1's bilateral upper legs. The incident investigation revealed that the hot chocolate was prepared by a CNA who added ice cubes to cool it down, but it remained too hot, as evidenced by the burns sustained by R1. The CNA admitted to having her back turned to R1 when the spill occurred, indicating a lack of supervision. The Dietary Manager, who was not present during the incident, later confirmed that the coffee and water temperatures were excessively high, measuring between 159 and 168 degrees Fahrenheit, which is above the recommended serving temperature. The facility's policy on handling hot beverages was not adequately followed, as it requires staff to monitor and serve hot beverages safely, especially to high-risk residents like R1. The policy suggests serving temperatures should be 10-15 degrees lower than the brewing temperature, which was not adhered to in this case. The Maintenance Director also confirmed the absence of a policy for regulating water temperatures in the coffee maker, contributing to the unsafe serving conditions.
Failure to Notify Family of Resident's Condition Change
Penalty
Summary
The facility failed to notify a family representative of a change in condition for a resident who was reviewed for accidents/incidents. The resident, who has medical diagnoses including unspecified dementia, Alzheimer's disease, repeated falls, and muscle weakness, was observed with a large bruise on the forehead and a smaller bruise under the left eye. The bruises were first noticed by a Licensed Practical Nurse (LPN) on 11/24/24, but there was no documentation confirming that the resident's nurse had notified the doctor or the family about the incident. The Director of Nursing (DON) confirmed that an agency nurse was responsible for the resident's care when the bruises were identified, but there was no documentation of any notifications made. The facility's policy requires that suspicious bruises or abnormalities be reported and documented, with the resident's physician and representative notified. However, the responsible nurse admitted to not notifying a family member, leading to a deficiency in the facility's compliance with its abuse prevention program.
Failure to Resolve Resident Grievances of Missing Belongings
Penalty
Summary
The facility failed to resolve grievances related to missing personal belongings for two residents, R2 and R4, who were both cognitively intact with a Brief Interview of Mental Status score of 15 out of 15. R2 reported missing $33, which was brought to the attention of the Social Service Director by R2's daughter. An investigation was initiated, but the facility was unable to recover the missing money or confirm its prior possession by R2, as the facility did not maintain an inventory of residents' belongings. Despite the investigation, the facility chose not to reimburse R2 for the missing money, citing corporate protocol. Similarly, R4 reported missing a butterfly necklace, car/house keys, and $25 in cash. While the necklace and keys were eventually found in R4's room, the cash was not recovered. R4 had kept the money in an envelope in her room and could not recall when she last saw it. The facility conducted a search and interviewed staff and residents but could not confirm the presence of the money. R4 mentioned a resident who frequently entered her room and took items, but this could not be confirmed during the survey. The facility did not reimburse R4 for the missing cash, adhering to the same corporate protocol. The facility's grievance policy and abuse prevention program emphasize the importance of addressing resident concerns and preventing misappropriation of property. However, the facility did not document residents' belongings on inventory sheets, which hindered their ability to confirm the presence of the missing items. The facility's actions did not align with the residents' rights to have their grievances addressed promptly and to have their personal property protected, as outlined in the facility's pamphlet and abuse prevention program.
Failure to Report and Investigate Resident's Facial Bruise
Penalty
Summary
The facility failed to recognize and report a facial bruise of unknown origin for a resident, identified as R6, to the Abuse Prevention Coordinator. R6, who has severe cognitive impairment and uses a wheelchair for mobility, was observed with a large bruise on the left forehead and a smaller bruise under the left eye. Despite the presence of these bruises, there was no documentation of a fall or incident in R6's medical record or the facility's incident/accident log. The neurological assessments were initiated without a clear reason documented, and the facility staff did not report the bruise to the appropriate authorities in a timely manner. The report details that the bruise was first noticed by an agency RN, V22, who initiated neurological checks but failed to document the incident or notify the family and physician. The bruise was later observed by V3, an LPN, who assumed the incident had already been reported to the Administrator, V1, due to the initiation of neurological checks. However, V1 was not informed until receiving a group email six days later, which did not specify the size or location of the bruise. The Director of Nursing, V2, also failed to document his observations or take further action upon being notified. The facility's policy requires that all incidents be documented and investigated, especially those involving injuries of unknown origin. The policy also mandates notification of the Department of Public Health and the resident's physician and family. However, these procedures were not followed, leading to a delay in reporting the incident to the Illinois Department of Public Health. The facility's failure to adhere to its abuse prevention program and reporting protocols resulted in a deficiency in handling the resident's injury appropriately.
