Renwick Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Joliet, Illinois.
- Location
- 3401 Hennepin Drive, Joliet, Illinois 60435
- CMS Provider Number
- 145694
- Inspections on file
- 43
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Renwick Nursing And Rehab during CMS and state inspections, most recent first.
The facility failed to maintain safe and comfortable temperatures for all residents after a power outage and boiler malfunction, resulting in prolonged cold conditions throughout the building. A maintenance director reset the boilers but left after noting the facility was warming, while multiple residents reported being very cold for extended periods, relying on numerous blankets, extra clothing, and room changes. Staff, including CNAs, LPNs, and an RN, acknowledged that the building felt cold, that residents complained, and that they used all available blankets and moved some residents to warmer areas, but they did not consistently notify on-call leadership or maintenance about the ongoing lack of heat. Temperature logs documented readings in the upper 50s to low 60s°F in various areas, and not all residents had body temperatures monitored, despite facility policy requiring notification of administration and maintenance, regular room temperature checks, and observation of residents for adverse effects during loss of heat.
Essential heating equipment was not properly maintained following a power outage, resulting in a period without adequate heat for all residents. The Maintenance Director did not know the boilers required manual resetting after the outage and did not reset all units, and an assistant later had to reset an additional boiler. A heating contractor identified a failed pump motor that was critical for the heat pumps to function and advised immediate replacement, but facility leadership chose to delay the work until normal business hours, despite staff reporting that they were cold. A technician later replaced the defective pump motor and components and confirmed that room temperatures were rising.
Surveyors identified extensive sanitation and hygiene deficiencies in the kitchen, including dirty handwashing stations, stained equipment, spoiled food, and improper staff hygiene practices such as inadequate handwashing and incomplete hair covering. Staff were observed wearing personal clothing in food prep areas and using cracked equipment, while food contact surfaces and storage areas were found with visible residue, stains, and food particles. Facility policies requiring cleanliness and infection control were not consistently followed.
A resident with a history of falls and behavioral challenges was being assisted with toileting when she attempted to pull up her own pants, became unstable, and fell, sustaining a head injury. The staff member assisting did not use a gait belt as required by facility policy, instead attempting to support the resident manually, which was insufficient to prevent the fall.
A resident at high risk for falls, with multiple medical conditions and on blood thinners, was injured after being transferred with a sit to stand lift by a single CNA, despite facility policy requiring two staff for such transfers. The resident fell forward and sustained a bleeding injury to the forehead. The care plan did not specify fall precautions, and staff interviews confirmed the transfer was not performed according to policy.
A resident with moderate cognitive impairment and depression threatened his severely cognitively impaired roommate with a pocketknife, making alarming statements and causing mental distress. Nursing staff moved the threatened resident to another room and later discovered the knife when the resident's family arrived. The facility failed to protect the resident's right to be free from mental abuse, as defined by its own abuse prevention policy.
A resident with schizophrenia and recent elopement attempts was subject to involuntary transfer and discharge procedures initiated by facility staff without the required physician documentation or orders. The DON completed the necessary forms at the direction of corporate staff, but the forms were not signed by a physician and lacked detailed medical justification. Hospital evaluation found no immediate safety concerns, and the resident's medical record did not contain physician progress notes or orders supporting the transfer or discharge.
A resident with hemiplegia and obesity fell from bed during care due to inadequate assistance, resulting in fractures and a knee dislocation. The CNA, working alone, directed the resident to turn onto her affected side, leaving her close to the bed's edge. Despite the resident's care plan requiring two-person assistance, no additional staff were available, leading to the fall and subsequent hospitalization.
A resident with severe cognitive impairment and multiple health issues was injured during a transfer when a CNA used a gait belt instead of the prescribed mechanical lift with two staff members. This improper transfer led to a leg laceration requiring sutures. Facility staff confirmed that the expectation was to follow therapy's recommendations for safe transfers, as outlined in the care plan and facility policy.
The facility failed to maintain sanitary practices during food preparation and service, affecting 92 residents. A cook was observed using a dirty blender and lid, with uncovered facial hair, and storing personal items on prep counters. Uncovered and undated food items were found in storage, and a dietary aide also had uncovered facial hair. Facility policies on food storage and preparation were not adhered to.
