Quincy Healthcare & Sr Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Quincy, Illinois.
- Location
- 1440 North 10th Street, Quincy, Illinois 62301
- CMS Provider Number
- 145457
- Inspections on file
- 29
- Latest survey
- August 22, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Quincy Healthcare & Sr Living during CMS and state inspections, most recent first.
A resident with multiple medical conditions requiring assistance for toileting waited several hours for staff to respond to her call light, resulting in her soiling herself and experiencing emotional distress. Facility policy requires call lights to be answered within five minutes, but staff failed to provide timely assistance, and the incident was confirmed by both the resident and a CNA.
A deficiency was identified when the facility failed to provide sufficient CNA staffing hours, resulting in unmet resident needs such as delayed call light responses, unassisted toileting, and lack of feeding assistance during meals. Multiple residents reported or were observed experiencing delays or lack of care, and staff interviews confirmed ongoing staffing shortages and burnout. The facility was also operating without a DON or Infection Control Preventionist, contributing to the inability to maintain adequate staffing levels.
The facility did not have a full-time DON in place after the previous DON stepped down and resumed duties as a floor nurse, leaving the DON position vacant for an interim period. This was confirmed by facility records and staff interviews, affecting all residents in the facility.
The facility did not have a qualified Infection Preventionist in place after the previous staff member left, leaving the infection prevention and control program without oversight for all residents. The Administrator in Training confirmed that no interim staff had been assigned to this role, despite facility policy and job descriptions requiring such coverage.
The facility did not post daily staffing sheets that included the total hours worked by CNAs, RNs, and LPNs for each 24-hour period. Instead, only lists of staff scheduled to work were posted, without the required breakdown of hours for each nursing role. This practice was confirmed by both administrative and scheduling staff, and affected all residents in the facility.
A resident with multiple health conditions fell during a transfer using a mechanical lift when a CNA operated the lift alone, against facility policy requiring two staff members. The resident was not positioned correctly in the wheelchair, leading to the fall. The CNA had a history of similar unsafe practices and was previously disciplined and retrained.
The facility failed to respond to call lights in a timely manner, as required by their policy, affecting three residents. One resident, cognitively intact, experienced waits of 30 minutes to an hour, with documented delays up to nearly two hours. Another resident with moderate cognitive impairment reported waits over 30 minutes, while a third resident faced delays of 15 minutes to two hours. The interim administrator cited issues with the call light system and recent leadership changes as contributing factors.
The facility failed to respond to residents' call lights in a timely manner, with documented delays of over two hours for some calls. Several residents expressed frustration over waiting for assistance, and the DON was unaware of the reasons for these delays, despite the facility's policy requiring prompt responses.
The facility failed to notify the Ombudsman of resident discharges and transfers and did not provide written transfer notices to residents and their representatives. This deficiency affected several residents who were transferred to hospitals without proper documentation or notification, as confirmed by facility staff.
The facility failed to provide bed hold notifications to residents or their representatives during hospital transfers, as required by policy. This deficiency affected five residents who were transferred to the hospital for various medical conditions, including congestive heart failure and leukocytosis. The Business Office Manager confirmed the lack of documentation for these notifications, violating the facility's policy.
The facility failed to follow its respiratory care policies, resulting in deficiencies such as undated and improperly stored oxygen and nebulizer equipment for several residents. One resident lacked an oxygen sign, and another had equipment lying on the floor. Staff were unaware of the requirements, leading to non-compliance with established protocols.
A long-term care facility failed to provide physician-ordered medications for four residents due to unavailability, resulting in missed doses. The facility's policy mandates 24/7 pharmaceutical services, but issues with the pharmacy led to medications like Levothyroxine, Spiriva, Metoprolol, and Furosemide being unavailable at the time of administration. An LPN noted ongoing problems with obtaining medications, necessitating reorders.
The facility failed to provide snacks and complete meals to residents, as six residents reported not receiving evening snacks and incomplete meal services, including missing beverages. The dietary manager was unaware of these issues, and the Director of Nursing confirmed that residents were not consistently receiving fresh ice water during each shift.
The facility failed to provide the required Medicare Advance Beneficiary Notice of Non-Coverage to two residents, as per the facility's policy. The Accounts Receivable staff could not provide documentation or confirm communication regarding the termination of Medicare A coverage for these residents, indicating a lapse in the notification process.