Failure to Follow Wound Care Protocols and Prevent Cross-Contamination
Penalty
Summary
The facility failed to follow physician orders and prevent cross-contamination during wound care treatment for a resident with severe cognitive impairment. The resident had full-thickness burns on both thighs, acquired in-house, and was prescribed treatment with silver sulfadiazine 1% cream. However, during the wound care procedure, the Licensed Practical Nurse (LPN) used gloves that were removed from her uniform pocket, which were potentially contaminated, to palpate the resident's burns and apply the cream. The LPN did not clean the resident's wounds with normal saline before applying the cream, as per the physician's orders. Additionally, the LPN used her gloved finger to apply the cream directly from the jar, instead of using an applicator, which led to cross-contamination between the wounds. The LPN also failed to cover the burns with the prescribed thick-layered cotton dressing after applying the cream. Both the LPN and the Wound Nurse Practitioner acknowledged the importance of hand hygiene, using clean gloves, and following the physician's orders for wound care. They confirmed that the procedure should have been done separately for each wound to prevent cross-contamination. The facility's policy on wound care, which outlines the steps for maintaining a clean field and using sterile techniques, was not followed during this incident.
Failure to Maintain Accurate Medical Records for Resident with Bruise
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with diagnoses of unspecified dementia, Alzheimer's disease, repeated falls, and muscle weakness. The resident was observed with a large bruise on the left forehead, which was not documented in terms of measurement or cause. There was no incident or accident report logged for the resident, and no documentation of vital signs or notifications to the physician, family, or administrator. The bruise was first noticed by nursing staff during morning rounds, but no falls or trauma were reported or witnessed. The resident denied any falls or head injuries and remained alert and oriented. The Director of Nursing was notified of the bruise six days after neurological assessments were initiated, but did not document the observation. A Nurse Practitioner added a progress note to the resident's chart fourteen days after the bruise was identified, documenting the bruise and the resident's condition. An Agency RN admitted to forgetting to document the bruise after working a long shift. The lack of documentation and timely notification contributed to the deficiency in maintaining accurate medical records for the resident.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to adequately monitor and address significant weight loss in four residents, leading to ongoing weight loss and the development of pressure ulcers. Resident 8 experienced a significant weight loss of 8.3% over three months, yet there were no documented nutritional interventions or supplements provided. The Registered Dietitian (RD) was unaware of the resident's weight loss and pressure ulcers, and no nutritional assessment was conducted since March 2024. Similarly, Resident 44 lost 19.55% of their weight, developed a Stage III pressure ulcer, and had not been evaluated by the RD. Resident 52 experienced a 5.79% weight loss and developed a Stage II pressure ulcer, but the RD was not notified of these changes. The facility's failure to communicate significant weight loss and wound development to the RD resulted in a lack of nutritional evaluation and intervention. Resident 25 also experienced a significant weight loss of 5.92% in one month, but neither the Nurse Practitioner nor the RD was informed, and no new nutritional supplements were ordered. The facility's policies require that residents with significant weight loss or wounds be evaluated by the RD, but these protocols were not followed. The RD stated that the facility does not notify them of significant weight loss or wounds, preventing timely nutritional assessments and interventions. The Director of Nursing was unaware of the weight loss in Resident 25, indicating a breakdown in communication and monitoring processes within the facility.
Failure to Protect Residents' Belongings and Money
Penalty
Summary
The facility failed to protect residents from the misappropriation of their personal belongings and money, affecting four residents. One resident, who is cognitively intact and suffers from Major Depressive Disorder, Agoraphobia, Anxiety, and PTSD, reported the loss of a commemorative coin set and $100 from a lock box. The resident expressed emotional distress over the loss of the coins, which held significant sentimental value. Despite reporting the incident to the facility's administrator and social services, no documented investigation was conducted, and the items were not returned. Another resident, also cognitively intact, reported withdrawing $140 from the bank and storing it in her purse, only to find it missing after returning from therapy. The resident expressed disappointment over the loss, which was intended for family use. Although the facility's grievance log noted the incident, there was confusion among staff about whether the resident had been reimbursed, and the money was never returned. Two additional residents reported missing money. One resident had $100 and later $20 stolen from his wallet, which was left in his nightstand drawer. The resident reported the thefts to staff, but there was a delay in the facility's awareness and response. Another resident reported $100 missing after a room move, with the theft reported to staff but not promptly addressed. These incidents highlight a pattern of inadequate protection of residents' property and insufficient investigation and resolution of reported thefts.
Inadequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for four residents, leading to the development and worsening of pressure ulcers. The facility did not complete weekly pressure ulcer assessments, implement treatment orders timely, or administer treatments as ordered. Additionally, the facility failed to maintain wound dressings, accurately complete skin and wound assessments, and implement interventions to prevent the development and worsening of pressure ulcers. These failures resulted in one resident developing a stage three pressure ulcer and another developing an unstageable pressure ulcer. One resident, who was cognitively intact and required assistance for mobility, developed a stage three pressure ulcer on the right buttock and later on the left hip. The facility did not update the resident's care plan to include the pressure ulcers or new pressure-relieving interventions. The resident experienced significant weight loss, and there was no documentation of a dietitian evaluation since March 2024. The facility also failed to implement the wound physician's recommendations for vitamins and a Group 2 mattress in a timely manner. Observations revealed the resident sitting in a wheelchair for extended periods without repositioning, and the resident's wounds were found uncovered and without dressings. Another resident, with severe cognitive impairment, developed two facility-acquired pressure ulcers, one stage three and one unstageable. The facility did not document Braden assessments or update the care plan to include the pressure ulcers or new interventions. The resident's treatment orders were not initiated timely, and there were no documented assessments of the wounds until they had deteriorated. The resident's wheelchair cushion was not fully inflated, and the resident was observed sitting in a stationary chair without a pressure-relieving cushion. The facility did not notify the dietitian of the resident's wounds, and the dietitian was unaware of the resident's pressure ulcers.