The facility failed to follow its Infection Prevention and Control Program, with the ADON not completing infection surveillance tools since October 14, 2024. The Maintenance Director was unaware of the water management plan for legionella, leading to no monitoring of water systems. Staff also neglected hand hygiene and Enhanced Barrier Precautions, with CNAs not wearing gowns or performing hand hygiene between tasks, affecting residents with conditions like ESBL resistance and Candida Auris.
The facility failed to maintain comfortable room temperatures, affecting six residents who reported inadequate heating in their rooms. Temperatures dropped to 58 degrees Fahrenheit at night, forcing residents to use extra blankets. The issue arose from a contractor's error in the electrical system, delaying the installation of new heating units. The facility's policy for loss of heat was not effectively implemented.
The facility failed to serve the correct portion sizes for pureed diets as per the menu guidelines, affecting six residents. The cook substituted pureed chicken for pork and mashed potatoes for rice, and dietary aides used an incorrect scoop size, leading to a deficiency in meeting nutritional needs.
The facility failed to assist six residents with personal hygiene, grooming, and incontinence care. Residents with cognitive impairments and physical limitations were observed with dirty fingernails, overgrown facial hair, and inadequate incontinence care. Despite needing total or extensive assistance, their grooming needs were unmet, highlighting a deficiency in maintaining hygiene and dignity.
The facility failed to provide adequate perineum and catheter care for four residents, increasing the risk of UTIs. One resident was not fully cleaned after incontinence, another's uncircumcised penis and groins were not properly cleaned, a third resident's pubic area and labia were inadequately cleaned, and a resident with a suprapubic catheter did not receive proper catheter care. Facility guidelines for incontinence and catheter care were not adhered to.
The facility failed to label and date opened medications, including insulin and inhalers, to determine expiration dates. Additionally, narcotic medications with broken seals were not discarded as required, posing risks of medication diversion and infection. These deficiencies were identified during inspections of medication storage areas.
A resident with a history of cerebral infarction and rheumatoid arthritis experienced tooth pain for over six months without receiving recommended extractions. Despite multiple dental visits, no action was taken, leading to significant discomfort and a downgraded diet. Communication issues and financial concerns were noted, with the resident's daughter seeking insurance-covered options.
The facility failed to provide necessary splint and therapy services to two residents, leading to a decline in their range of motion (ROM). One resident, with hemiplegia, was not wearing the prescribed hand splint for several days, resulting in a decline in ROM. Another resident, with severe contractures, was observed without a splint, and an occupational therapist recommended splinting and an orthopedic consult. These deficiencies highlight the facility's failure to maintain or improve residents' ROM.
The facility did not follow its antibiotic stewardship policy, impacting all 92 residents. The ADON, newly appointed as Infection Preventionist, had just started reviewing antibiotic use. The facility lacked documentation for tracking antibiotic use since early September, as confirmed by the Regional Nurse Consultant.
The facility failed to implement proper infection control practices following a COVID-19 exposure, affecting 55 residents. Residents were not tested for COVID-19 despite known positive cases, and the facility did not adhere to its COVID-19 policy. A CNA who tested positive had contact with residents and staff without appropriate precautions. The facility lacked documentation of testing and tracking, resulting in inadequate infection control measures.
The facility failed to maintain a safe and comfortable environment for residents due to a malfunctioning air conditioning system. Despite being notified of the issue, the facility did not take timely action, resulting in high room temperatures and resident discomfort. The facility did not follow its hot weather policy, using inappropriate tools to measure air temperature and failing to provide adequate fluids to residents. The HVAC contractor had informed the facility of underground pipe leaks, but temporary cooling solutions were delayed, affecting all 98 residents.
The facility failed to follow hot weather policies when the air conditioning malfunctioned, resulting in room temperatures exceeding 85°F. The administration did not ensure temperature and humidity were monitored every two hours, and residents were left in hot conditions without water. The facility lacked the necessary equipment to measure air temperatures and humidity, and staff were not informed of the procedures to follow during the malfunction.
