Prairie Oasis
Inspection history, citations, penalties and survey trends for this long-term care facility in South Holland, Illinois.
- Location
- 16000 South Wabash, South Holland, Illinois 60473
- CMS Provider Number
- 145927
- Inspections on file
- 45
- Latest survey
- March 21, 2026
- Citations (last 12 mo.)
- 34 (1 serious)
Citation history
Health deficiencies cited at Prairie Oasis during CMS and state inspections, most recent first.
A resident with multiple comorbidities, dementia, and a documented history of falls was assessed as high fall risk and had care plan interventions requiring proper non-skid footwear and adjustment of room furniture to reduce fall risk. After a prior incident in which the resident was found on the floor between the bed and dresser following an unassisted self-transfer, surveyors later observed the resident in a wheelchair wearing regular socks instead of non-skid socks, and the bed remained positioned next to furniture. An LPN acknowledged that non-skid socks were a fall intervention, and a CNA admitted she had not applied them without any specific reason, while leadership stated that staff are expected to follow all fall interventions as outlined in the fall prevention program and care plan.
Two residents with severe dementia and high fall risk were not adequately supervised, and environmental hazards were not corrected, leading to serious injuries. One resident, nonverbal and requiring substantial assistance with mobility and ADLs, was in a low bed positioned near a floor radiator with a loose or missing cover that staff reported had been in disrepair for months. The assigned CNA did not complete required 2‑hour rounds, did not see the resident for most of the shift, and later found the resident wedged between the bed and wall, lying directly on the exposed heater, resulting in extensive second‑degree and deep burns to the shoulder, arm, and hip that required burn ICU care and skin grafting. Staff interviews and maintenance statements confirmed there was no documented preventive maintenance system for heater covers and that housekeeping and nursing staff had observed the loose cover previously without effective correction. Another resident sustained a left eye laceration requiring sutures and traumatic subdural hematomas necessitating ICU care and subsequent hospice admission, further demonstrating the facility’s failure to ensure a hazard‑free environment and adequate supervision to prevent accidents.
The facility failed to maintain sufficient nursing staff to meet resident needs and to follow its own staffing plan, as frequent call-ins and no-call/no-shows left multiple shifts, particularly nights, below the CNA levels identified in the facility assessment. A cognitively intact resident with complex medical conditions and total dependence for toileting reported waiting hours for assistance, being left in a Hoyer lift in feces, and frequently remaining in urine and feces for prolonged periods, with POC records showing numerous shifts without documented toileting care. Other cognitively intact residents also reported long waits and missed incontinence care, and staff, including a CNA and an LPN, stated they were often short-staffed and responsible for large resident assignments, while leadership acknowledged call-ins that sometimes delayed care but asserted staffing was adequate.
The facility failed to ensure sufficient dietary staffing to prepare and serve meals on time, affecting all residents who received food from the kitchen. Multiple cognitively intact residents with complex medical conditions, including diabetes, malnutrition, COPD, hemiplegia, and hypertension, reported that meals were frequently late, sometimes by more than an hour, and occasionally cold. Surveyors observed a lunch service where only one cook and two dietary aides were working, plating did not begin at the scheduled start time, and the last tray in a dining room was served 1 hour and 47 minutes after the scheduled lunch time. Staff interviews confirmed that more kitchen staff were needed, and schedule reviews showed repeated shifts with only one dietary aide or one cook during key meal periods. The facility assessment and policies did not specify a dietary staffing plan or define the number and types of dietary staff required to meet meal service times.
Surveyors found that the facility failed to provide adequate menu variety, honor resident preferences and cultural/ethnic considerations, and follow dietician-approved menus and recipes. Multiple residents reported that meals, especially dinners, frequently consisted of sandwich-style entrees, lacked flavor, and were often unappealing, with one resident describing culturally important Sunday dinners being reduced to dry ham sandwiches. Observations showed staff substituting ground beef for ground turkey in stuffed peppers, serving carrots instead of creamed corn for mechanically altered diets, using canned spray whipped cream without honey instead of the required prepared whipped topping for a spiced peach parfait, and replacing burnt cornbread with plain wheat bread for several residents, all without RD approval. A test tray lacked the posted stuffed pepper, cornbread, and spiced peach dessert, and resident council minutes documented food concerns without clear follow-up on requested changes, despite facility policies requiring variety, documentation of menu changes, and dietician oversight.
The facility failed to provide palatable and attractive meals to residents, as evidenced by multiple cognitively intact residents describing the food as terrible, nasty, bland, and often inedible, and by frequent daily complaints reported by CNAs and LPNs about poor taste, cold food, and incorrect meal items. Surveyors observed desserts with whipped topping smeared into plastic wrap, a large portion of burnt cornbread that was discarded without replacement, and at least six residents receiving plain wheat bread instead of the planned cornbread. Pureed vegetables and cornbread appeared thick, lumpy, and gelatinous rather than smooth, and a test tray contained a plain piece of bread, corn, and an unidentifiable rice/meat mixture in tomato sauce on a Styrofoam plate, after the cook stated the kitchen had run out of stuffed peppers, cornbread, and dessert. Resident council minutes also documented concerns about improperly cooked grits and a desire for vegetables on sandwiches, while the facility’s own policy required food to be palatable, attractive, and served at safe, appetizing temperatures.
The facility failed to procure and serve sufficient food items to follow the approved menu for all residents who eat from the kitchen. Cognitively intact residents reported that the food was poor in quality, that the main entrée and substitutes frequently ran out, and that they sometimes did not receive what they ordered or did not eat. Staff, including a CNA and an LPN, confirmed daily complaints and instances where residents were given sandwiches or other unplanned items when the entrée or substitute was unavailable. A cook used ground beef instead of the ground turkey specified for stuffed peppers, substituted carrots for creamed corn on mechanically altered diets, and served plain wheat bread instead of cornbread after burning a large portion, stating there was no more cornbread. A test tray lacked the stuffed pepper, cornbread, and dessert listed on the menu. The dietary manager later stated that the correct meat and additional cornbread were actually available, and the RD reported no approval of any menu changes. The administrator acknowledged that the menu should be followed and that all needed ingredients should be procured, and also stated there was no policy for food procurement/ordering.
The facility failed to complete a comprehensive facility-wide assessment that identified residents’ ethnic, cultural, and religious factors affecting care and did not define the number of dietary staff needed, listing only a Dietary Director without specifying cooks or dietary aides. The written assessment section on cultural factors contained only general statements about interviewing residents and discussing preferences in resident council, with no documented specific needs. Cognitively intact residents, including one with multiple chronic conditions and malnutrition, reported poor food quality, lack of variety, and culturally important meals (such as Sunday dinners) not being honored, while other residents reported meals being served significantly late. Review of dietary schedules showed frequent shifts with only one dietary aide or one cook, and the Dietary Manager and a cook acknowledged that the kitchen was often short-staffed and that meals were sometimes late, reflecting that actual staffing needs and cultural food preferences were not incorporated into the facility assessment.
Multiple residents with significant medical conditions and dependence on staff for toileting and incontinence care did not have required assistance provided and/or documented each shift as required by facility policy. Cognitively intact residents reported long waits for help, sometimes lasting several hours, and described being left in urine and feces, while a roommate corroborated that residents needing incontinence care had to wait a long time for staff. Review of Point of Care (POC) records showed numerous shifts with no documented toileting or incontinence care for these residents, despite care plans and MDS assessments indicating total dependence and frequent incontinence. A restorative nurse (LPN) confirmed that many shifts of ADL charting were missing, and the DON acknowledged that staff are required to document ADL assistance every shift, yet no additional records were found to show that the care had been provided.
A dependent, cognitively impaired resident with multiple comorbidities was admitted with intact skin and had a physician order for weekly skin assessments on bath or shower days. From admission until a Stage 2 coccyx pressure ulcer was identified, there was no documentation of the ordered weekly assessments, and later the wound progressed to Stage 3. CNAs were expected to complete shower and skin alteration sheets and report changes, and nurses were expected to perform and document weekly skin checks per facility policy and standard of care, but the facility did not retain shower/skin sheets beyond a month and no routine weekly assessments were found in the EMR or MAR. The facility’s own pressure injury policy required weekly licensed nurse assessments and daily observation for skin breakdown, yet the lack of documentation meant the facility could not show that these assessments occurred or that the ulcer was unavoidable.
A resident had a physician order for weekly skin assessments on shower or bath days, and facility policy required weekly head-to-toe skin assessments by licensed nurses, daily CNA skin observations, and documentation in the medical record or on approved forms. Surveyors found that only an admission skin assessment and one assessment after skin breakdown were documented, with no routine weekly or daily assessments in the EMR or on the MAR. The Wound Care Nurse and DON reported that shower sheets and skin alteration sheets used by CNAs to document skin observations were not retained beyond one month per facility policy, preventing verification that ordered and policy-required skin monitoring was completed.
Two residents suffered harm due to the facility's failure to prevent abuse and neglect. One resident with severe cognitive impairment sustained a fractured arm after being handled roughly by a CNA, with no evidence of a fall and multiple witnesses reporting rough treatment and yelling. Another resident, dependent on staff for toileting, developed multiple open wounds from inadequate incontinence care, with documentation showing missed care and showers. Staff interviews confirmed inconsistent care and incomplete documentation, leading to significant pain and injury.
A resident who was fully dependent on staff for ADL care did not receive regular incontinence care or showers, as confirmed by documentation gaps, direct observation, and interviews with staff, the resident, and family. The resident developed multiple open areas with moisture-associated skin damage and reported significant pain, while staff failed to provide timely peri-care or document care as required by facility policy.
A resident suffered a left arm fracture with no documented fall or accidental cause, and multiple staff reported concerns of physical abuse by a CNA. The facility failed to immediately suspend the accused staff member, fabricated documentation to support an unsubstantiated fall narrative, and terminated an LPN who reported suspected abuse, violating the facility's abuse prevention and anti-retaliation policies.
A resident with multiple chronic conditions did not receive scheduled showers for an extended period, despite repeated complaints by the resident and family. Grievance documentation was incomplete, lacking evidence of resolution, follow-up, or administrator review, and shower records confirmed missed care. Facility policy for grievance resolution and shower documentation was not followed.
A resident was found with a swollen and painful arm, later diagnosed as a closed supracondylar fracture. Staff were unsure how the injury occurred, with conflicting accounts from witnesses and the resident unable to provide a clear explanation. The facility delayed reporting the injury to the state agency, treating it as a fall with injury rather than a potential abuse case, resulting in a report that was sent well after the required two-hour window.
A resident who was totally dependent on staff for all ADLs and required two-person assistance due to hemiparesis and poor mobility was left in the care of a single CNA. During morning care, the resident fell from the bed, resulting in a dislodged gastrostomy tube that required hospitalization for replacement. Staff interviews and records confirmed that the resident's care plan required two-person assistance, but this was not followed due to staffing shortages.
The facility did not consistently provide RN coverage for at least 8 consecutive hours per day, 7 days a week, as required. Staffing records and interviews confirmed that on multiple days, especially weekends and holidays, RNs worked less than the mandated hours, and on some days, time punch records were unavailable. This deficiency had the potential to affect all residents.
During lunch service, staff did not use proper measurement tools to portion zucchini, lettuce, and cheese, and failed to provide pureed tortilla for residents on pureed diets. This affected all residents receiving regular and pureed diets, as the facility did not follow its own recipes and serving size requirements.