Failure to Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to immediately report allegations of misappropriation of resident property to the facility's administrator, the State Agency (SA), and law enforcement. This deficiency was identified for four residents out of five reviewed for misappropriation in a sample of 46 residents. The facility's Abuse Prevention Program policy requires immediate reporting of such incidents to the administrator and relevant authorities, but this protocol was not followed. One resident, who is cognitively intact and has a history of Major Depressive Disorder, Agoraphobia, Anxiety, and PTSD, reported the theft of $100 and eight commemorative coins from a lock box. Despite reporting the incident to the administrator and social services, no investigation was documented, and the incident was not reported to the SA or police. Another resident, also cognitively intact, reported $140 missing from her purse after withdrawing it from the bank. The facility's grievance log noted the incident, but there was no documented investigation or report to the SA or police. Two other residents reported thefts of money totaling $120 and $100, respectively. These incidents were reported internally within the facility, but the administrator chose to handle them through the grievance process rather than reporting them to the SA or law enforcement. The facility's failure to follow its own policy and regulatory requirements for reporting suspected misappropriation of resident property has the potential to affect all 73 residents residing in the facility.
Failure to Investigate Misappropriation Allegations
Penalty
Summary
The facility failed to investigate allegations of misappropriation of money and personal property for four residents, which has the potential to affect all 73 residents residing in the facility. The facility's Abuse Prevention Program policy requires that all incidents or allegations of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property be documented and investigated. However, the facility did not follow this policy, as evidenced by the lack of documented investigations for the reported incidents. One resident, who is cognitively intact, reported that $100 and eight commemorative coins were taken from their lock box. Despite the resident's family member confirming the presence of the items the day before they went missing, the facility administrator stated that the incident was treated as a grievance, and no documented investigation was conducted. Another resident, also cognitively intact, reported missing money after withdrawing it from the bank and storing it in their purse. The facility failed to provide documentation of an investigation or follow-up for this allegation. Two additional residents reported thefts of money, with one resident stating that money was stolen on two separate occasions. The facility's Social Services Director completed grievance forms and reported the allegations to the administrator, but no investigations were conducted. The facility's administrator indicated that the corporate office directed them to handle the incidents internally through the grievance process, without involving external authorities such as the Illinois Department of Public Health or the police.
Failure to Investigate Misappropriation Allegations
Penalty
Summary
The facility failed to prevent, investigate, and implement systemic interventions to address allegations of misappropriation affecting four residents and potentially all 73 residents residing in the facility. The facility's Abuse Prevention Program mandates that all incidents or allegations of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property be documented and investigated. However, the facility did not conduct documented investigations into the reported incidents of misappropriation. The Administrator acknowledged the lack of documented investigations and stated that corporate instructions were to treat these incidents as grievances. Specific incidents include a resident who reported $100 and commemorative coins missing from a lock box, another resident who noticed money missing from her purse after withdrawing it from the bank, a resident who reported $100 missing from his wallet, and another resident who had $100 stolen during a room move. Despite these reports, the facility did not provide documented investigations, and the Administrator admitted to not reporting the allegations to the state agency or police, as required when there is a reasonable suspicion of a crime.
Deficient QAPI Program and Resident Care in LTC Facility
Penalty
Summary
The facility failed to develop, implement, and maintain an effective Quality Assurance Performance Improvement (QAPI) program, which led to the systematic failure in identifying and addressing problematic areas. This deficiency affected seven residents and had the potential to impact all 73 residents in the facility. The facility's grievance log documented incidents of misappropriation of money for four residents, but the administrator, who had been employed for only three weeks, did not investigate or report these allegations. Instead, the administrator was instructed by corporate to handle the issue internally by logging it on the grievance log, without implementing any changes to prevent further incidents. Additionally, the facility failed to address significant weight loss in four residents, as there were no assessments or nutritional interventions implemented. The Director of Nursing and the Registered Dietitian had conflicting expectations regarding the notification process for significant weight loss, leading to a lack of timely intervention. The facility's QAPI plan, dated 2018, emphasized a proactive approach to improving care and engaging with residents, but the current practices did not align with this plan, as evidenced by the lack of systematic monitoring and improvement in resident outcomes.
Failure to Implement QAPI and Address Identified Concerns
Penalty
Summary
The facility failed to take actions aimed at performance improvement, implement those actions, measure its success, and track performance, which has the potential to affect all 73 residents residing in the facility. The Quality Assurance Improvement Plan dated 10/1/18 outlines the purpose of QAPI (Quality Assurance Performance Improvement) as a proactive approach to continually improving care and engagement with residents, caregivers, and other partners. Despite this, the facility did not follow through on its QAPI efforts, which are supposed to involve all employees, departments, and services provided. On 10/31/24, the Director of Nursing/Former Administrator stated that the facility meets monthly for QAPI and has identified problems with wounds and laboratory services as areas of concern. However, despite developing Performance Improvement Projects (PIPs) for these areas, no steps for improvement have been implemented, nor has there been any follow-up on these concerns. The Director cited a lack of time due to the constant presence of state surveyors in the building as the reason for this inaction.