Failure to Maintain Safe Indoor Temperatures and Monitor Residents During Heating System Malfunction
Penalty
Summary
The deficiency involves the facility’s failure to maintain safe and comfortable indoor temperatures for all 102 residents following a power outage and subsequent heating system malfunction. After a power outage occurred on a Saturday, the Maintenance Director reported that the power was restored within approximately 45 minutes and stated there were no heating issues at that time. The next day, the Administrator notified the Maintenance Director that the heat was not working, and the Maintenance Director manually reset the boiler system, which he stated was required after the outage but had not been done earlier because he was unaware of the need. He reported that after resetting the boilers, the heat began working and temperatures taken throughout the facility showed it was warming up, and he then left the building. Despite this, residents and staff reported that the building remained cold over the weekend and into Monday. One resident stated that heating issues began on Saturday evening when the power went out and that the thermostat in his room read 55–60°F for 18 hours before he was moved to another room on Sunday afternoon. Another resident reported that it was very cold and that his nose was freezing to the touch, and staff provided extra blankets. A third resident’s room temperature was measured at 62.4°F by the Assistant Maintenance staff, and this resident reported that his room had been cold for two to three days, had already had his roommate moved out, and had asked his son to bring winter gloves. Another resident reported that his room was freezing the previous night, that he had 10 blankets on to stay warm, and that multiple people attempted but were unable to fix the heater in his room. A fifth resident reported that the heat was not working, that he used four blankets and two pairs of pants to stay warm, and that he remained in his room during this time. Staff interviews and facility records further demonstrated that the facility did not adequately monitor or respond to the cold conditions. A CNA reported working a morning shift when the building was cold, wearing her winter jacket while assisting residents in the dining room, and hearing residents complain of the cold; she stated that residents were moved to warmer areas but that she did not obtain temperatures on any residents. An LPN working a 12-hour day shift stated the facility was cold when she arrived and that she only took body temperatures on residents who could not verbalize if they were cold. An RN working the night shift reported that the facility felt cold when she arrived, that the previous shift had told her it was getting colder throughout the day, and that she instructed CNAs to add clothing and blankets and repositioned a resident’s bed away from a window, but she did not call anyone about the cold. Another LPN working night shifts over three days stated that heating issues started Saturday night, that staff were told maintenance had done everything possible, and that although it was cold on subsequent nights, she did not notify anyone on Sunday night. Temperature logs for the day of January 19 showed multiple readings below typical comfort levels, with recorded temperatures ranging from as low as 57.8°F to 71.4°F at various times between 8:00 AM and 6:00 PM. The Maintenance Director stated he was not notified by staff or administration on Sunday night into Monday morning that the heat was not working properly and that he did not become aware of the ongoing heating problem until he arrived Monday morning. The Assistant DON, who was the on-call nursing manager Sunday night, reported receiving no calls about the heat not working, and the Administrator similarly reported receiving no calls about the cold conditions that night, while stating that staff should have notified him or the Maintenance Director. The DON stated that staff began taking resident temperatures on Monday evening and acknowledged that not all residents’ temperatures were checked and that all residents should have been monitored, including on Sunday night if staff felt the facility was cold. The facility’s written policy on “Loss of Heat During Cold Weather” required that staff be oriented and educated to procedures for individual room heat malfunction and loss of heat to the entire facility. For individual room malfunctions, the policy directed staff to notify maintenance and to check room temperatures as needed, sampling at least every two hours when residents were in the room, and recommended moving residents if room temperatures fell below 55°F for 12 hours or more. For loss of heat to the facility, the policy required notification of the Administrator and Maintenance Department and observation of residents for signs of adverse effects of cooler temperatures. The report indicates that the facility did not document monitoring of all residents for signs and symptoms of hypothermia, including temperature checks, during the period when the facility lacked adequate heat on Sunday night and Monday, and that staff did not consistently follow the notification and monitoring procedures outlined in the policy.