The facility failed to properly sanitize dishes by using a malfunctioning dishwasher that did not dispense the required sanitation solution, as confirmed by test strips and staff interviews. Additionally, raw pork was improperly thawed on a stovetop, reaching unsafe temperatures after being left out for several hours, in violation of facility policy and food safety guidelines.
Two residents were found without call light cords within reach, with one cord dangling behind a bed and another wrapped on a nightstand out of reach, contrary to facility policy requiring call lights to be easily accessible at all times.
A resident was administered Seroquel for agitation without a documented psychiatric diagnosis or specific behavioral indication. Despite ongoing use, records showed no evidence of psychiatric manifestations, no attempts at gradual dose reduction, and the care plan lacked an associated diagnosis, contrary to facility policy requiring a supporting psychiatric diagnosis for antipsychotic use in dementia.
A resident was found with a cigarette lighter despite facility policy prohibiting such items, and staff interviews revealed confusion and lack of documentation regarding which residents are at-risk smokers. The resident's care plan and smoking risk assessment were not updated to reflect their smoking status, and the required list of at-risk smokers was not maintained or accessible to staff, resulting in a failure to follow the facility's smoking at risk program policy.
A resident with multiple diagnoses, including severe protein-calorie malnutrition and diabetes, experienced significant weight loss due to the facility's failure to implement and document effective nutritional interventions. Despite care plans and physician orders for supplements and appetite stimulants, interventions were not consistently carried out, and staff were unaware of ongoing weight concerns, leading to continued unintended weight loss.
A resident was administered quetiapine without a documented psychiatric diagnosis or evidence of behavioral symptoms to justify its use. Facility staff could not provide a clear rationale for the medication, and records showed no psychiatric manifestations or attempts at gradual dose reduction, contrary to facility policy.
A resident with multiple medical conditions experienced tooth pain for about a week due to a cracked tooth and was unsure about the status of a planned dental extraction. Although a referral for extraction was documented, the DON was not aware of it until several days later, causing a delay in arranging the dental appointment.
A nurse did not sanitize or wash her hands between administering medications to two residents, contrary to facility policy and infection prevention protocols. The nurse acknowledged forgetting to perform hand hygiene, and the DON confirmed that hand hygiene is required between residents during medication administration.
A resident with dementia, known for wandering and entering others' rooms, was physically assaulted by another cognitively intact resident after repeated incidents of going through personal belongings. Despite prior complaints to staff, no interventions were implemented, leading to a physical altercation where both residents sustained minor injuries. The facility failed to follow its abuse prevention policy and did not protect the vulnerable resident from abuse.
Several residents, including those with dementia, unsteady gait, and impaired mobility, were left unsupervised in dining rooms without staff present, despite care plans requiring frequent monitoring for fall prevention. Staff acknowledged gaps in supervision and assignment sheets showed periods with no designated monitoring, contrary to facility policy emphasizing resident safety.
A facility failed to conduct a post-fall assessment and notify the physician after a resident's fall, resulting in a delayed diagnosis of a hip fracture. Additionally, two residents did not receive their prescribed medications as ordered, with one missing chemotherapy doses and the other not receiving medications for kidney disease and oral antifungal treatment. Abnormal lab results were also not communicated to the physician.
The facility failed to implement individualized care plans for two residents, one with a high risk of falls and another at risk for dehydration. The care plans lacked specific interventions despite clear risk factors, and staff interviews revealed a lack of adherence to care planning policies.
A resident with a complex medical history was admitted to a facility without a completed nutrition assessment or hydration care plan, despite being at risk for dehydration. Abnormal lab results indicating dehydration risk were not communicated to the physician, leading to the resident being hospitalized with symptoms of dehydration and treated for acute kidney injury.
Two residents with severe cognitive impairment experienced falls due to inadequate supervision in an LTC facility. One resident attempted to transfer herself without assistance, while another fell in the dining room with only one CNA supervising 20 residents. The facility failed to follow its fall prevention program and care plans, resulting in injuries.
A facility failed to protect a resident with severe cognitive impairment from physical abuse and did not develop care plan interventions for two residents. During lunchtime, one resident scratched another with a fork, but both were unable to recall the incident due to cognitive impairments. Staff intervened quickly, but the facility lacked specific care plans for the residents involved, contributing to the deficiency.
The facility failed to replace a broken water heater, resulting in inadequate hot water supply for residents' bathrooms and showers. Eight residents experienced cold water temperatures, significantly below the required range, affecting their ability to maintain personal hygiene. The maintenance director confirmed the issue, and heating personnel indicated a delay in obtaining a replacement unit.
A resident with a history of diabetes and peripheral vascular disease was sent to the hospital without a proper skin assessment, resulting in unidentified wounds on the heels. The facility's staff, including a newer nurse, failed to perform necessary assessments and document the resident's condition, leading to a deficiency in wound care management.
A high fall risk resident with dementia and osteoporosis fell and fractured their hip after being left unsupervised during a scheduled monitoring period. The CNA assigned to monitor the resident was attending to another resident and did not request additional staff for assistance, contrary to facility policy. The resident attempted to reach for an object, slid out of their chair, and fell, highlighting a lapse in the facility's fall prevention program.
A resident with cognitive impairment and multiple health conditions was injured during a transfer using a mechanical lift due to the facility's failure to follow the care plan requiring two-person assistance. The resident was later found with a bruise and swelling, leading to a hospital evaluation. Staff interviews revealed confusion and lack of documentation regarding the incident, and the Director of Nursing was initially unaware of the injuries.
A resident, cognitively intact and ambulatory, sustained an eye injury after hitting it on improperly used bed rails. Despite the resident's request for removal and lack of a physician order, the bed rails were in the up position without padding. The facility's policy on bed rail use, requiring an order, assessment, and consent, was not adhered to, leading to the incident.
A resident with a history of falls and medical conditions experienced multiple falls due to inadequate supervision and ineffective interventions. Despite being assessed as requiring supervision, the resident was often found walking without assistance, leading to falls and hospital transfers. The facility's fall prevention policy was not effectively implemented, resulting in repeated incidents and injuries.
A resident with cognitive awareness reported a possible abuse incident involving a staff member during room cleaning. The nurse practitioner informed the DON, but the incident was not reported to the administrator or state agency within the required two-hour window. The administrator was unaware of the allegations until the next day, and the facility's initial abuse report was documented late, violating the facility's abuse prevention policy.
The facility failed to provide adequate nursing staff to meet the needs of 105 residents, resulting in delayed responses to call lights and overwhelmed staff. A resident reported long wait times for assistance during certain shifts, and a surveyor observed an unanswered call light for 20 minutes. Staff interviews revealed heavy workloads, with a CNA responsible for 27 residents. The staffing coordinator noted challenges in covering call-offs, particularly after 4:00 PM, leading to insufficient staffing levels.
A resident with severe cognitive impairment was found with a black eye, but the LPN failed to notify the family or doctor and did not perform a comprehensive assessment. The facility's abuse prevention program requires immediate reporting of such incidents, but the LPN did not adhere to this policy, resulting in a deficiency.
The facility failed to provide adequate abuse prevention education, affecting 63 residents. An LPN did not properly assess or report a resident's injury due to a lack of training. The DON confirmed the LPN's failure to follow procedures, highlighting a gap in staff education despite the facility's policy requiring such training.
A resident with severe cognitive impairment was found with a black eye, but the LPN failed to notify the family, doctor, or DON, and did not report the incident within the required two-hour window. The facility's policy mandates immediate reporting of suspected abuse, but the LPN was not trained on this upon hire, leading to a delay in reporting.
A resident with severe cognitive impairment was found with a black eye, and the LTC facility failed to conduct a thorough investigation. The LPN did not notify the family or doctor, and the DON initiated an investigation only after a family member called the police. The Administrator reviewed footage but could not determine the cause, and the investigation did not include interviews with nearby residents, leading to a deficiency finding.
The facility failed to follow physician orders and its own policy for restorative programs, leading to deficiencies in care for residents with limited range of motion. One resident with hemiplegia was not wearing a prescribed splint, and staff were unaware of its location. Another resident with cerebral palsy lacked physician orders for palm protectors, which were inconsistently applied. Documentation discrepancies were noted, highlighting a failure to adhere to restorative care protocols.
A cognitively impaired resident with severe dementia sustained an unexplained injury at a facility, highlighting inadequate monitoring and supervision. The resident, known to wander and interact with others, was found with a hematoma under her eye, but staff were unaware of the cause. Family concerns about staffing and supervision were noted, and the facility's investigation was inconclusive, with no clear documentation or immediate notification to family and physician.
A facility failed to provide a resident's representative with an arbitration agreement allowing a 30-day rescission period, instead offering only seven days. The resident, with cognitive impairments and a POA, had a family member unfamiliar with the agreement's terms. Staff interviews revealed inconsistencies in policy understanding and document updates, leading to the deficiency.
Two residents with complex medical histories experienced multiple falls due to the facility's failure to update care plans with effective interventions. Despite known risk factors, the facility did not implement personalized measures or revise care plans after falls, as required by their fall prevention policy.
Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement fall prevention measures for a resident identified as high risk for falls. The resident is an older adult with multiple diagnoses including cerebral infarction, aphasia, dysphagia, essential and secondary hypertension, hyperlipidemia, anemia, osteoporosis, insomnia, a right artificial hip joint, dementia, depression, a history of falling, low back pain, and a personal history of urinary tract infections. Fall risk reviews dated 9/25/25 and 2/28/26 identified the resident as high risk for falls. The care plan for risk of falls, in place since 1/1/24, included an intervention to ensure the resident is wearing appropriate footwear, specifically non-skid socks or other described proper footwear, when ambulating or mobilizing in a wheelchair. On 2/28/26, a facility-reported incident documented that staff found the resident sitting on the left side of the bed between the dresser and the bed after an apparent self-transfer from bed without assistance. The resident denied pain, was able to move all extremities, and had all limbs in good alignment, but staff noted gait imbalance and unsteadiness, and a small hematoma to the right side of the face with bruising. The incident occurred in the context of the resident’s known confusion, unawareness of safety needs, unsteady gait, impulsiveness, and history of falls, which were identified in the care plan as contributing factors to the resident’s fall risk. A care plan intervention dated 2/28/26 also specified moving furniture away from the bed as part of fall prevention. On 3/21/26, surveyors observed the resident sitting in a wheelchair without shoes and wearing regular socks instead of non-skid socks, and the room setup showed the bed positioned next to furniture (nightstand/dresser) on the left side of the bed. An LPN stated that the resident should have non-skid socks as a fall intervention but was unsure about the bed and furniture arrangement as an intervention. A CNA reported that she had dressed the resident and did not put on the non-skid socks, stating there was no particular reason for not doing so. The DON and Administrator both stated that their expectation is for staff to follow and implement all fall interventions for high-risk residents and that interventions are available in the resident’s point-of-care chart and communicated by restorative staff. Despite the facility’s written fall prevention policy requiring implementation of individualized interventions and monitoring of proper non-skid footwear, the resident’s care plan interventions regarding footwear and room furniture arrangement were not consistently implemented at the time of surveyor observation.