Inconsistent Attendance at QAPI Meetings
Penalty
Summary
The facility failed to hold quarterly Quality Assurance Performance Improvement (QAPI) meetings with all required attendees, potentially affecting all 73 residents. The QAPI sign-in sheets revealed that the former Director of Nursing (DON)/Infection Preventionist and the Medical Director were not consistently present at these meetings. Specifically, the sign-in sheet for the meeting on October 9, 2024, did not include the signature of the former DON/Infection Preventionist. Additionally, the sign-in sheet for the meeting on July 26, 2024, lacked both the former DON/Infection Preventionist and the Medical Director's signatures, and the sheet for April 10, 2024, did not include the Medical Director's signature. The facility's administrator, who had been employed for only three weeks, confirmed the inconsistency in attendance, as did the medical records staff responsible for taking meeting minutes.
Deficiencies in Water Management and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to develop a comprehensive water management plan to mitigate the risk of Legionella and other pathogens in its water system. The plan lacked a risk assessment, control measures, and testing protocols necessary to prevent the growth and spread of waterborne pathogens. The Maintenance Supervisor confirmed the absence of written protocols for flushing the water system after boil orders or when fixtures remain unused for extended periods, potentially affecting all 73 residents. The facility also failed to implement Enhanced Barrier Precautions (EBPs) and provide proper hygienic wound care for several residents. For instance, a resident with a Stage Three Pressure Ulcer did not have an EBP order or signage, and staff did not wear appropriate PPE during high-contact care activities. Another resident with wounds on the heel and coccyx had EBP signage, but staff failed to adhere to the precautions, such as wearing gowns and changing gloves during wound care. Additionally, a resident with a surgical wound and a urinary catheter had EBP signage, but staff did not follow the necessary precautions. The LPN did not perform hand hygiene or change gloves during wound care, and there was a lack of training on EBPs among the staff. The Director of Nursing confirmed that staff should wear gowns and gloves during high-contact care for residents on EBPs, but there was a noted deficiency in staff education on these precautions.
Failure to Administer and Document Vaccinations
Penalty
Summary
The facility failed to adhere to its influenza vaccination policy for five residents, which has the potential to affect all 73 residents in the facility. The policy requires that all residents be offered the influenza vaccine between October 1st and March 31st, with new admissions offered the vaccine within five days unless contraindicated. However, the Director of Nursing/Infection Preventionist admitted that the facility had not yet offered the 2024 influenza vaccine to residents, as they were still in the process of scheduling a flu clinic. Additionally, the facility had not attempted to order the vaccine from their pharmacy or contacted the local health department for assistance. There was no documentation of the 2024 flu vaccine consent forms or administration in the electronic medical records of the residents reviewed. The facility also failed to track and offer pneumococcal vaccinations to ensure residents are up to date. Three residents reviewed for immunizations did not have documentation of pneumococcal vaccination history or evidence that the vaccine was offered. The Director of Nursing stated that pneumonia vaccines should be offered upon admission and annually, but there was no documentation in the residents' electronic medical records to support that the vaccine was offered or administered. The facility's failure to document and offer the pneumococcal vaccine was confirmed by the Administrator and Restorative Nurse. The report highlights that the facility's failure to follow its vaccination policies and procedures could potentially affect all residents, especially those at higher risk for serious flu complications. The CDC recommends that everyone over six months, particularly those over 65 and with chronic conditions, receive annual influenza vaccinations by the end of October. The facility's lack of timely action and documentation regarding both influenza and pneumococcal vaccinations represents a significant deficiency in their immunization practices.
Failure to Maintain Compliance and Ethics Committee
Penalty
Summary
The facility failed to adhere to its Compliance and Ethics Program by not having a compliance committee that meets quarterly, as required by its own policies and procedures. The facility's Compliance Policies and Procedures, dated October 29, 2017, mandate the establishment of a compliance committee that includes key personnel such as the Administrator, Director of Nursing (DON), Social Services Director (SSD), Director of Admissions, Minimum Data Set Coordinator, and Corporate Compliance Officer. However, interviews with staff members revealed a lack of awareness and participation in such meetings. The DON, who served as the facility's administrator for several months in 2024, was unaware of the Compliance and Ethics Program or committee and mistakenly believed compliance was addressed during Quality Assurance meetings. Further interviews with the SSD, who has been in the role since March 2024, confirmed the absence of Compliance and Ethics committee meetings. The SSD reported that concerns were typically filed as grievances for follow-up, rather than being addressed in a structured committee setting. A review of the Quality Assurance meeting minutes from January, April, July, and October 2024 showed no mention of the Compliance and Ethics Program or committee, indicating a systemic oversight in maintaining the required compliance structure. This deficiency potentially affects all 73 residents residing in the facility, as documented in the Long-Term Care Facility Application for Medicare and Medicaid dated October 27, 2024.