The facility failed to conduct required Level II PASRR screenings for two residents diagnosed with mental illness, as mandated by the Medicaid PASRR process. One resident with Schizoaffective Disorder and another with Schizophrenia, Anxiety Disorder, and Depressive Disorder did not receive the necessary evaluations. The DON confirmed the screenings were not requested, and the Administrator-In-Training expressed uncertainty about the process.
A resident experienced a decline in functional ability due to the facility's failure to provide necessary therapy or restorative services. Despite a change in transfer status from sit-to-stand to a non-weight bearing mechanical lift, the resident did not receive therapy to address this decline. The Physical Therapist cited altered mental status as a reason for not initiating therapy, and the lack of Interdisciplinary Team meetings contributed to the oversight.
A resident at moderate risk for pressure ulcers developed a Stage II ulcer due to the facility's failure to perform weekly skin checks and timely treatment. The resident was not repositioned as required, and staff were unaware of repositioning orders. The DON confirmed the ulcer was facility-acquired.
A resident with hemiplegia and muscle wasting did not receive necessary range of motion (ROM) exercises or therapy, despite having functional limitations in an upper extremity. The resident's care plan did not address these limitations, and the Restorative Aide confirmed the absence of a restorative program for ROM exercises, contrary to the facility's policy.
A facility failed to provide proper dialysis care for a resident with ESRD by not maintaining communication with the dialysis center, monitoring the dialysis access site, or documenting post-dialysis observations. The resident reported that facility staff did not monitor her access site, and the Director of Nursing confirmed the lack of communication and documentation. The resident's care plan lacked interventions for monitoring or emergency care of the dialysis access site.
The facility failed to document targeted behaviors and diagnoses to justify the use of antipsychotic medications for two residents with Dementia. Despite policy requirements for gradual dose reductions and non-pharmacological interventions, there was no documentation of evaluations or interdisciplinary team meetings to justify the continued use of these medications. Observations and staff interviews indicated the absence of significant behaviors that would warrant such medication use.
The facility failed to explain the arbitration agreement to residents or their representatives in a manner they could understand, did not state that the agreement could be rescinded within 30 days, and did not require acknowledgment of understanding. Interviews revealed that residents were unaware of the arbitration agreement and its implications, and a Power of Attorney was not informed about waiving litigation rights. The contract lacked provisions for rescinding the agreement and acknowledgment of understanding.
The facility failed to implement enhanced barrier precautions for 16 residents, including those with wounds and indwelling devices, despite having a policy in place. Staff were observed providing care without using gowns or gloves, and a registered nurse was unaware of the precautions. The facility administrator confirmed the policy had not been implemented.
A resident with a right heel unstageable pressure ulcer did not receive proper care as ordered. The resident's heels were not elevated, and heel protectors were not used. The dressing, which was supposed to be changed daily, was found to be soiled and dated six days prior. The nursing staff reused the foam bordered gauze against manufacturer's instructions, leading to inadequate care.
The facility failed to safely dispense medications to three residents. An LPN left medications at the bedside for residents to take later, without ensuring they were taken. The DON confirmed that nurses should not leave medications in residents' rooms without supervision.
A resident with multiple diagnoses did not receive their scheduled 7:00 am and 8:00 am medications, including insulin, until 9:35 am, after completing breakfast. The LPN and DON confirmed that medications should be administered at their scheduled times, highlighting a significant medication error.
Failure to Respond Timely to Call Light for Toileting Assistance
Penalty
Summary
The facility failed to ensure timely response to a resident's call light for toileting assistance, resulting in the resident soiling herself and remaining in that condition for several hours. The resident, who has diagnoses including urinary tract infection, chronic heart failure, respiratory failure, morbid obesity, and chronic kidney disease, requires assistance from staff for toileting due to her inability to transfer safely. On the evening in question, the resident requested help from a CNA, who stated she would return but did not. The resident then activated her call light, but no staff responded until several hours later, by which time she had already soiled herself and experienced significant emotional distress. Facility policies require that call lights be answered within five minutes and that residents be treated with dignity and respect, including prompt assistance with toileting. Interviews with the resident and a CNA confirmed the delay in response and the resident's resulting distress. The administrator in training was unaware of the incident prior to the surveyor's inquiry but acknowledged that such a delay in assistance is unacceptable.