Failure to Maintain Hazard-Free Environment and Adequate Supervision Resulting in Severe Injuries
Penalty
Summary
The deficiency involves the facility’s failure to maintain a hazard‑free environment and provide adequate supervision, resulting in serious injuries to two residents. One resident with Alzheimer’s disease, dementia, insomnia, palliative care, restlessness, agitation, and a history of falls had a BIMS score of 7, indicating severely impaired cognition. Her care plans documented poor balance, decreased strength, impaired ambulation, limited mobility, and the need for substantial/maximal assistance with bed mobility and transfers, including one‑person assistance and mechanical lift designation. She was also on hospice for end‑stage Alzheimer’s disease, required total care with ADLs, was nonverbal or minimally verbal, impulsive, frequently attempted to get up on her own, and was considered at high risk for falls. On the night of the incident, the resident’s bed was a low bed positioned near a floor radiator heater. The CNA assigned to her shift from 11:00 p.m. to 7:00 a.m. stated she did not complete required two‑hour rounds, admitting she initially rounded at the start of the shift and then not again until approximately 4:45–5:00 a.m. She reported that the privacy curtain around the resident’s bed was pulled fully across and that she did not see the resident at all during the shift prior to discovering the fall. The CNA and another CNA had spent about 30 minutes assisting another resident back to bed, after which the assigned CNA focused on documenting point‑of‑care tasks instead of rounding. The CNA acknowledged she was negligent in not doing her rounds and stated that the resident was confused, tried to get up all the time, and was not steady on her feet. Around 5:15 a.m., the CNA called the LPN/charge nurse into the room, where the resident was found lying on her right side between the bed and the wall, directly on the exposed floor radiator heater with the heater cover off. The LPN and CNA assisted the resident back to bed and noted blistered areas on the right shoulder and right hip. Facility internal documentation and hospital records described multiple intact and burst blisters, areas of pink flesh, charred skin, subcutaneous tissue exposure, and deep burns down to and through deltoid muscle, requiring debridement and split‑thickness skin grafts to the right upper and lower extremities. The LPN reported that she had last seen the resident around 3:00–3:15 a.m. sleeping, while the CNA stated she had not seen the resident at all before the incident. Staff interviews indicated that the radiator heater cover in this room had been loose or coming off for months, with multiple staff (a CNA and an LPN) stating the cover was in disrepair and would come off prior to the incident, and the CNA stating the cover had been off for over nine months. The facility’s Administrator acknowledged that at the time of the incident the radiator cover in the resident’s room was not attached and believed it came off when the resident fell out of bed. However, the CNA and another CNA reported that the radiator cover had been loose or off for an extended period before the incident, and an LPN stated it had been that way for at least a couple of months, despite housekeeping cleaning the room daily. The Maintenance Director confirmed there had been no documented protocol or regular documentation of radiator heater checks prior to the incident and that only hot water and common area temperatures were being monitored. He also confirmed that two screws on each end were needed to secure the heater covers and that the resident was thin enough to fit between the radiator and the floor. These combined failures—lack of timely supervision/rounding for a cognitively impaired, high‑fall‑risk resident and failure to identify and correct a known physical hazard (an unsecured radiator heater cover adjacent to the resident’s bed)—led to the resident’s prolonged contact with the uncovered heater and the resulting severe burn injuries. The deficiency also involved another resident who suffered a laceration to the left eye requiring sutures and traumatic subdural hematomas that required ICU admission and ultimately resulted in hospice admission due to the subdural hematoma. This second resident was one of four reviewed for hazards/supervision and was noted in the deficiency statement as an additional example of the facility’s failure to provide a hazard‑free environment and adequate supervision to prevent accidents. The report attributes both residents’ injuries to the facility’s failure to ensure the environment was free from accident hazards and to provide sufficient supervision to prevent accidents.
Removal Plan
- Visited all resident rooms on all units and rearranged beds as necessary to ensure no beds are pushed against walls or close to heating units.
- Placed bedside cabinets/nightstands between the bed and the wall that houses the floor radiator to provide separation from bed to wall; continued monitoring with education provided to residents who resisted.
- Removed R1’s bed from the wall and heating unit.
- In-serviced on-duty nursing staff and housekeepers that no resident beds are to be pushed to walls or close to heating units and that bedside cabinets/nightstands are to be placed between bed and wall radiators.
- Provided verbal education to staff on safety protocol covering: not positioning beds against walls; not positioning beds close to heating units; ensuring proper protection/covering of wall heating units; importance of visual rounds/increased visual monitoring; consequences for noncompliance; use of bedside cabinets/nightstands as separation; and fall prevention program.
- Discussed the R1 incident with the IDT as an impromptu QAPI with instructions to increase visual rounding on all units and scheduled follow-up discussion at the next QAPI.
- In-serviced staff on hourly rounding and implemented an hourly rounding form.
- In-serviced nurses and CNAs verbally on: not positioning beds against walls; not positioning beds close to heating units; placing bedside cabinets/nightstands between bed and wall radiators; ensuring proper protection/covering of wall heating units; importance of visual rounds/increased visual monitoring; consequences for noncompliance; and fall prevention program.
- Implemented a system for preventive maintenance rounds in all resident rooms: Maintenance Director and Assistant Director perform rounds daily when on duty; on weekends, each housekeeper performs rounds on assigned units; needed repairs reported immediately; if a potentially harmful repair cannot be completed immediately, resident will be placed in an alternate room until repair is completed.
- Checked heating units for secure protective coverings, with ongoing daily monitoring by Maintenance Director/assistant and weekend housekeepers.
- Initiated hourly rounding with recordings on all units.
- Assigned oversight/monitoring responsibilities for compliance during routine daily rounds; in their absence, Charge Nurse, Facility Manager on Duty, and assigned weekend housekeepers monitor compliance.
- Brought the event to the monthly QAPI meeting for discussion and re-evaluation of interventions, with additional interventions to be implemented if needed.
Insufficient Nursing Staff and Missed Toileting Care Due to Frequent Call-Ins
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet resident needs and to staff in accordance with its own facility assessment. The facility census ranged from 109 to 113 residents during the review period, with the facility assessment identifying a need for 11 CNAs on day shift, 10 on evening shift, and 9 on night shift, and 4 licensed nurses on first and second shifts and 3 on third shift. Daily staffing sheets from late January to mid-February documented frequent call-ins and no-call/no-shows among CNAs and nurses, resulting in reduced CNA coverage on multiple night shifts, including nights when only 6–8 CNAs worked instead of the 9 CNAs specified in the staffing plan. The scheduler and DON acknowledged frequent call-ins that sometimes caused disruptions or delays in resident care when replacement staff could not be found. A cognitively intact resident with multiple complex diagnoses, including lumbar spine fusion, inflammatory spondylopathy, type 2 diabetes with neuropathy, malnutrition, neuromuscular bladder dysfunction, obesity, COPD, and major depressive disorder, reported that there was not enough staff and described waiting 3–4 hours for assistance. This resident, who is dependent on staff for toileting, stated they had been left hanging in a Hoyer lift for over three hours in feces in October and frequently left in urine and feces for hours, including at the time of the interview. Point of Care (POC) documentation for this resident showed multiple dates and shifts where no toileting assistance was recorded. The same resident also reported hearing staff discuss another resident who allegedly fell from bed onto a radiator and sustained third-degree burns after not being checked on for hours, though the reporting resident did not witness the event and could not identify the resident involved. Two additional cognitively intact residents, both dependent on staff for toileting or reporting incontinence care needs, stated that there were not enough aides, that they had to wait a long time for help, and that incontinence care was sometimes not provided. POC records for one of these residents showed multiple dates and shifts with no documented toileting assistance. Staff interviews corroborated concerns about insufficient staffing: a CNA stated they were usually short-staffed due to frequent call-ins, and an LPN reported being assigned to 42 residents alone and did not believe this was safe, especially given the number of residents with dementia. In contrast, the administrator and DON stated they believed staffing was sufficient overall and reported no staffing complaints, though they acknowledged call-ins occurred at least every other day and that care could be delayed when coverage could not be secured, resulting in more residents per staff member and delayed care.
Insufficient Dietary Staffing Leading to Delayed Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient dietary staff to meet resident needs and to serve meals at the scheduled times. The facility census showed 112 residents, with 6 identified as NPO, leaving 106 residents dependent on food prepared in the facility kitchen. Multiple cognitively intact residents reported that meals were generally served late and sometimes cold. One resident with diagnoses including rhabdomyolysis, lumbar spine fusion, type 2 diabetes with neuropathy, malnutrition, COPD, obesity, and major depressive disorder stated that meals were generally late and sometimes cold while being observed eating lunch in their room. Surveyor observations on a lunch meal service day documented that at 11:37 AM there was one cook and two dietary aides in the kitchen, with the cook confirming that lunch was scheduled to begin at 12:00 PM. At 11:59 AM, the cook reported that plating had not started because the dietary aides had not finished prepping trays and estimated another 25 minutes would be needed before plating could begin. At 12:30 PM, the cook and two dietary aides were observed plating food for the first dining room, and the assistant administrator was present in the kitchen questioning the delay. The final tray in one dining room was not served until 1:47 PM, which was 1 hour and 47 minutes after the scheduled lunch start time. Additional resident interviews and record reviews supported a pattern of late meal service. A cognitively intact resident with trigeminal neuralgia, type 2 diabetes, hypertension, and osteoarthritis reported that food was never served on time and described receiving dinner at 7:10 PM when they were supposed to eat at about 5:00 PM, attributing delays to insufficient help in the kitchen and nursing. Another cognitively intact resident with hemiplegia, cataracts, hypertension, type 2 diabetes, and depression stated that most meals were served late. The dietary manager, employed for about two months, stated that more staff were needed in the kitchen despite efforts to streamline tasks and acknowledged that meals had been late. Review of dietary schedules showed frequent shifts with only one dietary aide or one cook on duty during key meal periods, and the facility assessment did not identify a dietary staffing plan or specify the number and types of dietary staff needed, while the administrator confirmed there was no written policy for dietary staffing beyond a general reference to regulatory language.