Failure to Maintain Safe Laundry Dryer Conditions
Penalty
Summary
The facility failed to maintain laundry dryers in a safe operating condition, creating a potential fire hazard that could affect all 73 residents. During an inspection, it was observed that the facility's laundry dryers and surrounding areas, including floors, walls, ductwork, electric motors, and utility conduits, were covered in lint ranging from 0.25 to 1 inch in thickness. The floor area behind the dryers was heavily covered with lint, obscuring the floor surface, and the lint also covered the rear dryer cabinets and electric motor casings. The exterior surfaces of the dryers were hot to the touch. Interviews with facility staff revealed uncertainty about the frequency of cleaning behind the dryers. A laundry aide acknowledged the lint accumulation as a fire hazard and mentioned that maintenance staff were responsible for cleaning the area, but was unsure of the cleaning schedule. The laundry manager confirmed the fire hazard and reported that maintenance staff were supposed to clean the area weekly, but the last cleaning was uncertain. Despite management's request for cleaning two or three weeks prior, the cleaning had not been completed.
Deficiencies in ADL Care and Hygiene
Penalty
Summary
The facility failed to provide adequate care and assistance for activities of daily living (ADLs) for several residents, as evidenced by observations, interviews, and record reviews. Five residents were identified as not receiving timely fingernail care, bathing, and toileting/incontinence care. The Resident Council Group Concern Form and grievance logs documented complaints about staff not providing timely nursing care, including delayed responses to call lights and inadequate shower and toileting assistance. One resident, who requires substantial assistance for toileting due to reduced mobility and osteoarthritis, reported long waits for staff assistance, resulting in discomfort and numbness while waiting on a commode. Another resident, completely dependent on staff for toileting hygiene, also reported extended wait times for call light responses, sometimes exceeding 30 minutes. A Certified Nurse Aide confirmed staffing challenges, particularly during staff call-offs, which affected their ability to respond promptly. Additional deficiencies were noted in bathing routines. One resident, admitted to the facility, did not receive a shower for nearly two weeks, contrary to their usual routine. Another resident, fully dependent on staff for bathing, went 16 days without a shower. A third resident, with moderately impaired cognition, had infrequent bathing and poor fingernail hygiene, with debris caked under their nails. The facility's policies on call light response and shower/tub bath procedures were not adhered to, contributing to these deficiencies.
Unattended Medications Pose Hazard
Penalty
Summary
The facility failed to ensure a safe environment free from hazards for seven residents who were reviewed for safety and supervision. During an observation, two weekly pill organizers containing at least 27 unidentified pills were found unattended on an entryway table accessible to residents. This table was located at the front entry of the building, leading to areas frequently accessed by residents, such as the 100 hall and the chapel/dining room area. The Director of Nursing confirmed that the pill organizers belonged to a resident of the attached assisted living facility and should not have been left there. A Certified Nursing Assistant/Receptionist mentioned that the pharmacy typically dropped off the pills at that location. The Director of Nursing removed the pill containers after acknowledging the issue. A list provided by the Administrator documented that seven residents were independently ambulatory in the vicinity of the entry table, indicating they had access to the medications left unattended.
Failure to Regularly Assess Psychotropic Medication Use
Penalty
Summary
The facility failed to regularly assess the use of psychotropic medications for several residents, as required by their policy. For Resident 1, the Medication Administration Record for October 2024 showed prescriptions for Lorazepam, Quetiapine, Fluoxetine, and Buspar. However, the most recent assessments for Quetiapine and Buspar were outdated, and there were no assessments for Lorazepam or Fluoxetine. Additionally, informed consents for increased dosages of Quetiapine and Fluoxetine, as well as for Lorazepam, were missing. The Director of Nursing confirmed these deficiencies. Resident 44's Medication Administration Record indicated prescriptions for Lorazepam, Zoloft, Zyprexa, and Trazadone. The most recent assessment for Zyprexa was from January 2024, with no documented assessments for the other medications. The Director of Nursing confirmed the absence or outdated status of informed consents and assessments for these medications. Resident 46's records showed prescriptions for Amitriptyline, Lorazepam, Bupropion, and Sertraline, but the last psychotropic medication assessment was from December 2023, contrary to the facility's policy of quarterly assessments. Similarly, Resident 8's records documented prescriptions for Duloxetine, Abilify, and Depakote, with the last psychotropic medication review not addressing Depakote's use. The facility's policy required assessments on admission, quarterly, and with any medication changes, but these were not completed as required.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consents for the use of psychotropic medications for two residents, R8 and R37, as required by their Psychotropic Medication Policy. R8 had been receiving Depakote, an anticonvulsant and mood stabilizer, for Bipolar Disorder and a seizure disorder since July 2024. However, there was no documented consent for this medication in R8's electronic medical record. The Restorative Nurse/Registered Nurse confirmed the absence of consent for Depakote, despite acknowledging that R8's treatment involved dual medication for psychiatric and seizure conditions. Similarly, R37 was receiving trazodone hydrochloride and fluoxetine hydrochloride, both psychotropic medications, as per the physician's orders and medication administration records. However, R37's electronic medical record did not contain documented informed consents for these medications. The facility administrator was uncertain about whether consents had been obtained and was unable to provide any documentation of consent for R37's medications before the survey concluded.