Inadequate Staffing Leads to Unmet Resident Needs and Delayed Care
Penalty
Summary
The facility failed to provide adequate direct care staffing hours to meet the needs of all residents, as evidenced by observations, interviews, and record reviews. The facility's own Facility Assessment indicated an expected 196 CNA hours per 24-hour period, but on the reviewed date, only 116 CNA hours were provided for 75 residents. Resident council minutes documented ongoing concerns about unmade beds, unchanged sheets, and delayed call light responses. Multiple residents reported that their requests for assistance were not answered in a timely manner, with one resident stating she soiled herself after waiting for help with toileting for several hours. During meal times, residents requiring assistance with eating were observed left unattended in the dining room, with no staff present to provide necessary support. Two residents were seen with full plates of uneaten food, one of whom was sleeping at the table, and another who required encouragement and physical assistance to eat. Staff interviews confirmed that CNA coverage was insufficient, with one CNA stating she was the only aide on her hall and unable to keep up with resident needs, especially for those requiring two-person transfers or feeding assistance. Further interviews with staff, including a LPN and the scheduler, revealed that staffing shortages had worsened over the past month due to call-ins and unfilled shifts. The scheduler was unaware of state minimum staffing requirements and acknowledged that staff were experiencing burnout and unwilling to work extra shifts. The facility also lacked a DON and an Infection Control Preventionist at the time of the survey, further impacting the ability to ensure adequate staffing and supervision.
Failure to Maintain Full-Time Director of Nursing
Penalty
Summary
The facility failed to provide the services of a full-time Director of Nursing (DON) as required by its own Facility Assessment and job description. According to the Administrator in Training, a significant number of management staff, including the DON, stepped down from their positions on the same day. The former DON reverted to working as a floor nurse and ceased fulfilling DON responsibilities, leaving the facility without anyone in the DON role for an interim period. This lapse was confirmed by facility records and interviews, and at the time of the survey, the facility had 75 residents and no designated DON overseeing nursing services.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist to oversee the infection prevention and control program, as required by their own Facility Assessment and job descriptions. The Facility Assessment, dated 4/15/25, indicated that the facility would provide nursing services that include an Infection Preventionist, and the job description outlined specific infection control responsibilities. However, record review and interviews confirmed that the position was vacant after the previous Assistant Director of Nursing/Infection Control Preventionist left approximately two weeks prior to the survey, and no interim replacement had been assigned. At the time of the survey, the facility had 75 residents, and the Administrator in Training acknowledged that the Infection Preventionist role was unfilled due to multiple management staff resigning on the same day. The absence of a designated Infection Preventionist meant that no one was responsible for supervising infection control protocols, monitoring isolation procedures, or ensuring compliance with infection prevention standards as outlined in facility policy.
Failure to Post Required Daily Nurse Staffing Hours
Penalty
Summary
The facility failed to ensure that daily staffing postings accurately documented the total number of hours worked by Certified Nursing Assistants (CNAs), Registered Nurses (RNs), and Licensed Practical Nurses (LPNs) for each 24-hour period. Review of daily staffing sheets posted from 3/25/25 to 4/25/25 revealed that none included the required total hours for each category of nursing staff. Instead, the postings only listed the names of employees scheduled to work each day, without specifying the breakdown of hours for RNs, LPNs, or CNAs. Interviews with facility staff confirmed that the posted staffing sheets, generated from the facility's scheduling system, did not provide the necessary hour totals for each nursing role. The Administrator In Training and the Human Resources/Scheduler both acknowledged that the current practice was to post only the list of staff on duty, and that this method had been in place prior to the current administrator's tenure. At the time of the survey, the facility had 75 residents, all of whom could be affected by the lack of proper staffing documentation.