Failure to Provide Menu Variety, Honor Preferences, and Follow Dietician-Approved Menus
Penalty
Summary
The deficiency involves the facility’s failure to provide menu variety, honor resident preferences and cultural/ethnic considerations, follow written recipes and menus, and obtain dietician input for menu and recipe substitutions, affecting 106 residents who consume food from the facility’s kitchen. The facility census showed 112 residents, with 6 documented as NPO, leaving 106 residents dependent on the kitchen for meals. Residents reported that the food was of poor taste, often cold, and lacked variety, with frequent sandwich-style dinners. One resident with multiple diagnoses including type 2 diabetes mellitus with diabetic neuropathy, unspecified protein calorie malnutrition, obesity, COPD, and major depressive disorder stated that the food was “terrible,” often caused diarrhea, and that dinner was “always just sandwiches of some sort,” describing being served a dry ham sandwich without condiments and expressing that this was particularly problematic given the cultural importance of Sunday dinners in the Black community. Other residents described the food as “nasty” and lacking variety, and confirmed that many dinners consisted of sandwiches. Surveyors observed multiple instances where staff did not follow the written menu or recipes and made unapproved substitutions. During a lunch service, the cook reported that the stuffed pepper recipe called for ground turkey but ground beef was used instead, stating that ground turkey was not available, despite the dietary manager later stating that the correct meat had been thawed and available. For mechanically altered diets, the menu called for creamed corn, but the cook prepared carrots instead, without knowing why creamed corn was unavailable. At the same meal, desserts labeled as spiced peach parfait were prepared using canned spray whipped cream directly onto peaches, then covered with plastic wrap, which caused about half of the whipped cream to adhere to the plastic. The dietary aide confirmed using spray whipped cream and that no honey was mixed into the topping, despite the recipe requiring whipped topping prepared from mix with honey incorporated. There was no visible indication that honey had been added, and the facility did not provide a pureed carrot recipe when requested. Additional observations showed failure to follow the posted menu and to obtain dietician approval for substitutions. Cornbread listed on the menu was partially burnt; the cook discarded the burnt portion and did not prepare additional cornbread, later serving plain wheat sandwich bread in its place. The cook and dietary aide confirmed that at least six residents received plain bread instead of cornbread and that the dietician was not notified of this change. A test tray provided to surveyors contained corn, a plain piece of bread, and an unidentifiable rice/meat mixture in tomato-based sauce, without the stuffed pepper, cornbread, or spiced peach dessert listed on the menu. The cook stated that the rice/meat mixture was the inside of the stuffed pepper used for mechanical soft diets and that the facility had run out of stuffed peppers, cornbread, and the spiced peach dessert. The dietary manager, employed for about two months, acknowledged that the corporate-approved menu cycle contained many sandwich-style dinner entrees and that residents had complained about lack of flavor and palatability. Resident council minutes documented concerns about vegetables on sandwiches and noted an in-service on making grits, but did not document corrective action regarding residents’ expressed preferences for vegetables on sandwiches. The consultant RD confirmed not being informed of or approving any ingredient substitutions or menu changes for the observed meal and affirmed that food should be prepared as directed by the recipes and menu. Facility policies required that menu items be served as planned whenever possible, that changes be documented and of similar nutritional value, and that permanent changes be approved by the dietician, as well as that cycle menus provide variety and reflect religious, cultural, and ethnic needs and resident preferences, which did not occur in these instances.
Failure to Provide Palatable and Attractive Meals
Penalty
Summary
The deficiency involves the facility’s failure to prepare and serve food and beverages that are palatable, attractive, and consistent with its own policy on food palatability and temperature. The facility census showed that 106 residents consumed food from the kitchen. Cognitively intact residents with multiple medical conditions, including one with rhabdomyolysis, lumbar spine fusion, inflammatory spondylopathy, type 2 diabetes with neuropathy, malnutrition, COPD, and major depressive disorder, and another with trigeminal neuralgia, type 2 diabetes, hypertension, and osteoarthritis, reported that the food was terrible, barely edible, nasty, and often caused them to avoid the entrée. One resident stated that the food tasted bad and looked bad, and that many other residents disliked the food but could not speak up due to dementia or impaired cognition. Staff interviews corroborated frequent resident complaints about the food. A CNA reported that residents complained almost every day that the food did not taste good or was cold, often leaving food on trays or requesting alternative items such as sandwiches. An LPN stated that residents complained that they did not like the food, that it did not taste good, or that they did not receive the meals they ordered. Another LPN who no longer worked at the facility recalled daily complaints that the food looked gross, lacked taste or seasoning, and was too bland. Resident council minutes documented concerns about specific items such as grits needing to be cooked longer and a desire for vegetables on sandwiches. Direct observations of meal preparation and service showed unappetizing and inconsistent food presentation. Dessert cups of peaches had a small dollop of whipped cream that was smashed into the plastic wrap, causing about half of the topping to adhere to the plastic. A large portion of a cornbread pan was burnt and not used, and no replacement cornbread was prepared, resulting in at least six residents receiving plain wheat sandwich bread instead of the menu item. Pureed bell peppers, carrots, and cornbread appeared thick, lumpy, and unappetizing; the pureed carrots had a gelatinous, shiny texture that the dietary manager later stated was not appropriate, as pureed carrots should resemble mashed potatoes. A test tray provided to surveyors contained corn, a plain piece of bread, and an unidentifiable rice/meat mixture in tomato sauce on a Styrofoam plate wrapped in plastic, with the cook acknowledging that the facility had run out of stuffed peppers, cornbread, and spiced peach dessert, and that the rice/meat mixture was the inside of the stuffed pepper used for mechanical soft diets. The administrator agreed that the test tray did not appear appetizing or palatable.
Failure to Procure and Serve Food According to Approved Menu
Penalty
Summary
The deficiency involves the facility’s failure to procure and provide sufficient food items and ingredients to follow the written, approved menu for all residents who consume meals from the kitchen. The census showed 112 residents, with 6 NPO, meaning 106 residents relied on the facility’s food service. Cognitively intact residents reported that the food was “terrible,” “barely edible,” and “nasty,” and described frequent situations where the main entrée or substitutes were unavailable, resulting in them receiving different items than ordered or not eating at all. A CNA and an LPN confirmed that residents complained about the taste of the food almost daily and that there were times when the main meal or substitute ran out, requiring staff to serve sandwiches or other unplanned items instead of the planned entrée. Surveyor observations in the kitchen showed that the cook did not follow the written menu and recipes due to missing or unused ingredients. For a stuffed pepper entrée, the cook stated the recipe called for ground turkey but used ground beef instead, believing ground turkey had not been ordered. For mechanically altered diets, the menu called for creamed corn, but the cook prepared carrots instead, stating there was no creamed corn available. The cook also burned a large portion of the cornbread and chose not to use it, stating there was no more cornbread and that no additional cornbread would be made, resulting in residents receiving plain wheat sandwich bread in place of the cornbread listed on the menu. A dietary aide confirmed that at least six residents would receive plain sandwich bread instead of cornbread. A test tray provided to the survey team contained corn, a plain piece of bread, and an unidentifiable rice/meat mixture in tomato-based sauce, without the cornbread, stuffed pepper, or spiced peach dessert specified on the menu. The cook stated they had run out of stuffed peppers, cornbread, and the spiced peach dessert. The dietary manager later stated that the correct meat for the stuffed peppers and additional cornbread were actually available and thawing, and did not know why the cook failed to use them or follow the menu. The consultant RD reported not being aware of any ingredient substitutions or menu changes and had not approved any changes for that day, and stated that the facility should be following the approved menus and recipes. When asked, the administrator acknowledged that the facility should be following the written menu and procuring all needed ingredients, and further stated that the facility had no policy for food procurement/ordering, despite having a written “Menu Changes” policy requiring that changes be documented, nutritionally similar, and, if permanent, approved by the dietitian.
Failure to Address Cultural Food Needs and Define Dietary Staffing in Facility Assessment
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document a comprehensive facility-wide assessment that identifies ethnic, cultural, or religious factors affecting resident care and a specific staffing plan for dietary services, including cooks and dietary aides. The written facility assessment dated 2/12/2026 includes a section instructing the facility to describe ethnic, cultural, or religious factors that may impact care, such as activities and food and nutrition services, and to list any specific or unique factors affecting care. However, the assessment only notes that residents and/or representatives will be interviewed to determine preferences and that activities will discuss these issues in resident council, and it lists the facility’s average age. It does not document any actual ethnic, cultural, or religious needs of the resident population, nor does it identify any specific or unique factors affecting care. The assessment also requires the facility to describe its staffing plan based on resident needs, including other ancillary staff such as dietary. In the staffing plan section, the facility lists one Dietary Director but does not identify the requisite number of cooks or dietary aides needed to meet resident needs. During interview, the Administrator stated that the facility assessment does not have to list cooks or dietary aides and asserted that following the federal regulation only requires having enough staff to create and serve food, without specifying numbers in the assessment. This omission occurred despite the assessment tool’s instructions that the facility-wide assessment is to determine what resources, including staff and staffing plans, are necessary to care for residents competently during day-to-day operations and emergencies. Interviews and record review further showed that resident cultural food preferences and dietary staffing needs were not adequately addressed in practice. One cognitively intact resident with multiple medical diagnoses, including type 2 diabetes mellitus with diabetic neuropathy, unspecified protein calorie malnutrition, obesity, COPD, and major depressive disorder, reported that the food was “terrible,” lacked variety, and that dinners were routinely sandwiches, which did not align with their cultural expectation of a substantial Sunday dinner in the Black community. Other cognitively intact residents reported that meals were often served late, with one resident stating they received dinner at 7:10 p.m. instead of around 5:00 p.m. Dietary staff schedules for February 2026 showed frequent shifts with only one dietary aide or one cook on duty, and the Dietary Manager, employed for about two months, acknowledged that more kitchen staff were needed and that meals had been served late. These findings demonstrate that the facility assessment did not capture or plan for ethnic, cultural, or religious food needs or define adequate dietary staffing levels, contributing to the identified deficiency.
Failure to Provide and Document Incontinence Care for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required incontinence and toileting care for multiple residents who were dependent on staff for these activities of daily living (ADLs). Four residents with significant medical conditions and documented dependence on staff for toileting—R1, R3, R4, and R5—had numerous shifts with no recorded assistance with toileting or incontinence care in their Point of Care (POC) Response History. Facility policies required incontinent residents to be checked every two hours and to receive perineal and genital care after each episode, as well as at least daily during routine CNA care, and required staff to document ADL assistance every shift. Despite these requirements, the POC records for each of the four residents showed multiple dates and shifts with no documentation of toileting assistance, and no additional documentation was found to show that care was provided. R1 had diagnoses including Alzheimer’s disease, severe dementia with behavioral disturbance, malnutrition, chronic kidney disease, adult failure to thrive, and convulsions, and was documented on the MDS and care plan as totally dependent on staff and always incontinent of bowel and bladder. R1’s POC history showed no documented toileting assistance on multiple specified dates and shifts. R3, who had hemiplegia, cataracts, hypertension, type 2 diabetes, and depression, was cognitively intact per MDS and dependent on staff for toileting with frequent incontinence. R3 reported having to wait a long time for help, sometimes not receiving incontinence care, and stated that staffing was inadequate. R3’s POC history also lacked documentation of toileting assistance on numerous dates and shifts, and a cognitively intact roommate (R8) corroborated that roommates needing incontinence care had to wait “forever” for staff assistance. R4 had diagnoses including rhabdomyolysis, lumbar spine fusion, inflammatory spondylopathy, type 2 diabetes with neuropathy, malnutrition, neuromuscular bladder dysfunction, obesity, COPD, and major depressive disorder, and was cognitively intact but dependent on staff for toileting with frequent incontinence. R4 reported that there was not enough staff, that it could take 3–4 hours to get help, and described being left hanging in a Hoyer lift for over three hours in feces and being left in urine and feces for hours, including at the time of interview. R4’s POC history showed many shifts without documented toileting assistance. R5, with severe dementia, traumatic subdural hemorrhage, osteoporosis, lymphedema, malnutrition, and muscle wasting, was cognitively impaired and dependent on staff for toileting with frequent incontinence; R5’s POC history also showed multiple dates and shifts without documented toileting assistance. The restorative nurse (LPN) responsible for monitoring ADL status and charting confirmed that these residents were dependent on staff for toileting and that many shifts of ADL charting were missing, acknowledging ongoing problems with CNA completion of charting. The DON affirmed that staff are required to document ADL assistance every shift, yet no further documentation was available to show that toileting or incontinence care had been provided to these residents during the identified periods.