Lack of Physician's Order and Care Plan for Restraint Use
Penalty
Summary
The facility failed to have a physician's order and care plan for the use of a physical restraint for one resident, identified as R8, who was observed with a lap cushion in place while seated in a wheelchair. The facility's policy requires a physician's order for restraints, specifying the type, reason, duration, and justification for use, and mandates that the care plan reflect specific circumstances and medical symptoms for restraint use. However, R8's October 2024 physician orders did not include an order for the lap cushion restraint, and the care plan lacked a problem, goals, and interventions related to the restraint. R8, who has diagnoses including Dementia, Anxiety Disorder, and Bipolar Disorder, was observed multiple times with the lap cushion in place and was unable to remove it independently, indicating it functioned as a restraint. The lap cushion was used as a fall intervention due to R8's unsteady gait and frequent falls. Despite this, the care plan did not address the restraint use or include a reduction plan, and the Director of Nursing confirmed that a physician's order should have been in place for the restraint.
Failure to Address Significant Weight Loss in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing significant weight loss for a resident diagnosed with Alzheimer's Disease. The resident's care plan, dated May 7, 2024, included general instructions to encourage adequate nutrition and offer small, frequent feedings. However, the care plan did not document the resident's ongoing weight loss, which was recorded as a 17.6% decrease from 143.2 pounds on May 28, 2024, to 118 pounds on September 2, 2024. Despite the dietician's recommendations on June 15, 2024, to add a nutritional supplement and further increase it on September 13, 2024, due to continued weight loss, these interventions were not reflected in the care plan. On October 30, 2024, the Care Plan Coordinator confirmed that the resident's weight loss was not included in the care plan.
Failure to Follow Wound Care Orders
Penalty
Summary
The facility failed to ensure that wound dressing changes were completed as ordered by the physician for a resident with multiple diagnoses, including congestive heart failure, cellulitis of the right lower limb, and morbid obesity. The resident was found to have an open area on her right lower leg, which was tender to touch and had some blood-tinged drainage. A treatment order was obtained to clean the wound and apply a calcium alginate dressing covered with a bordered foam dressing daily. However, the treatment did not start until three days after the wound was identified. The resident's treatment administration record indicated that the dressing was not changed for at least nine days after the initial application. The wound nurse confirmed that she had forgotten to enter the order into the computer, resulting in the wound not being cleaned and dressed daily as required. This oversight led to the resident having a dirty and worn dressing on her right lower leg, which was not changed in accordance with the physician's orders.
Failure to Secure and Date Respiratory Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not dating and securing oxygen tubing, humidification bottle, and nebulizer tubing. The resident's care plan, updated on 12/4/24, indicated the need for nebulizer and oxygen therapies as ordered. A physician's order dated 9/20/24 required oxygen via nasal cannula to maintain an oxygen saturation of 90% or above at bedtime. On multiple occasions, the resident's oxygen tubing was found uncovered and lying on the floor, with the nasal prongs of the nasal cannula on the floor. The tubing and humidifier bottle were not dated, and the nebulizer mask, reservoir, and tubing were also not dated. The resident confirmed using the oxygen and stated that staff did not date the tubing or humidification bottle when changed.
Medication Administration Errors
Penalty
Summary
The facility failed to administer medications according to Physician's Orders for one of four residents reviewed for medication administration. This resulted in two medication errors out of 33 opportunities, leading to a 6.06% error rate. The facility's Medication Administration Policy requires drugs to be administered in accordance with licensed medical practitioners' orders and within one hour of the scheduled time unless otherwise specified. However, a Licensed Practical Nurse (LPN) administered Metoprolol Tartrate 25 mg half a tablet (12.5 mg) to a resident over 4 1/2 hours late and gave an incorrect dose of Vitamin D3, administering 5,000 units instead of the prescribed 2,000 units. The LPN attributed the late administration of Metoprolol to computer issues and acknowledged the error in Vitamin D dosage, stating she misread the units.