Resident Fall Due to Improper Transfer Procedure
Penalty
Summary
The facility failed to prevent a fall for a resident during a transfer using a mechanical sit-to-stand lift. The resident, a female with multiple diagnoses including End Stage Renal Disease and Chronic Kidney Disease, was dependent on staff for transfers and had an intact cognitive status. During the incident, the resident slid from her wheelchair to the floor while being transferred by a CNA who was operating the lift alone, contrary to the facility's policy requiring two staff members for such transfers. The CNA admitted to performing the transfer alone because other staff were busy, and the resident was not positioned correctly in the wheelchair, leading to the fall. The CNA involved had a history of similar incidents and had been previously disciplined and retrained for unsafe transfer practices. Despite this, the CNA continued to perform transfers alone, compromising resident safety. The facility's policy clearly mandates the presence of two staff members during mechanical lift transfers to ensure safety, but this was not adhered to, resulting in the resident's fall. The incident was documented by the facility's administrator and director of nursing, who confirmed the breach of policy and the CNA's failure to follow established procedures.
Delayed Call Light Response Times
Penalty
Summary
The facility failed to ensure that call lights were answered in a reasonable amount of time for three residents, leading to a deficiency in honoring residents' rights to a dignified existence and self-determination. The facility's policy requires that calls for assistance be answered within five minutes, with urgent requests addressed immediately. However, the facility's Alarm Response Reports documented significant delays in response times for the residents. One resident, who is cognitively intact, reported waiting between 30 minutes to an hour on several occasions, with documented wait times ranging from 22 minutes to nearly two hours over several days. Another resident with moderate cognitive impairment reported waiting over 30 minutes on some occasions, with documented wait times exceeding 30 minutes on two specific days. A third resident, also cognitively intact, reported waiting between 15 minutes to two hours, with documented wait times frequently exceeding 30 minutes and reaching up to nearly three hours. The facility's interim administrator acknowledged issues with the call light system, noting that the screens at nurse stations do not sound, making it difficult for staff to be aware of active call lights. Additionally, the facility had recently lost their Director of Nursing, which may have contributed to the leadership gap affecting call light response times. The ombudsman confirmed receiving complaints about delayed call light responses, indicating a broader issue within the facility. These findings highlight a failure to adhere to the facility's policy and ensure timely assistance for residents, compromising their right to a dignified existence and self-determination.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to respond to residents' call lights in a reasonable amount of time, as evidenced by the experiences of six residents. The facility's policy, dated September 2022, mandates that call lights should be answered as soon as possible, but no later than five minutes, with urgent requests addressed immediately. However, the Alarm Response Report for the week of August 18, 2024, through August 24, 2024, documented significant delays in response times. Two call lights were not answered for over two hours, and several others took over an hour to be addressed. Additional delays were noted, with numerous calls taking over 20 to 50 minutes to be answered. During a group meeting, several residents expressed their frustration with the prolonged wait times. They reported waiting for over an hour for assistance, with some instances where a CNA would turn off the call light but not return promptly. The Director of Nursing acknowledged that call lights should be answered in a reasonable time but was unaware of the reasons for the delays. The residents' testimonies and the documented response times highlight a significant deficiency in the facility's ability to meet the residents' needs for timely assistance.
Failure to Notify Ombudsman and Provide Transfer Notices
Penalty
Summary
The facility failed to notify the facility Ombudsman of resident discharges and transfers monthly, and did not provide written notice of transfer to the residents and their representatives for five residents reviewed in the sample. The facility's policy on Transfer or Discharge Documentation, dated December 2016, requires that details of the transfer or discharge be documented in the medical record and communicated to the receiving health care facility or provider. However, the facility did not adhere to this policy for residents R18, R33, R46, R66, and R75, as there was no evidence of notification to the family or ombudsman in their medical records. Specific instances include R18, who was admitted to the hospital with congestive heart failure and urinary tract infection, and R33, who was discharged to the hospital with possible dyspnea/aspiration pneumonia and acute renal insufficiency. Similarly, R75 was admitted to the hospital for leukocytosis, and R46 and R66 were also transferred to hospitals without proper notification. The Business Office Manager confirmed the lack of documentation for these residents, and the Service Director admitted to not including hospital transfers in the monthly list sent to the Ombudsman, indicating a gap in the facility's communication and documentation processes.