Failure to Maintain Essential Heating Equipment After Power Outage
Penalty
Summary
Failure to maintain essential heating equipment occurred after a facility-wide power outage that affected all 102 residents. The Maintenance Director reported that power was lost for approximately 45 minutes on a Saturday and was restored before he arrived, and he did not identify any heating issues at that time. The following day, the Administrator notified him that the heat was not working, and he then realized the facility’s boiler system required a manual reset after the outage, which he had been unaware of. An Assistant Maintenance staff member later confirmed that the Maintenance Director did not reset all boilers and that he himself had to manually reset one boiler supplying heat to the Administrator’s office. The Administrator acknowledged that the Maintenance Director, who had started working at the facility the previous month, could not be trained on all aspects of the building and stated that he should have contacted the regional maintenance team after the power outage to determine any additional required tasks. A heating company technician visited the facility on Sunday due to lack of heat and determined that a new motor and spring coupler were needed for the pump, documenting that the pump motor was a pivotal component for the heat pumps to work and needed immediate replacement. The technician recorded that the customer chose to wait until the next day during normal business hours, stating that the building temperature had risen and they preferred to delay the work. On Monday, the Maintenance Director reported that staff were complaining of being cold, and the regional maintenance team identified that the water pump was failing. A heating company technician arrived that afternoon with a replacement pump motor, confirmed the existing motor was bad, and ultimately installed a new motor and spring coupler later that evening after obtaining a functional replacement. The technician documented remaining on-site until staff were comfortable that room temperatures were rising, indicating that essential heating equipment had not been maintained in safe operating condition for a period following the outage.
Widespread Sanitation and Hygiene Failures in Kitchen Operations
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food preparation and sanitation. The kitchen hand washing sink was heavily stained with black residue, and food spatter and particle residue were present on the hand soap and sanitizer dispensers. Dust and stains were also found on the paper towel dispenser and garbage bin. Walls above food prep areas had yellow stains and food spatter, and the deep freezer contained a large box of bagels with a red sticky substance, as well as red spatter on the freezer doors. The ice machine had dark stains and buildup on both the interior and exterior, and the food prep sink faucet was covered in thick white stains. A box of apples stored under the prep table contained multiple rotted apples. Staff were observed failing to follow proper hygiene and infection control practices. One cook touched his mouth and continued handling dishware and meal prep without performing hand hygiene. Another dietary aide wore a personal coat in the kitchen and handled a personal cup in the food prep area. Staff were also seen with hairnets that did not fully cover their hair, and one cook repeatedly touched his lips and placed his hand in his pockets without washing hands before returning to food preparation. The dietary manager and consultant confirmed the presence of visible dust, particles, and stains on various kitchen surfaces and acknowledged the need for improved cleaning practices. Additional observations included cracked and leaking food processor equipment, heavily stained walls and basins, food particles and grease on shelves and stoves, and dirty dish racks and plate warmer cabinets. Beverage pitchers and clean cups were found with thick food particles and stains. The dietary manager stated that hairnets should fully cover hair, outside clothing should not be worn in the kitchen, and all kitchen equipment and surfaces should be clean. Facility policies required thorough cleaning and sanitizing of all kitchen areas and equipment, proper food storage, and strict hand hygiene, but these were not consistently followed.
Failure to Use Gait Belt During Transfer Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to implement required safety and fall prevention interventions during the transfer of a resident with a significant history of falls and multiple behavioral and medical conditions, including dementia, seizures, and muscle disorder. The resident, who was known to be noncompliant with care and at risk for falls, was being assisted to the toilet in the shower room. During the transfer from the toilet back to the wheelchair, the resident insisted on pulling up her own pants, became unstable, and fell, resulting in a head injury. Observations confirmed visible bruising above the resident's left eyebrow following the incident. Interviews and record reviews revealed that the staff member assisting the resident did not use a gait belt during the transfer, despite facility policy requiring gait belt use for residents at risk for falls and those needing assistance during transfers. The staff member attempted to support the resident by placing her arms around the resident's back, but was unable to prevent the fall. The facility's policy and statements from supervisory staff confirmed that gait belts are mandatory for such transfers, and the failure to use this safety device directly contributed to the incident.