Failure to Serve Palatable Meals
Penalty
Summary
The facility failed to serve palatable meals to a resident, affecting one resident out of a sample of 46. On October 27, 2024, the resident reported receiving cold food while eating meals in their room. On October 29, 2024, during meal service in the 200 hallway, the resident received a meal of biscuits and sausage gravy that measured 95 degrees Fahrenheit, which the resident reported as not warm enough. The cook explained that meals might not be arriving hot because trays are assembled in the main kitchen and then transported to the dining room, where drinks are prepared before serving the meals to residents. This process may delay meal service, resulting in cooler food temperatures.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to conduct timely and consistent pressure ulcer risk assessments for residents, as evidenced by the lack of recent Braden scale assessments for residents R1, R5, and R6. The facility's policy required these assessments to be conducted on admission, weekly for the first month, quarterly, and with any significant change in condition. However, the most recent assessments for R5 and R6 were outdated, and the facility was unable to provide documentation of consistent assessments. This lack of regular assessment contributed to the development and worsening of pressure ulcers in these residents. The facility also failed to obtain timely treatment orders for identified pressure ulcers and did not complete pressure ulcer monitoring and treatments according to physician orders. For instance, R5 developed a worsening stage 3 pressure ulcer on the coccyx, which was not treated according to physician orders on multiple occasions. Similarly, R6's pressure ulcers on the right shoulder and hip were not treated promptly, and there was confusion regarding the correct location of the ulcers due to documentation errors. These failures were compounded by the use of agency nurses unfamiliar with the residents and inconsistent shift schedules, leading to missed treatments. Additionally, the facility's documentation practices were inadequate, with missing or incomplete records of ulcer measurements and descriptions. For example, R5's and R6's nurses' notes lacked detailed documentation of ulcer characteristics, and there were discrepancies in the treatment administration records. The facility's reliance on telehealth for wound care assessments and the lack of a dedicated, trained wound care nurse further exacerbated these issues, resulting in inadequate pressure ulcer care for the residents.
Failure to Coordinate Infection Treatment Leads to Resident's Death
Penalty
Summary
The facility failed to ensure a resident received appropriate treatment for an infection of the heart muscle, leading to severe consequences. The resident was admitted to the facility following hospitalization for sepsis secondary to cellulitis, bacteremia with enterococcus with endocarditis, and other related conditions. The discharge instructions from the hospital included a recommendation for six weeks of intravenous Vancomycin. However, the facility did not coordinate with the physician or nurse practitioner regarding the infectious disease plan, resulting in a change to the Vancomycin order without proper justification or documentation. The change in the Vancomycin order was made by a registered nurse following instructions from the pharmacy, which was not intentional according to the pharmacist. The nurse practitioner signed off on the order change without being aware of the resident's diagnosis of bacterial endocarditis. Consequently, the resident received an incorrect dosage of Vancomycin, leading to elevated levels and kidney failure. Despite these alarming lab results, the resident continued to receive the incorrect dosage until it was discontinued, and Clindamycin was prescribed instead, which was not effective against enterococcus. The lack of communication and coordination among the facility's staff, including the medical director and nurse practitioner, resulted in the resident being rehospitalized with sepsis from endocarditis. The infectious disease physician from the hospital stated that the lack of appropriate care at the facility hastened the resident's death. The resident ultimately expired due to complications related to the untreated endocarditis.
Removal Plan
- All residents on IV antibiotics have the potential to be affected by this practice.
- R2 has the potential to be affected by the same deficient practice.
- All ancillary orders necessary for the care and maintenance of R2's access port were reviewed for accuracy.
- DON confirmed R2's antibiotic orders were correct with the prescribing MD.
- IT confirmed that the facility contracted Medical Director and Nurse Practitioner have remote access to Point Click Care and Point Click Care Connect.
- IV antibiotic orders for all current residents were reviewed for accuracy by Infection Preventions to include indication, dosage, access type and location, and all necessary ancillary orders. Any identified discrepancies were brought to the attention of the MD/NP.
- All new admission discharge notes will be reviewed during the AM clinical meeting by Medical Records or designee, the DON or designee, and the MDS coordinator or designee. All discrepancies will be reported to the MD/NP.
- Any pharmacy recommended antibiotic dosage changes, discontinuation of antibiotic treatment prior to end date ordered by the facility's contracted MD or NP, or initiation of another antibiotic in lieu of the facility's contracted MD's or NP's prescribed antibiotic treatment will first be approved by the prescribing physician.
- The DON, Nurse Practitioner, and the Infection Preventionist were educated by the Administrator on how to view new or changed antibiotic orders on the clinical dashboard in Point Click Care.
- Corporate Consultant educated DON on medication and treatment reconciliation for admissions/readmissions.
- The DON or designee will audit all new admission/readmissions to ensure that all orders and diagnoses have been accurately transcribed. This audit will be completed the next business day after each admission/readmission and will be an ongoing review. Any identified issues will be immediately corrected.
- Infection Preventionist or designee will review the Point Click Care dashboard daily for any new antibiotic orders to ensure that the antibiotic therapy is appropriate. Any changes to existing antibiotic orders or discrepancies will be reported to the MD/NP immediately to ensure that they are aware of the change and notified of the discrepancy. This will be an ongoing review. The QAPI Committee will monitor results for compliance.
Inadequate Infection Control and Antibiotic Management
Penalty
Summary
The facility failed to provide an effective infection prevention and control program, which had the potential to affect all 76 residents. The infection tracking for July and the specified date did not quantify infection numbers for specific sites or analyze locations to identify possible clusters of resident infections. There was no documentation indicating that the Infection Control team met or made recommendations regarding infection control. This lack of oversight and documentation contributed to the deficiency. A resident was admitted to the facility following hospitalization for sepsis secondary to cellulitis, bacteremia with Enterococcus, and endocarditis. The resident was discharged with a recommendation for six weeks of intravenous Vancomycin. However, the Vancomycin order was changed from every 48 hours to every 24 hours without documented rationale or lab tests to justify the change. This change was made based on pharmacy instructions, but the pharmacy later stated that the change was not intentional. The resident's lab results later showed a panic level of Vancomycin and kidney failure, yet another dose was administered before discontinuation. The resident's condition deteriorated, leading to rehospitalization with sepsis from endocarditis, and eventually, the resident expired. The medical director and infectious disease physician were not aware of the resident's endocarditis diagnosis, and the treatment with Clindamycin was inappropriate for the infection. The lack of appropriate care and communication within the facility contributed to the resident's rehospitalization and subsequent death. There was no documentation to support that the Infection Control Committee evaluated the resident's infection status or made recommendations during the resident's stay.