Failure to Provide Bed Hold Notifications During Hospital Transfers
Penalty
Summary
The facility failed to provide bed hold notifications to residents or their representatives during hospital transfers, as required by their policy. This deficiency was identified for five residents who were transferred to the hospital. The facility's Bed-Holds and Returns policy mandates that residents or their representatives receive written information about bed-hold policies both in advance of any transfer and at the time of transfer, or within 24 hours in the case of an emergency. However, for residents R18, R33, R46, R66, and R75, there was no evidence in their medical records that such notifications were provided. The deficiency was confirmed through interviews and record reviews. The Business Office Manager, responsible for tracking notices of transfers and bed holds, verified the lack of documentation for the affected residents. Specific instances included R18's transfer for congestive heart failure and other conditions, R33's transfer for dyspnea and other issues, and R75's transfer for leukocytosis, among others. Despite these transfers, the facility did not document the provision of bed hold notifications, violating their own policy and potentially impacting the residents' rights and understanding of their bed-hold status during hospital stays.
Deficiencies in Respiratory Care Practices
Penalty
Summary
The facility failed to adhere to its respiratory care policies, resulting in several deficiencies. For one resident, there was no oxygen sign placed on the door or in the room, and the oxygen tubing and humidifier bottle were not dated as required. This resident had been readmitted with diagnoses including Chronic Obstructive Pulmonary Disease and Acute Respiratory Failure with Hypoxia, and had a physician order for continuous oxygen. Additionally, another resident's oxygen tubing, nebulizer tubing, and nebulizer mask were found undated and unbagged, contrary to the facility's policy that mandates weekly changes and proper storage. Further observations revealed that another resident's oxygen tubing was lying on the floor undated, and the nasal cannula was uncovered, with the humidification bottle also undated. A Licensed Practical Nurse admitted to being unaware of the requirement to date the equipment. Similarly, another resident's nebulizer mask and tubing were found unbagged and undated on the nightstand, despite a physician order for regular nebulizer treatments. A Registered Nurse confirmed the oversight, noting that the night shift was responsible for changing and dating the equipment every seven days.
Medication Unavailability in LTC Facility
Penalty
Summary
The facility failed to obtain physician-ordered scheduled medications from the pharmacy for four residents, resulting in missed doses. The facility's policy requires that pharmaceutical services be available 24/7, ensuring residents have a sufficient supply of their prescribed medications. However, observations and interviews revealed that medications for residents were unavailable at the time of administration. For instance, a resident's Levothyroxine was not administered due to unavailability, and the LPN noted ongoing issues with the pharmacy in obtaining medications. Similarly, another resident's Spiriva inhaler was not available, preventing its administration as scheduled. The LPN expressed the need to reorder the medication, hoping for its arrival the next day. Additionally, a third resident missed multiple medications, including Metoprolol and Eliquis, due to unavailability. Lastly, a fourth resident's Furosemide was not administered as it was not available, necessitating a reorder from the pharmacy. These instances highlight the facility's failure to ensure timely access to necessary medications for its residents.
Failure to Provide Snacks and Complete Meals
Penalty
Summary
The facility failed to meet the nutritional needs and preferences of its residents, as evidenced by the lack of snacks and incomplete meal services. Six residents reported not receiving snacks in the evening, despite being informed upon admission that they would have access to snacks of their choice. Additionally, residents expressed dissatisfaction with the meals served in their rooms due to COVID-19 restrictions, noting that they often did not receive beverages with their meals and were not provided with alternatives if they disliked the food served. The facility's dietary manager was unaware of these issues and mentioned that the variety of snacks had been reduced to simplify the process. Furthermore, the facility did not consistently provide fresh ice water to residents during each shift, as confirmed by the Director of Nursing. Residents reported receiving ice water infrequently, sometimes only once a day, despite the expectation that it should be provided more regularly. This lack of adherence to the facility's policies and resident preferences was documented in the Resident Council Minutes, where residents had previously raised concerns about not receiving fresh ice water regularly.