Failure to Complete Ordered and Policy-Required Skin Assessments Leading to Stage 3 Pressure Ulcer
Penalty
Summary
The facility failed to provide timely skin assessments and implement preventative measures to prevent the development of a pressure ulcer for one resident, resulting in a facility-acquired Stage 3 pressure ulcer to the coccyx. The resident, who had multiple diagnoses including atrial fibrillation, seizure disorder, CVA, obesity, dementia, and severe cognitive impairment (BIMS 3/15), was totally dependent on staff for self-care and mobility, including turning, repositioning, and transfers. On admission, the resident’s skin was documented as intact, and the physician ordered weekly skin assessments on shower or bath day. However, from admission on 10/3/25 until 10/31/25, there were no documented weekly skin assessments. A Stage 2 pressure ulcer to the coccyx was first documented on 10/31/25, and by 11/11/25, the wound care physician documented a Stage 3 pressure ulcer to the sacrum measuring 4 x 5.5 x 0.1 cm. Interviews with the wound care nurse, DON, and Director of Clinical Services revealed that CNAs were expected to complete shower and skin alteration sheets and report changes to the nurse, and nurses were expected to complete weekly skin assessments and follow the physician’s orders. The facility, however, did not retain shower sheets or skin impairment sheets beyond one month, and no routine weekly skin assessments were found in the electronic medical record or MAR as required by the physician’s order and facility policy. The facility’s Pressure Injury and Skin Condition Assessment Policy required weekly skin assessments x4 for residents at high risk per Braden scale, daily observation for skin breakdown during care and on bath day, and documentation of weekly head-to-toe assessments by a licensed nurse. In the absence of documentation, the facility could not demonstrate that required skin assessments were completed or that the pressure ulcer was unavoidable in accordance with professional standards of practice and facility policy.
Failure to Maintain Complete and Retainable Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurate, and retrievable clinical records related to skin assessments and monitoring for one resident. A physician’s order dated 10/03/2025 required weekly skin assessments on the resident’s shower or bath day. The facility’s Pressure Injury and Skin Condition Assessment Policy dated 9/2016 required weekly head-to-toe skin assessments by a licensed nurse for residents at high risk, daily observation for skin breakdown by CNAs, and documentation of these assessments in the resident’s medical record or on facility-approved forms. During record review, only two skin assessments for the resident could be located in the medical record: one at admission on 10/03/2025 and one dated 10/31/2025 after skin breakdown was identified. The Wound Care Nurse (V4) reported that the facility used shower sheets and skin alteration sheets completed by CNAs to document skin observations, but stated that these records were not retained beyond one month per facility policy. The DON (V2) confirmed that the facility did not keep shower or skin assessment documentation beyond the current or previous month and that nurses were expected to complete and monitor skin assessments. The Director of Clinical Services (V3) stated that skin assessments were expected to be documented on the MAR, but review of the MAR showed no documented skin assessments as required by the physician order or facility policy. As a result, the facility could not produce documentation to verify that the ordered weekly skin assessments and required monitoring were performed for this resident.
Failure to Prevent Abuse and Neglect Resulting in Resident Injury and Skin Breakdown
Penalty
Summary
The facility failed to protect residents from abuse and neglect, resulting in significant harm to two residents. One resident with severe cognitive impairment and multiple comorbidities, including cirrhosis, dementia, and functional quadriplegia, sustained a fractured left humerus while under the care of a certified nursing assistant (CNA). Multiple interviews and witness statements indicated that the CNA was observed being rough with the resident, with reports of yelling, pulling, and a loud bang heard during care. The resident was later found to have a painful, swollen arm, and was diagnosed with a displaced supracondylar fracture. There was no documentation or credible evidence of a fall, and several staff and family members reported concerns about the CNA's rough handling and verbal aggression toward residents. The facility's investigation relied on uncorroborated statements and failed to document or substantiate a fall as the cause of injury. Another resident, who was cognitively intact and dependent on staff for toileting and hygiene, developed multiple open areas of moisture-associated skin damage (MASD) and skin breakdown due to inadequate incontinence care. The resident and their family reported frequent delays in being changed, lack of regular showers, and persistent pain and burning in the affected areas. Direct observation confirmed the presence of feces and multiple open wounds on the resident's buttocks and thighs, with no evidence of recent peri-care or appropriate wound treatment. Review of care documentation revealed multiple shifts with no record of incontinence care or showers provided, despite care plan instructions for regular toileting, cleansing, and skin monitoring. Staff interviews confirmed that documentation of care was incomplete and that the standard of checking and changing incontinent residents every two hours was not consistently met. The wound care nurse and restorative nurse acknowledged the presence of skin breakdown and the need for regular application of barrier creams, but also confirmed that care was not always provided as required. The facility's failure to ensure consistent, appropriate care and to protect residents from abuse and neglect directly resulted in physical harm and pain for the affected residents.
Failure to Provide Incontinence Care and Showers Resulting in Skin Breakdown
Penalty
Summary
A resident who was dependent on staff for activities of daily living (ADL), including incontinence care and showers, did not receive regular and adequate care as required by their care plan. The resident, who had a history of hemiplegia, type 2 diabetes mellitus, depression, hypothyroidism, and hypertension, was cognitively intact and reported being left in urine and feces for extended periods. The resident and their family repeatedly informed staff and administration about the lack of timely incontinence care and showers, with the resident experiencing significant pain and the development of open areas on the skin. Documentation and interviews confirmed that there were multiple shifts with no record of incontinence care or showers being provided, and the resident went at least 13 days without a shower. Direct observation by surveyors and staff revealed the resident had multiple open areas with serosanguinous drainage on the buttocks and thighs, consistent with moisture-associated skin damage (MASD). During a skin assessment, feces was observed between the resident's buttocks even after staff claimed to have provided peri-care. Staff, including the DON and LPNs, acknowledged that proper incontinence care was not consistently documented or provided, and that the standard of care requires residents to be checked and changed every two hours to prevent skin breakdown. The wound care nurse and restorative nurse confirmed that the lack of documentation indicated care was not provided, and that the resident's skin was wet and wrinkled during assessment, further supporting the finding of inadequate care. The facility's own policies required staff to observe skin during direct care, provide peri-care after each incontinence episode, and document any skin irritation or breakdown. Despite these requirements, there was no evidence that the resident received the necessary care, and staff failed to report or treat the skin breakdown in a timely manner. The medical director and other staff affirmed that the observed skin breakdown and presence of feces were clear signs that incontinence care was not being provided as required.
Failure to Implement Abuse Policy and Protect Staff from Retaliation
Penalty
Summary
The facility failed to implement its abuse prevention policy in response to an allegation of staff-to-resident physical abuse, specifically failing to immediately suspend the accused staff member from resident contact pending investigation. A resident was found with a swollen and painful left arm, later diagnosed as a closed supracondylar fracture of the left humerus. There was no documentation or evidence of a fall or other accidental cause for the injury in the resident's records. Multiple staff interviews indicated that the resident and another resident reported that a staff member had been rough or abusive during care, with statements describing the staff member as having snatched and hit the resident's arm against the bed rail. Despite these reports, the accused staff member was not immediately suspended and was reassigned to a different unit rather than removed from resident contact. The investigation process was further compromised by inconsistent and fabricated documentation. The Director of Nursing (DON) and Administrator attempted to attribute the injury to an unreported fall, despite the lack of any supporting documentation or witness statements, except for the statement from the accused staff member. Other staff, including CNAs and an LPN, consistently denied that a fall had occurred and expressed concerns that the injury was a result of physical abuse. The DON was observed fabricating a witness statement to support the fall narrative, and no evidence was provided to substantiate that a fall had taken place. Additionally, the facility failed to protect staff from retaliation after reporting suspected abuse. An LPN who reported concerns about abuse was terminated during the investigation, with the termination attributed to failure to report a fall that was not documented or corroborated by any evidence. The facility's own abuse policy prohibits retaliation against employees who report suspected abuse, but this policy was not followed. The Regional Supervisor confirmed that the environment created by such retaliation could discourage staff from reporting abuse, potentially affecting all residents.
Failure to Timely Resolve Resident Grievances Regarding Showers
Penalty
Summary
The facility failed to respond to and resolve a resident's grievances in a timely manner, specifically regarding concerns about receiving scheduled showers. A resident with a history of hemiplegia, type 2 diabetes mellitus, depression, hypothyroidism, and hypertension reported not having received a shower in over a month, despite multiple complaints made by both the resident and their family to staff and administration. Grievance records showed that concerns about missed showers were documented on several occasions, but the grievance dated 11/11/2025 lacked documentation of resolution, the complainant's response, or the administrator's signature. Interviews with staff confirmed that the grievance process was not completed as required, and there was no evidence of follow-up, investigation, or communication of resolution to the resident or family. Review of the resident's shower sheets confirmed that no showers were documented for a 13-day period, and the resident did not receive showers as scheduled until after the survey began. Facility policy requires grievances to be resolved within 72 hours and mandates documentation of all showers provided or declined. However, the process was not followed, as grievances were not properly reviewed, signed off by the administrator, or communicated back to the complainant, resulting in unresolved concerns and a lack of timely care for the resident.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the state survey agency within the required two-hour timeframe for one resident. The incident involved a resident who was observed with a swollen and painful left arm, which was later diagnosed at the hospital as a closed supracondylar fracture of the left humerus. Staff interviews and record reviews revealed that the facility became aware of the injury in the morning, but the initial report to the state agency was not faxed until the following afternoon, well beyond the mandated reporting window. The administrator confirmed awareness of the injury and acknowledged that the cause was unknown, but the facility treated the incident as a fall with injury rather than as a potential abuse case, which delayed the reporting process. Multiple staff members, including the Social Services Director and the DON, recounted that there were conflicting accounts regarding how the injury occurred. One resident reported seeing a CNA hurt the injured resident, while another account suggested only hearing a loud noise without witnessing the event. The injured resident was unable to clearly communicate what happened due to fluctuating cognition. The facility's abuse policy requires reporting serious bodily injury with reasonable suspicion of a crime within two hours, but this protocol was not followed. The failure to report the injury promptly was confirmed by the administrator and supported by documentation of the delayed facsimile transmission.
Failure to Provide Required Two-Person Assistance During Resident Care
Penalty
Summary
The facility failed to ensure that two-person assistance was provided during care for a resident who was care planned as requiring such assistance for all activities of daily living (ADLs) due to total dependence and inability to assist with turning or repositioning. Despite the care plan and staff knowledge that the resident was dependent and unable to turn or hold herself on her side, a certified nurse aide (CNA) provided morning care alone, citing insufficient staffing as the reason for not having a second staff member present. During this unsupervised care, the resident fell from the bed, resulting in the dislodgement of her gastrostomy tube. The resident had a history of stroke with hemiparesis, was non-ambulatory, and was dependent on staff for bed mobility, toileting, hygiene, and bathing. The resident's care plan and assessments consistently documented the need for two-person assistance for all care, and staff interviews confirmed awareness of this requirement. The fall occurred while the CNA was changing linens and the resident was positioned on her side, leading to the resident sliding off the bed and sustaining an injury that required hospitalization for gastrostomy tube replacement.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to provide sufficient registered nurse (RN) coverage for the second quarter of 2025, as required by federal regulations. Specifically, the facility did not have an RN on duty for at least 8 consecutive hours per day, 7 days a week, as evidenced by payroll-based journal (PBJ) records and staffing sheets. Signage posted at the main receptionist desk indicated that the facility did not meet minimum staffing ratios for the quarter ending March 31, 2025. The Director of Nursing (DON) confirmed that for 21 days during the second quarter, there was no RN present for the required 8 consecutive hours. Review of staffing sheets and time punches for January, February, and March revealed multiple days where RNs worked less than 8 hours, particularly on holidays and weekends, and on some days, time punch records were not made available for review. These deficiencies were corroborated through observations, interviews with the DON and RNs, and record reviews. The lack of consistent RN coverage had the potential to affect all residents in the facility, as there was not always an RN present for the required duration on several days throughout the quarter. No specific residents or their medical conditions were mentioned in the report.