Deficiency in IV Therapy Administration
Penalty
Summary
The facility failed to provide intravenous (IV) therapy to residents in accordance with professional standards of practice. This deficiency was observed in the care of three residents, R1, R2, and R3, who were receiving IV medications. The facility did not complete necessary IV dressing changes, monitor and document required measurements, or specify the type and anatomical location of the IV access devices. Additionally, there were no orders for IV dressing changes, device flushes, or monitoring for signs of infection and infiltration. Resident R1 was admitted with a percutaneous intravenous central catheter (PICC) line for six weeks of intravenous Vancomycin following hospitalization for sepsis and other conditions. However, there was no documentation in R1's medical record regarding the care of the PICC line, including monitoring for infection or infiltration. The care plan for R1 did not include PICC line maintenance, and the facility administrator acknowledged the failure to add necessary parameters for the PICC line. Resident R2 had a PICC line for IV Vancomycin administration, but the physician order summary did not document the type of IV access, location, or necessary flush orders. There was also no documentation of dressing changes or monitoring in the medication administration record (MAR) and treatment administration record (TAR). Similarly, Resident R3, who was receiving IV antibiotics post-toe amputation, had no documentation of the type of IV access, location, or necessary flush orders. The care plans for both R2 and R3 were incomplete, lacking details on IV site monitoring and care, which was confirmed by the care plan coordinator and other staff members.
Failure to Prevent Verbal Abuse Between Residents
Penalty
Summary
The facility failed to protect residents from verbal abuse, as evidenced by an incident involving two residents in a shared room. The facility's Abuse Prevention Program outlines the residents' right to be free from abuse, including verbal abuse, which is defined as the use of language that includes disparaging and derogatory terms. Despite this policy, a verbal altercation occurred between two residents, where one resident threatened violence and used expletive language towards the other resident and staff. This incident was documented in the Abuse Investigation Summary, which confirmed the occurrence of verbal abuse and threats of violence. The residents involved in the incident have documented medical conditions that may contribute to their behavior. One resident is diagnosed with anxiety and cognitive impairment, and is noted to be severely cognitively impaired according to their Minimum Data Set (MDS). This resident is also at moderate risk for abuse due to their dependency on others and mental health conditions. The other resident, diagnosed with Parkinson's Disease and depression, is moderately cognitively impaired and has a history of inappropriate behavior. Staff interviews confirmed the verbal altercation and threats, highlighting the facility's failure to prevent such incidents.
Failure to Prevent Misappropriation of Resident's Medication
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse by not preventing the misappropriation of the resident's physician-prescribed medication. The incident involved a resident diagnosed with Diabetes, who was prescribed Semaglutide Injectable medication. The medication was brought in by the resident's family and stored in the facility's refrigerator. However, when the Licensed Practical Nurse (LPN) went to administer the medication, it was discovered missing. Despite a thorough investigation by the facility, the medication could not be located, and the responsible party was not identified. The resident, who is cognitively intact and at moderate risk for abuse due to dependence on others, depression, and chronic pain and anxiety, confirmed that the facility replaced the missing medication, which had a significant out-of-pocket cost. The LPN reported the missing medication to the Administrator, who confirmed the misappropriation but was unable to determine who took the medication. This incident highlights a failure in the facility's Abuse Prevention Program, which defines abuse to include the misappropriation of resident property.
Failure to Safeguard Resident Financial Affairs
Penalty
Summary
The facility failed to safeguard the financial affairs of four residents, as evidenced by the mismanagement of their funds. The issue arose when it was discovered that former employees, including the Former Business Office Manager (FBOM), Former Administrator (FA), and Former Social Services Director (FSSD), still had access to the resident trust accounts. This was confirmed by the Local Bank and Trust Personal Banker, who stated that these former employees were still listed on the resident trust accounts, despite having left the facility. The current Business Office Manager (BOM) was unaware of who was authorized to sign on the resident trust account, indicating a lack of oversight and management of the residents' financial affairs. Interviews with facility staff revealed a lack of communication and understanding regarding the management of resident funds. The BOM admitted to having debit cards in the names of former employees but did not know how to handle them or who was responsible for the resident trust account. The Administrator also confirmed a lack of awareness regarding the signatories on the resident trust account. The Corporate Director of Operations acknowledged that former employees should not have access to facility debit cards or the resident trust account. The facility's policy and procedure documents state that the Administrator, Office Manager, Social Services Director, and Business Office Personnel are responsible for managing resident monies, yet this responsibility was not adequately fulfilled, leading to the deficiency.
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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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