Failure to Provide Medicare Coverage Notices
Penalty
Summary
The facility failed to provide the required Medicare Advance Beneficiary Notice of Non-Coverage to two residents, identified as R232 and R329, out of a sample of 38 residents. According to the facility's document dated September 2022, residents should be informed in advance when changes occur to their bills, specifically when Medicare will not cover certain services. The Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) should be issued in situations of initiation, reduction, or termination of services when Medicare coverage is expected to end. Additionally, a Notice of Medicare Non-Coverage should be issued at least two days before the end of a Medicare-covered Part A stay. During an interview on August 28, 2024, the Accounts Receivable staff member, identified as V22, admitted to not having documentation of the SNFABN for residents R232 and R329. V22 was unable to confirm when or what these residents were informed regarding the termination of their Medicare A coverage. This lack of documentation and communication indicates a failure to comply with the required notification process, potentially leaving residents uninformed about their coverage status and financial responsibilities.
Failure to Conduct Required Level II PASRR Screenings
Penalty
Summary
The facility failed to obtain a Level II PASRR screening for two residents diagnosed with mental illness, which is a requirement under the Medicaid Pre-Admission Screening and Resident Review (PASRR) process. The facility's policy mandates that all new admissions and readmissions be screened for mental disorders, intellectual disabilities, or related disorders. If a Level I PASRR screen indicates a potential mental health condition, a Level II evaluation must be conducted by the state PASARR representative. However, for one resident, identified as R32, there was no evidence of a Level II PASRR screening being obtained after being diagnosed with Schizoaffective Disorder. The Director of Nursing confirmed that no PASRR Level II was requested for this resident. Similarly, another resident, identified as R34, had a Level I PASRR screen that indicated the need for a Level II evaluation due to diagnoses of Schizophrenia, Anxiety Disorder, and Depressive Disorder. Despite this indication, the medical record did not show evidence of a Level II PASRR screening being completed. The Director of Nursing acknowledged that the screening had not been done, and the Administrator-In-Training admitted uncertainty about when to request Level II PASRR assessments. These oversights highlight a failure to adhere to the facility's admission criteria policy and the PASRR process requirements.
Failure to Provide Therapy Services Leading to Resident's Functional Decline
Penalty
Summary
The facility failed to provide necessary therapy or restorative services to prevent a functional decline for a resident, identified as R46, who was reviewed for Activities of Daily Living (ADL) decline. According to the facility's policy, residents should receive care to maintain or improve their ADLs unless a clinical condition makes decline unavoidable. R46's care plan indicated a change from a sit-to-stand lift with two staff assistance to a non-weight bearing mechanical lift, yet no therapy or restorative services were provided to address this decline. The resident expressed a desire to receive therapy to regain strength and improve her ability to stand, but reported not receiving any physical therapy or exercises from the facility. The Director of Nursing and the Physical Therapist/Director of Rehab provided conflicting information regarding the resident's transfer status and therapy needs. The Physical Therapist noted that R46 was evaluated twice but was not picked up for therapy due to altered mental status and inability to follow cues. The therapist also mentioned that attending daily Interdisciplinary Team (IDT) meetings could have facilitated adding R46 to the therapy caseload, but was unable to attend due to productivity concerns. The resident's medical record lacked documentation of IDT meetings reviewing her functional decline or therapy needs, indicating a gap in the facility's care coordination and oversight.
Failure in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident identified as R41. The facility did not perform weekly skin checks as required, with a missed assessment on 8-19-24. R41, who was moderately cognitively impaired and at moderate risk for pressure ulcers according to the Braden Scale, developed a Stage II pressure ulcer on the left buttock. Despite the identification of the ulcer, no treatment was administered until four days later, on 8-27-24. The resident's care plan indicated a need for frequent repositioning to prevent pressure ulcers, but this was not consistently implemented. Observations revealed that R41 was left sitting in a wheelchair for extended periods without repositioning, contrary to the care plan's instructions. Interviews with staff, including CNAs, indicated a lack of awareness regarding the repositioning orders for R41. The Director of Nursing acknowledged that the pressure ulcer was facility-acquired due to pressure and confirmed the lapse in weekly skin checks and delayed treatment application.
Failure to Implement ROM Services for Resident with Hemiplegia
Penalty
Summary
The facility failed to develop and implement services to maintain and/or improve range of motion (ROM) limitations for a resident diagnosed with hemiplegia following a cerebral infarction and muscle wasting. The resident, identified as R49, was observed to have functional limitations in the range of motion in one of the upper extremities and did not receive any passive or active ROM restorative programs or therapy. Despite being cognitively intact, the resident's current care plan did not address these limitations, and the resident reported not receiving any exercises from the staff. The facility's Restorative Nursing Services policy emphasizes individualized and resident-centered care to promote safety and independence, including maintaining or strengthening physical and psychological resources. However, the facility did not adhere to this policy for R49, as confirmed by the Restorative Aide, who stated that the resident was not on a restorative program to receive ROM exercises. This oversight indicates a failure to provide necessary restorative care to support the resident's physical health and independence.