Failure to Follow Menu Recipes and Portioning for Regular and Pureed Diets
Penalty
Summary
The facility failed to follow its established recipes and portioning guidelines during lunch service, as observed on the kitchen tray line. The cook did not use measurement tools or scoops to serve zucchini, lettuce, and cheese, instead using tongs and gloved hands to portion these items, which did not ensure the correct serving sizes as specified in the facility's recipes. Specifically, the recipe required 1/2 cup of lettuce and tomato with a tablespoon of shredded cheese as garnish, and a #8 scoop for 1/2 cup of seasoned zucchini per serving, but these standards were not followed. Additionally, for residents on pureed diets, the facility did not provide pureed tortilla as required by the recipe, resulting in pureed trays containing only refried beans, beef, and zucchini, with no pureed tortilla included. These deficiencies had the potential to affect all 58 residents on regular diets and 20 residents on pureed diets, as documented in the facility's diet list.
Improper Dish Sanitization and Unsafe Food Thawing Practices
Penalty
Summary
The facility failed to ensure proper sanitation of dishes and utensils by continuing to use a dishwasher that was not dispensing the required sanitation solution. Observations and interviews revealed that the chlorine test strips did not indicate the presence of sanitizer during multiple meal services, and staff acknowledged the issue but continued to use the dishwasher for breakfast and lunch. Documentation showed no corrective action was taken prior to servicing, and the dishwasher log lacked entries for the affected meal periods. The repairman later confirmed that a leaking tube prevented the machine from receiving enough sanitation solution, resulting in dishes not being properly sanitized before use for 99 residents receiving meals. Additionally, the facility did not follow its own thawing policy for time/temperature control for safety foods. Raw pork was observed thawing on a stovetop that was off, rather than in a refrigerator or under running water as required. The pork reached a temperature of 60 degrees Fahrenheit after being left out for over four hours, exceeding safe temperature guidelines. Staff confirmed the improper thawing method and intended to use the pork for a future meal, contrary to facility policy and CDC food safety recommendations.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
Surveyors observed that the facility failed to ensure call light cords were within reach for two residents. One resident's call light cord was found dangling behind the bed, requiring the resident to lower the bed and stretch her arm above her head to access it. Another resident was found calling out for help while seated in a wheelchair in the middle of the room, with the call light cord wrapped on the nightstand approximately three feet behind her and not within reach. The facility's policy requires that call lights be available and easily accessible to residents at all times, but this was not followed in these instances.
Lack of Appropriate Diagnosis for Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that an appropriate diagnosis and specific behavioral indication were present for the use of an antipsychotic medication in one resident. Interviews and record reviews revealed that a resident was receiving Seroquel (quetiapine fumarate) for agitation, but there was no documented psychiatric diagnosis or behavioral manifestation to justify the use of this psychotropic medication. The Assistant Director of Nursing (ADON) acknowledged that the resident was on hospice care and suggested contacting the hospice physician to add a diagnosis after the medication had already been initiated. The Director of Nursing (DON) deferred responsibility for psychotropic medications to the ADON and did not provide further information. The resident in question had diagnoses of Alzheimer's disease and moderate dementia without behavioral, psychotic, or mood disturbances. The physician order sheet indicated quetiapine was prescribed for monitoring related to dementia, but the medication administration record showed ongoing administration without evidence of psychiatric manifestations or behavioral conditions. The psychotropic drug review noted no attempts at gradual dose reduction and no psychiatric symptoms. The care plan referenced the need for psychotropic medication but did not include an associated diagnosis. Facility policy requires a supporting psychiatric diagnosis for antipsychotic use in residents with dementia, which was not present in this case.
Failure to Implement and Document Smoking Risk Care Plan
Penalty
Summary
The facility failed to follow its smoking at risk program policy and did not develop an appropriate care plan for a resident identified as an at-risk smoker. During a survey, the resident was observed in possession of a cigarette lighter, which is against facility policy. Interviews with staff, including the DON and LPN, revealed inconsistencies in identifying and monitoring residents who smoke, as well as a lack of awareness regarding which residents are considered at-risk smokers. The list of at-risk smokers was not available on the unit, and staff could not confirm who should be monitored for smoking risks. Record review showed that the resident's smoking risk assessment was outdated and inaccurately indicated that the resident did not smoke, despite evidence to the contrary. The care plan did not reflect the resident's status as an at-risk smoker, and the required interventions, such as individualized care planning and proper documentation, were not implemented. The facility's policy requires that at-risk smokers be identified, listed, and monitored, with care plans developed accordingly, but these steps were not followed for the resident in question.
Failure to Prevent Significant Weight Loss in Resident with Severe Malnutrition
Penalty
Summary
The facility failed to implement effective interventions to prevent significant weight loss in a resident diagnosed with type II diabetes, hypertension, anemia, severe protein-calorie malnutrition, and blindness. Despite being identified as at risk for weight loss and having a care plan that included interventions such as administering medications, providing dietary supplements, offering snacks, and monitoring intake, the resident experienced a significant weight loss of 6% in one month and 11.3% over six months. The resident's body mass index (BMI) remained below 14, indicating severe underweight status. Medical and dietary records showed that the resident's intake varied widely, with appetite described as mostly fair and intake ranging from 26% to 100%. Although the care plan called for interventions like nutritional supplements and high-calorie diets, there was no documentation of new or adjusted interventions in response to ongoing weight loss. Physician orders for appetite stimulants such as Megestrol Acetate were not consistently administered, as confirmed by the Director of Nursing and review of medication administration records. Interviews with facility staff, including the medical doctor, revealed a lack of awareness regarding the resident's weight concerns and the absence of a clear medical diagnosis contributing to the weight loss. Despite recommendations from dietary staff to add health shakes and ready care supplements, there was no evidence that these interventions were effectively implemented or that the resident's nutritional needs were consistently met, resulting in continued unintended weight loss.
Failure to Justify Antipsychotic Use Without Appropriate Diagnosis
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not having an appropriate diagnosis or identified behavior to justify the use of an antipsychotic medication. Specifically, a resident was receiving quetiapine fumarate (Seroquel) for agitation, but there was no documented psychiatric diagnosis or behavioral manifestation to support its use. Interviews with the ADON revealed uncertainty about the necessity of a diagnosis prior to initiating psychotropic medication, and the DON deferred responsibility for psychotropic medications to the ADON. The resident's physician order sheet listed quetiapine for dementia without behavioral disturbance, and the medication administration record showed ongoing administration of the drug over several months. Further review of the resident's records, including the psychotropic drug review and care plan, indicated that the resident did not exhibit psychiatric manifestations or behavioral conditions, and no gradual dose reduction had been attempted. The facility's own policy required a supporting psychiatric diagnosis for antipsychotic use in residents with Alzheimer's or dementia, but this was not present in the documentation. The lack of a specific diagnosis or behavioral justification for the antipsychotic medication constituted a failure to comply with requirements for unnecessary medications.
Failure to Arrange Timely Dental Referral and Appointment
Penalty
Summary
The facility failed to arrange a timely dental referral and appointment for a resident who required a tooth extraction. The resident, who had diagnoses including type II diabetes, dementia, hypertension, epilepsy, anxiety, and weakness, reported experiencing tooth pain for about a week due to a cracked tooth and expressed uncertainty about the status of the planned dental extraction. Documentation showed that a referral for extraction was made, but the Director of Nursing was not aware of the referral until several days later, resulting in a delay in scheduling the dental appointment.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
During a medication pass, a nurse failed to perform hand hygiene between administering medications to two residents. Specifically, after giving morning medications to one resident, the nurse returned to the medication cart and prepared medications for another resident without washing her hands or using hand sanitizer. The nurse acknowledged that she was supposed to clean her hands between residents but stated she forgot to do so. The Director of Nursing confirmed that hand hygiene should be performed between residents during medication administration to prevent the spread of infections. The facility's hand hygiene policy requires hand hygiene before contact with a resident or their environment.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident with dementia from physical abuse by another cognitively intact resident. The incident occurred when the resident with dementia repeatedly went through the belongings of the other resident, despite being asked to stop. The cognitively intact resident, after reporting the behavior to staff and receiving no intervention, pushed the resident with dementia against a wall, leading to a physical altercation where both residents sustained minor head lacerations. Staff were not present during the altercation and only became aware after the incident was reported by the involved resident. Interviews and record reviews revealed that the resident with dementia had a history of wandering and entering other residents' rooms due to severe cognitive impairment, as documented in care plans and assessments. The cognitively intact resident had no prior history of aggression and was assessed as having minimal risk for aggressive behavior. Despite repeated complaints to staff about the ongoing behavior, no preventative measures were implemented to address the situation or protect the residents involved. The facility's abuse prevention policy affirms the right of residents to be free from abuse and requires the prevention of mistreatment and neglect. However, the facility did not follow its own policy, as staff failed to intervene or implement strategies to prevent the altercation, resulting in substantiated physical abuse. Both residents required medical evaluation for their injuries, and the incident was confirmed as abuse by facility leadership.
Failure to Provide Adequate Supervision and Monitoring in Dining Areas
Penalty
Summary
The facility failed to provide adequate supervision and monitoring for six residents who were identified as being at risk for falls and required staff oversight according to their care plans. On the morning of 04/26/2025, one resident was observed sitting alone in a wheelchair in the dining room without staff present, despite care plan instructions for frequent monitoring and supervision due to dementia and an unsteady gait. A CNA confirmed responsibility for the resident but stated she could not watch everyone and acknowledged the risk of falls or choking if residents were left unsupervised. The CNA assignment sheet indicated that no staff were scheduled to monitor the dining room until 9:00 AM, leaving a gap in supervision. Later that day, five additional residents, three of whom were in wheelchairs, were observed unsupervised in another dining room. Staff, including the DON and two CNAs, entered the room after the residents had been left unattended, with one CNA confirming it was her scheduled monitoring time and acknowledging the importance of supervision to prevent falls. The care plans for these residents documented risks for falls due to factors such as decreased safety awareness, impaired mobility, use of antidepressant medication, and need for assistance with activities of daily living. Facility policy emphasized the importance of resident supervision and safety, but staff assignments and observed practices did not ensure continuous monitoring as required.