Failure to Monitor Dialysis Access Site and Communicate with Dialysis Center
Penalty
Summary
The facility failed to provide adequate dialysis care and services for a resident with End Stage Renal Disease (ESRD) who requires dialysis. The facility did not maintain ongoing communication with the dialysis center, monitor the dialysis access site, document observations post-dialysis, or implement a care plan for monitoring, care, and emergency management of the dialysis access site. The facility's policies require regular checks for infection and patency of the access site, documentation of post-dialysis observations, and communication with the dialysis center, none of which were followed for the resident in question. The resident, who attends hemodialysis at a local facility three times a week, reported that the facility staff never monitor her access site, leaving this responsibility to the dialysis staff. The facility's Director of Nursing confirmed the lack of communication with the dialysis center and the absence of documentation in the resident's medical record regarding the monitoring of the dialysis access site. Additionally, the resident's care plan did not include any interventions related to the monitoring or emergency care of the dialysis access site, indicating a significant oversight in the resident's care management.
Failure to Justify and Evaluate Antipsychotic Medication Use
Penalty
Summary
The facility failed to document targeted behaviors and diagnoses to justify the use of antipsychotic medications, perform antipsychotic evaluations and assessments, and perform gradual dose reductions of scheduled antipsychotic medications for two residents diagnosed with Dementia. The facility's policy requires that residents on psychotropic medications receive gradual dose reductions unless clinically contraindicated, and that non-pharmacological interventions be used to minimize the need for medications. However, for both residents reviewed, there was no documentation of targeted behaviors or evaluations to justify the continued use of antipsychotic medications. For one resident, the physician's orders documented the use of Quetiapine for Dementia with Delusional Disorder, with increases in dosage over time. Despite the increases, the resident's Minimum Data Set (MDS) assessments indicated no behaviors that would justify the use of such medication, and there was no documentation of interdisciplinary team meetings to discuss the necessity of the medication. Observations noted the resident was often sleeping, and staff reported the resident was easily redirected when exhibiting minor behaviors, such as yelling out. For the second resident, the physician's orders included Seroquel for Major Depressive Disorder and Dementia with other behavior disturbances. The MDS assessment showed no behavioral symptoms that would justify the use of antipsychotic medication. Staff interviews confirmed the absence of significant behaviors, and the resident's care plan lacked documentation of targeted behaviors or non-pharmacological interventions. The facility did not conduct antipsychotic drug assessments or evaluations, as required by their policy, to determine the appropriateness of the medication therapy.
Failure to Properly Explain Arbitration Agreement
Penalty
Summary
The facility failed to adequately explain the arbitration agreement to residents or their representatives in a manner they could understand. The arbitration agreement did not clearly state that it could be rescinded within 30 days of signing, nor did it require residents or their representatives to acknowledge their understanding of the agreement. This oversight had the potential to affect all residents residing in the facility. Interviews and record reviews revealed that the facility's marketing and admissions staff did not inform residents or their representatives that signing the arbitration agreement would waive their right to sue the facility. The staff member responsible for explaining the agreement instructed residents to read the options and decide which one to sign, without ensuring they understood the implications. During a Resident Council Meeting, several residents expressed that they were unaware of the arbitration agreement and did not know if they or their representatives had signed it. Additionally, a resident's Power of Attorney stated that she was not informed about waiving the right to litigation through the courts and would have preferred to know this information before choosing arbitration. The facility's contract did not include a provision for residents to rescind the arbitration agreement within 30 days, nor did it provide a section for residents or their representatives to acknowledge their understanding of the agreement. This lack of communication and documentation contributed to the deficiency identified by the surveyors.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBPs) to prevent the spread of multi-drug resistant organisms (MDROs) among 16 residents reviewed for infection control. The facility's policy, dated August 2022, outlines the use of EBPs, including gown and glove use during high-contact resident care activities, for residents infected or colonized with specific MDROs or those with wounds and indwelling medical devices. Despite having a policy in place, the facility did not implement these precautions for residents with wounds, indwelling catheters, and a feeding tube. During an observation, certified nursing assistants and a registered nurse assisted a resident with perineal care and wound care without wearing gowns or using enhanced barrier precautions. Additionally, there was no signage or equipment indicating the need for EBPs near the resident's room. When questioned, the registered nurse was unaware of the enhanced barrier precautions, indicating a lack of training or communication regarding the policy. The facility administrator confirmed that the policy had not been implemented, and a list of residents requiring enhanced barriers had not been compiled.
Failure to Provide Proper Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident with a right heel unstageable pressure ulcer and suspected deep tissue injury. The resident's Physician Order Sheet (POS) required heel protectors to be worn at all times and specified a daily dressing change using a 0.25% sodium hypochlorite solution on moist gauze, followed by an abdominal pad and gauze wrap. However, during an observation, the resident's heels were not elevated with offloading boots or pillows, and the heel protectors were not in use. Additionally, the dressing on the resident's right heel was found to be soiled and dated six days prior, indicating it had not been changed daily as ordered. The Director of Nursing (V2) confirmed that the nursing staff had been peeling back and reusing the foam bordered gauze for six days, contrary to the manufacturer's instructions, which warned against reuse due to potential deterioration and cross-contamination. This practice was inconsistent with the physician's orders and the facility's wound care policy, which outlined specific steps for changing wound dressings, including daily changes. The failure to adhere to the prescribed treatment regimen and the facility's wound care policy resulted in inadequate care for the resident's pressure ulcer.
Failure to Safely Dispense Medications
Penalty
Summary
The facility failed to safely dispense medications to three residents (R2, R3, and R4) as observed by surveyors. For R2, the Licensed Practical Nurse (LPN) left the resident's 8:00 am medications on the bedside table without ensuring they were taken. The medications included Atenolol, Torsemide, Senna Lax, Aspirin, Carbidopa/Levadopa, Gabapentin, Acetaminophen, Losartan, Folic Acid, Cyanocobalamin, and Pantoprazole. The LPN admitted to leaving the medications for the resident to take after waking up and eating breakfast, acknowledging that this practice was inappropriate. Similarly, R3's 8:00 am medication, Polyethylene Glycol Powder, was left at the bedside by the same LPN, who did not stay to ensure the medication was taken. R3 stated they would take the medication after finishing breakfast. For R4, a medication cup containing multiple tablets and inhalers was left on the bedside table. R4 indicated they would take the medications after eating breakfast but was unsure of all the medications in the cup. The LPN confirmed the medications included Metoprolol, Eye Vitar, Vitamin C, Docusate Sodium, Multivitamin, and Citalopram, along with inhalers Symbicort and Spiriva. The Director of Nursing (DON) stated that nurses should not leave medications in residents' rooms without ensuring they are taken.
Failure to Timely Administer Medications
Penalty
Summary
The Facility failed to timely administer medications as ordered by the Physician for one resident (R3). The resident had multiple diagnoses including Sepsis, Cellulitis of Lower Limb, Pressure Ulcer Left Heel, Osteoarthritis, Diabetes Mellitus, Hypertension, Atrial Fibrillation, Transient Cerebral Ischemic Attack, Morbid Obesity, Bronchitis, and Chronic Kidney Disease. The Physician Order Sheet (POS) documented specific times for medication administration, including a 7:00 am dose of Humalog KwikPen sliding scale and various 8:00 am medications. However, on the observed date, the resident's breakfast tray was delivered at 9:13 am, and the resident completed the meal by 9:35 am. The Licensed Practical Nurse (LPN) administered the 7:00 am and 8:00 am medications at 9:35 am, which was after the scheduled times and after the resident had finished breakfast. The LPN acknowledged that the resident received medications, including insulin, after the scheduled times and after the meal. The Director of Nursing (DON) confirmed that medications, especially insulin, should be administered at their scheduled times and not after meals. This delay in medication administration constitutes a significant medication error, as it did not adhere to the physician's orders and the facility's medication administration policy, potentially compromising the resident's health and safety.
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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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