Failure in Post-Fall Assessment and Medication Administration
Penalty
Summary
The facility failed to complete a post-fall assessment and notify the physician after a resident, R3, experienced a fall. R3, a male with a history of COPD, heart failure, and other conditions, was found on the floor by staff but was not properly assessed for injuries. Despite being assisted back to bed, no incident report or fall assessment was documented, and the physician was not notified. Two days later, R3 was sent to the hospital due to altered mental status and was found to have a hip fracture requiring surgery. Another resident, R4, did not receive her prescribed Anastrozole medication for breast cancer on nine occasions over an 11-day period. The medication was reportedly awaiting delivery, but this delay was not addressed, resulting in missed doses of her hormone-based chemotherapy. This oversight in medication administration was documented in the resident's medication administration record. Additionally, R5, a male with multiple diagnoses including quadriplegia and end-stage renal disease, did not receive his prescribed medications, Lanthanum Carbonate and Nystatin, as ordered. His medication administration records showed multiple missed doses, and his abnormal lab results, indicating high phosphorus levels, were not communicated to the physician. This lack of medication administration and failure to notify the physician of lab abnormalities contributed to the resident's compromised care.
Deficiencies in Care Planning for Fall Prevention and Hydration
Penalty
Summary
The facility failed to develop and implement comprehensive care plans tailored to the individual needs of residents, specifically in the areas of fall prevention and hydration management. For one resident, identified as R3, the care plan did not adequately address his high risk for falls despite multiple assessments indicating significant risk factors such as the use of psychotropic medications, mobility limitations, and impulsive behavior. The care plan lacked specific interventions like bed positioning, maintaining a clutter-free environment, and ensuring assistive devices were within reach. Additionally, the care plan did not address the resident's behaviors or the use of psychotropic medications, which could contribute to fall risk. Another resident, identified as R5, was admitted with a history of dehydration and other complex medical conditions. Despite being at risk for dehydration, the initial care plan did not include interventions to address this risk until after the resident was hospitalized for acute kidney injury related to dehydration. The facility's policy required that a care plan for hydration be developed upon admission, but this was not done in a timely manner, leading to a delay in addressing the resident's hydration needs. Interviews with facility staff revealed a lack of awareness and adherence to the facility's care planning policies. The Director of Nursing and Assistant Director of Nursing acknowledged that care plans were not consistently updated unless a fall occurred, and there was a misunderstanding of the need for individualized interventions based on each resident's specific risk factors. The facility's policies clearly stated the need for individualized care plans and specific interventions for high-risk residents, but these were not implemented effectively, resulting in deficiencies in resident care.
Failure to Implement Hydration Protocols for At-Risk Resident
Penalty
Summary
The facility failed to adhere to its hydration policy and procedures for a newly admitted resident at risk for dehydration. The resident, a male with a complex medical history including quadriplegia, heart failure, end-stage renal disease, and dehydration, was admitted to the facility without a completed nutrition assessment or a developed hydration care plan. Despite being identified as at risk for dehydration, the facility did not implement necessary interventions or notify the physician of abnormal lab results indicating dehydration risk. The resident's lab results showed elevated BUN and creatinine levels, which were not communicated to the physician, leading to a lack of follow-up on these critical indicators. The resident was eventually sent to the hospital with symptoms consistent with dehydration, including dry oral mucosa and tachycardia, and was treated for acute kidney injury with IV fluids. The Director of Nursing acknowledged that the lab results should have been reported and followed up with appropriate medical consultation.
Inadequate Supervision Leads to Resident Falls and Injuries
Penalty
Summary
The facility failed to provide adequate supervision and monitoring for residents with severe cognitive impairment, leading to accidents and injuries. Resident R3, who has severe cognitive impairment and a history of falls, was observed attempting to transfer herself from a wheelchair to a chair without staff supervision, despite her care plan indicating she requires assistance during transfers. R3 has been found on the floor multiple times, indicating a lack of adequate supervision and monitoring as per her care plan. Resident R4, also with severe cognitive impairment and a history of falls, fell in the dining room and sustained fractures in the hip/pelvic area. At the time of the fall, only one CNA was present to supervise approximately 20 residents, which was insufficient to provide the necessary close supervision required for high-risk residents like R4. The facility's policy requires close supervision for residents at risk of falls, but this was not adequately implemented, leading to R4's fall and subsequent injury. The facility's fall prevention program and care plans for both residents were not effectively followed, as evidenced by the lack of adequate supervision and monitoring. The facility's policy states that interventions should be changed with each fall, and residents should be checked approximately every two hours or as per the care plan. However, these measures were not effectively implemented, resulting in the deficiencies observed in the care of R3 and R4.
Failure to Protect Residents from Abuse and Lack of Care Plan Interventions
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment from physical abuse and did not develop care plan interventions to prevent abuse for two residents. The incident involved a resident with Alzheimer's Disease and severe cognitive impairment, who was scratched on the cheek by another resident wielding a fork. Both residents involved in the incident were unable to recall the event due to their cognitive impairments. The incident occurred during lunchtime when one resident suddenly stood up and reached for another resident's face with a fork. Staff members quickly intervened to separate the residents and assessed the injured resident, who sustained a superficial scratch. Despite the intervention, the facility did not have an abuse care plan in place for either resident, nor was there a care plan regarding the use of a spoon only during mealtime for the resident who initiated the incident. Interviews with staff revealed that the residents involved had no prior history of violent behavior, and the incident was unexpected. The facility's abuse prevention policy emphasizes the importance of creating a resident-sensitive environment and identifying residents with increased vulnerability to abuse. However, the lack of specific care plans for the residents involved in the incident indicates a failure to adhere to these procedures, contributing to the deficiency.
Facility Fails to Provide Adequate Hot Water for Residents
Penalty
Summary
The facility failed to replace a broken domestic water heater, which resulted in inadequate hot water supply to residents' bathroom sinks and shower rooms. This issue affected eight residents, who experienced cold water temperatures significantly below the required range of 105 to 115 degrees Fahrenheit. The maintenance director confirmed that one of the two water heaters was broken, and the remaining heater was unable to handle the workload, leading to water temperatures as low as 77 degrees Fahrenheit. Residents reported having to bathe with cold water, with some refusing to shower due to the discomfort and potential health concerns. The heating and air conditioning personnel confirmed that the facility needed a new water heater, as the existing one had a cracked heat exchanger and was leaking. Despite efforts to find a replacement, there was no immediate availability, and the facility was informed that it could take 4-6 weeks to obtain a new unit. The lack of hot water persisted, affecting the residents' ability to maintain personal hygiene and comfort, as evidenced by their complaints and the maintenance director's temperature readings.
Failure to Identify and Treat Resident's Wounds Before Hospital Transfer
Penalty
Summary
The facility failed to identify and treat wounds on a resident before the resident was sent to the hospital. The resident, who had a medical history of type 2 diabetes, peripheral vascular disease, and rheumatoid arthritis, was found to have wounds on the heels that were not identified or treated by the facility staff. The resident was sent to the hospital for altered mental status, and upon arrival, the hospital staff identified a full-thickness wound on the sacrum and additional wounds on the left heel and ankle. The facility's nursing staff, including a newer nurse, did not perform a skin assessment before the resident's transfer to the hospital, which is a crucial step to document the resident's condition upon leaving the facility. The wound care nurse and the Director of Nursing confirmed that a full head-to-toe assessment should be performed daily on residents with wounds, and the facility's policy requires skin assessments during routine care and before discharge or transfer. However, the facility's records did not document any wounds on the resident's heel or ankle prior to the hospital transfer. The hospital records indicated that the resident had a sacral wound infection and additional pressure injuries on the left heel and ankle, which were not documented by the facility. The facility's care plans and policies emphasize the importance of regular skin assessments and prompt reporting of any skin changes, but these procedures were not adequately followed, leading to the deficiency in wound care management for the resident.
Failure to Monitor High Fall Risk Resident Leads to Injury
Penalty
Summary
The facility failed to adequately monitor a high fall risk resident, resulting in the resident suffering a right fractured hip. The resident, who has a history of falling, dementia, and age-related osteoporosis, was left unsupervised during a scheduled monitoring period. The resident attempted to reach for an object in another chair, slid out of their chair, and fell onto their right hip. This incident occurred despite the facility's policy requiring constant supervision for high fall risk residents. The CNA assigned to monitor the resident was providing care to another resident in the same room when the fall occurred. The CNA did not request additional staff to assist with monitoring, as required by the facility's policy. The CNA reported that the resident had a behavior of trying to get up unassisted and was known to be impulsive and confused, necessitating constant redirection and supervision. Interviews with facility staff, including the CNA, nurse, and medical director, confirmed that the resident was a high fall risk and required 1:1 supervision. The facility's fall prevention program mandates that staff assigned to monitor high fall risk residents should not leave them unsupervised and should call for additional staff if needed. However, this protocol was not followed, leading to the resident's fall and subsequent injury.
Failure to Follow Care Plan for Resident Transfer
Penalty
Summary
The facility failed to adhere to the care plan for a dependent resident, identified as R2, who required a two-person assist with a mechanical lift for transfers. On a specific date, R2 was transferred using a mechanical lift, but it was unclear if the required two-person assistance was provided. Subsequently, R2 was observed with a bruise over the left eyebrow and swelling to the right jaw, leading to a hospital evaluation where a forehead contusion was diagnosed. R2, a female resident with a history of unspecified dementia, Alzheimer's disease, hypertension, heart disease, heart failure, presence of a cardiac pacemaker, COPD, and chronic kidney disease, was noted to have cognitive impairment and was dependent on assistance for transfers. The care plan specified the use of a mechanical lift with two-person assistance due to R2's inability to bear weight on her legs and poor sitting balance. However, during the incident, there was confusion among the staff about who assisted with the transfer, and it was not confirmed if the proper procedure was followed. Interviews with staff revealed a lack of communication and documentation regarding the incident. The CNA assigned to R2 on the night of the incident could not recall who assisted with the transfer, and other staff members denied involvement. The Director of Nursing was not initially aware of the injuries and did not investigate until later. The facility's policies on lifting and transferring emphasize the importance of using mechanical lifts with adequate staff assistance to ensure resident safety, but these protocols were not followed, resulting in the injury of R2.
Improper Bed Rail Use Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the proper use and safety of bed rails for a resident, leading to an injury. The resident, who was cognitively intact with a BIMS score of 15, sustained a discoloration and swelling to the right eye after hitting it on the bed rail. The resident reported that she did not fall or was hit by anyone but mentioned that she was rubbing her eye while sleeping on her right side with a mask on due to her roommate's coughing. The resident expressed that she had previously requested the removal of the bed rails, which were not padded, indicating a lack of adherence to her preferences and safety needs. The Director of Nursing acknowledged the incident and was investigating it. The facility's records showed that the resident was ambulatory and capable of getting in and out of bed unassisted, and the current side rail assessment indicated that the resident did not use the side rails for positioning and support. Despite this, the bed rails were in the up position, and there was no physician order for their use. The facility's side rail policy emphasized preventing injury and required an order, assessment, consent, and care plan addressing potential entrapment risks, which were not followed in this case.
Failure to Prevent Falls for High-Risk Resident
Penalty
Summary
The facility failed to provide an individualized plan of care with effective interventions to prevent falls for a resident, resulting in multiple falls and hospital transfers. The resident, who has a history of altered mental status, anxiety disorder, dementia, and other medical conditions, experienced three falls in the last three months, two of which required hospital treatment for a laceration and hematoma. The resident's care plan, which was revised in July 2024, identified her as at high risk for falls but did not include adequate interventions to prevent these incidents. Observations and interviews revealed that the resident was often found walking without supervision, despite being assessed as requiring supervision or assistance for walking. On one occasion, the resident was hit by a door opened by another resident, causing a fall and a laceration. Staff members reported that the resident frequently walked without her walker and was difficult to monitor due to her confusion and aggressive behavior. The facility's fall prevention policy required regular safety checks and documentation, but these measures were not effectively implemented for the resident. The facility's Director of Nursing acknowledged that the resident's last three falls were unwitnessed and that the care plan should be individualized to provide more supervision. Despite the resident's high fall risk and history of falls, the facility did not adequately supervise her or implement effective interventions to prevent further falls, leading to repeated incidents and injuries.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to adhere to its abuse policy by not immediately reporting an allegation of staff-to-resident physical abuse to the administrator and failing to notify the state agency within the required two-hour window. A resident, who was cognitively intact with a mental status score of 12/15, reported a possible incident involving a staff member during room cleaning. The resident mentioned to a nurse practitioner that someone might have hurt her, but she was unclear about the details. The nurse practitioner informed the Director of Nursing (DON) about the allegation before the resident was sent to the hospital. However, the DON did not report the incident immediately and only attempted to send a reportable to the state agency after being informed by the hospital that the resident had a detached retina and claimed to have been assaulted. The administrator was unaware of the abuse allegations until the following day, indicating a breakdown in communication and reporting procedures within the facility. The facility's abuse prevention program policy mandates that any incident, allegation, or suspicion of abuse must be reported immediately to the administrator or a designated person. In cases of serious bodily injury, such as physical abuse, the policy requires reporting to the state survey agency and local law enforcement within two hours. The facility's initial abuse report was documented after the two-hour window, highlighting a failure to comply with the established reporting timelines.
Insufficient Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its 105 residents, as observed during a survey. On one occasion, a resident expressed concerns about long response times to call lights during the second and night shifts, indicating that staff responded at their convenience. During an inspection of unit 300, the surveyor found no staff present at the nursing station or in the hallways, and a call light went unanswered for 20 minutes until prompted by the surveyor. Interviews with staff revealed that they felt overwhelmed by their assignments, with a Certified Nurse Assistant responsible for 27 residents and expressing difficulty in completing tasks and documentation. The staffing coordinator explained the staffing structure across the facility's three units, with varying numbers of residents and staff ratios. The union guidelines for nurse aides were noted as 15:1, but actual assignments often exceeded this ratio. The staffing coordinator also mentioned challenges in covering call-offs, particularly after 4:00 PM, when the responsibility shifted to the Director of Nursing and Assistant Director of Nursing. The facility's assessment tool indicated that staff assignments should be based on individual resident needs and adjusted accordingly, but the survey identified multiple call-offs and insufficient staffing levels, contributing to the deficiency.
Failure to Notify and Assess Resident Injury
Penalty
Summary
The facility failed to notify responsible parties and perform a comprehensive assessment for a resident with an injury of unknown origin. A resident, who is a female with chronic kidney disease, cerebral infarction, unspecified dementia, and cognitive communication deficit, was found with a black eye. The resident has a BIMS score of 5, indicating severely impaired cognition. On the day of the incident, a CNA reported the injury to an LPN, who checked the resident's vital signs but did not perform any further assessment or notify the family or doctor. The LPN documented the incident in a progress note but did not follow through with the required notifications. The Director of Nursing stated that the nurse should have documented the incident and notified the responsible parties, including the doctor, family, and the DON. The LPN involved did not receive training upon hire regarding abuse or injuries, although the facility's abuse prevention program requires employees to report any incidents or suspicions of abuse immediately. The facility's administrator confirmed that staff abuse training is conducted annually, with the most recent training occurring in July 2024. Despite this, the LPN did not adhere to the facility's policy, resulting in a deficiency.
Inadequate Abuse Prevention Education for Staff
Penalty
Summary
The facility failed to provide adequate abuse prevention education to its staff, which potentially affected 63 residents. During an interview, a Licensed Practical Nurse (LPN) reported that a Certified Nursing Assistant (CNA) informed her about a resident with a black eye. The LPN checked the resident's vital signs but did not conduct any further assessment or notify the family or doctor. The LPN also did not receive any training upon hire regarding abuse or injuries, which contributed to the lack of appropriate action. The Director of Nursing (DON) confirmed that the LPN did not follow through with the necessary documentation and notification procedures. The facility's Abuse Prevention Program outlines the requirement for staff training on abuse prevention, including the obligation to report incidents. However, the LPN's acknowledgment of the abuse policy was dated months before the incident, indicating a gap in ongoing education. The facility's administrator stated that abuse training is conducted annually, but the LPN did not receive adequate training upon hire, leading to the deficiency.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident in a timely manner to the state regulatory agency. The resident, a female with severe cognitive impairment, was found with a black eye by a CNA, who reported it to an LPN. The LPN assessed the resident's vital signs but did not notify the family, doctor, or Director of Nursing (DON) about the injury. The incident was documented in a progress note, but no further action was taken by the LPN to report the injury as required by the facility's abuse prevention policy. The Director of Nursing confirmed that the initial report of alleged abuse should be submitted within two hours, but the report for this incident was submitted over two hours after the injury was documented. The facility's policy requires employees to report any suspicion of abuse immediately to the administrator or a designated individual. The LPN involved did not receive training on abuse reporting upon hire, which contributed to the delay in reporting the incident. The facility's administrator acknowledged that the LPN was unaware of her ability to submit the report, which led to the deficiency.
Failure to Investigate Alleged Abuse Thoroughly
Penalty
Summary
The facility failed to thoroughly investigate an alleged abuse incident involving a resident, identified as R84, who was found with a black eye. R84, a female resident with severe cognitive impairment, was admitted with diagnoses including chronic kidney disease, cerebral infarction, unspecified dementia, and cognitive communication deficit. On the day of the incident, a CNA reported the injury to an LPN, who noted the bruise but did not conduct a full assessment or notify the family or doctor. The LPN documented the incident in a progress note but did not receive any training on handling abuse or injuries upon hire. The Director of Nursing (DON) was informed the following day by a family member who noticed the injury and called the police. The DON initiated an investigation but did not review the entire final report. The Administrator, who also serves as the Abuse Prevention Coordinator, was notified and began the reportable process. The investigation included reviewing R84's medical records and interviewing staff, but it was noted that the investigation did not include interviews with residents in adjacent rooms. The Administrator reviewed dining room footage but could not conclusively determine the cause of the injury. The facility's abuse prevention program outlines that the investigator should interview all relevant parties and review pertinent documents, which was not fully adhered to in this case. The absence of a thorough investigation and documentation related to the incident led to the deficiency finding.
Failure to Follow Physician Orders and Restorative Program Policies
Penalty
Summary
The facility failed to follow physician orders and its own policy for restorative programs, resulting in deficiencies in the care of residents with limited range of motion. Specifically, the facility did not obtain a physician order for a restorative device for one resident and failed to apply a splint or brace to prevent further contracture formation for two residents. These deficiencies were identified through observations, interviews, and record reviews. One resident, who is diagnosed with hemiplegia and hemiparesis following cerebrovascular disease, was observed without a splint or brace despite having a physician's order for a right resting hand splint to be worn daily or as tolerated. The resident was aware of the splint but did not know its whereabouts, and staff members were uncertain about the resident's order and the location of the splint. Documentation inconsistencies were noted, with restorative staff charting assistance with the splint even when it was missing. Another resident, diagnosed with cerebral palsy, was observed without bilateral palm protectors for wrist contractures. The resident's care plan required these protectors to be worn daily as tolerated, but there was no active physician order for them. Staff interviews revealed reliance on restorative aides and CNAs for applying the protectors, but inconsistencies in documentation and application were evident. The facility's policy mandates a physician's order for restorative devices, which was not adhered to in this case.
Failure to Monitor and Prevent Injury in Cognitively Impaired Resident
Penalty
Summary
The facility failed to adequately monitor and prevent an injury to a cognitively impaired resident, identified as R84, who was part of a sample of 42 residents reviewed for accidents. R84, a female resident with severe cognitive impairment, was admitted with diagnoses including chronic kidney disease, cerebral infarction, unspecified dementia, and cognitive communication deficit. On October 11, 2024, R84 was observed with a hematoma under her left eye, and neither the assigned nurse nor the CNA were aware of how the injury occurred. The facility lacked prior care plans addressing R84's behavior of bending over to remove her shoes, which posed a risk of injury. Interviews with staff and family members revealed a lack of clarity and communication regarding the incident. The family member, V24, reported noticing the injury on October 12, 2024, and expressed concerns about inadequate staffing and supervision, as well as an aggressive roommate. Staff interviews indicated that R84 was known to wander and had interactions with other residents, but there was no clear account of how the injury occurred. The facility's investigation, including a review of dining room footage, was inconclusive, and the staff did not witness any unusual occurrences. The facility's documentation and response to the incident were insufficient. The LPN on duty did not perform a comprehensive assessment or notify the family and physician immediately. The facility's abuse investigation was initiated after the family contacted the police, but the investigation did not substantiate abuse due to a lack of witnesses. The facility's policies required staff to monitor residents and report incidents promptly, but these protocols were not effectively followed in this case.
Failure to Provide Correct Arbitration Agreement
Penalty
Summary
The facility failed to provide a resident's representative with an arbitration agreement that allowed for a 30-day period to rescind the agreement, as required. Instead, the agreement provided only a seven-day cancellation period. This deficiency was identified during a review of the arbitration agreement for a resident with a diagnosis of cerebral infarction, who has a Power of Attorney (POA) in place due to cognitive impairments. The resident's family member, when interviewed, was not familiar with the details of the arbitration agreement, indicating a lack of proper communication regarding the agreement's terms. Interviews with facility staff revealed inconsistencies in the understanding and implementation of the arbitration agreement policy. The Admissions Director stated that residents and families are informed of a 30-day review period, but the agreement signed by the resident in question only allowed for seven days. The Assistant Administrator acknowledged that the agreement used was prefilled and suggested that corporate usually sends revised copies, indicating a possible lapse in updating the documents used. The facility's failure to provide the correct arbitration agreement reflects a breakdown in communication and adherence to policy updates.
Failure to Implement Effective Fall Prevention Measures
Penalty
Summary
The facility failed to adhere to its fall prevention policy and procedures, resulting in inadequate identification of risk factors and implementation of effective interventions for residents at risk of falls. Two residents, a female with a history of paranoid schizophrenia, COPD, schizoaffective disorder, bipolar disorder, recurrent severe major depressive disorder, and lymphedema, and another female with dementia, type 2 diabetes with diabetic neuropathy, stroke, and stage 2 chronic kidney disease, experienced multiple falls. The facility did not update their care plans with new interventions following these incidents, despite the residents' known risk factors and history of falls. The first resident was found on the bathroom floor after an unwitnessed fall while self-toileting. Her care plan, which was supposed to address her fall risk, did not include any new interventions after her fall. The Director of Nursing acknowledged that the resident often did not wait for assistance due to her condition, which includes frequent urination related to high blood sugar levels. Despite this, the care plan remained unchanged, failing to incorporate personalized interventions to prevent further falls. The second resident experienced several unwitnessed falls while attempting to self-transfer. Her care plan included general interventions but lacked specific measures to address the timing and frequency of her falls. The Director of Nursing admitted that the falls occurred more frequently at certain times of the day, which was not considered in the care plan. Additionally, the facility's fall prevention program policy, which requires changes in interventions after each fall, was not followed, as the care plans for both residents were not updated after their falls.
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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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