Failure to Provide Adequate Supervision During High-Risk Transfer
Penalty
Summary
A deficiency occurred when a resident at high risk for falls, with a history of cerebral infarction, dementia, depression, hypertensive heart disease, and protein-calorie malnutrition, was transferred using a sit to stand lift by a single CNA, contrary to facility policy requiring two staff members for such transfers. During the transfer from chair to bed, the resident fell forward and struck her head on the machine, resulting in a bleeding injury to her left eyebrow, which was exacerbated by her use of blood thinners. The resident's care plan did not specify any fall precautions, despite her high fall risk status as indicated in her assessment. Interviews with staff confirmed that the CNA performed the transfer alone and that the facility's policy mandates two staff for sit to stand lift operations. The incident was documented in progress notes, and the DON acknowledged that the transfer was not conducted according to policy. The facility's policy, revised in 2008, clearly states that two staff members are required for the use of portable lifts, but this protocol was not followed in this instance.
Failure to Protect Resident from Mental Abuse Following Threatening Incident
Penalty
Summary
A resident with moderate cognitive impairment and a history of depression was involved in a verbal altercation with his roommate, who has severe cognitive impairment. During the incident, the roommate alleged that the resident threatened him with a small pocketknife. Nursing staff responded by moving the roommate to another room for safety and conducted a room check, but did not initially find a knife. The resident refused a body check at that time. Later, when the resident's family arrived, the resident produced a small knife from his sock, which was then confiscated. Progress notes indicated that the resident was found agitated, holding a knife, and making alarming statements about having killed before and being willing to do so again. The facility's abuse prevention policy defines threats of harm as verbal abuse and mental abuse, including intimidation and threats of punishment. The facility failed to protect the resident's right to be free from mental abuse, as the threatening behavior was not immediately identified or addressed, resulting in a deficiency.
Failure to Obtain Required Physician Documentation for Involuntary Transfer/Discharge
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the required physician documentation was included in the medical record to support a resident's transfer and discharge rights. A resident with a history of schizophrenia and elopement behaviors was admitted to the facility and, shortly after admission, attempted to leave the facility twice. Following these incidents, facility staff initiated a Petition for Involuntary/Judicial Admission and a Notice of Involuntary Transfer or Discharge (IVD), citing the safety of individuals in the facility as the reason for the proposed transfer or discharge. However, the forms were completed by the Director of Nursing at the instruction of corporate personnel, and not by a physician. The IVD form indicated that the transfer was not an emergency, and the petition lacked detailed physician input or signature. Review of the resident's medical record and hospital documentation revealed that there were no physician orders for the involuntary psychiatric admission or for discharge. The hospital evaluation found no acute psychiatric or medical condition requiring intervention, and the petition from the facility was deemed invalid due to the lack of clear immediate safety concerns and improper completion. Additionally, the resident's electronic medical record contained no progress notes from a nurse practitioner or physician regarding the need for involuntary discharge or psychiatric admission, and behavioral monitoring documentation by CNAs was incomplete, only noting the resident as "not available." Facility policy requires physician confirmation and documentation in the medical record to support emergency transfers or discharges, as well as clear documentation of the danger posed by the resident. In this case, the required physician documentation and orders were absent, and the forms were not properly completed or signed by a physician, resulting in a failure to meet regulatory requirements for transfer and discharge rights.
Resident Falls Due to Inadequate Assistance During Bed Repositioning
Penalty
Summary
The facility failed to ensure a resident was positioned safely in bed during routine care, resulting in a fall and significant injuries. The resident, who had a history of hemiplegia, hemiparesis, rheumatoid arthritis, and obesity, was being cared for by a CNA who was alone in the room. The CNA directed the resident to turn onto her right side, which was her affected side, for peri-care. During this process, the resident's lower extremities slid off the bed, causing her to fall to the floor and sustain fractures and a knee dislocation. The incident occurred when the CNA, who was on the opposite side of the bed, reached over to the nightstand, leaving the resident closer to the edge of the bed. The resident attempted to alert the CNA that she was slipping, but the CNA was unable to prevent the fall. The CNA had previously cared for the resident with assistance from other staff members, but no additional help was available at the time of the incident. The resident's care plan indicated that she required assistance from two staff members for bed mobility due to her size and hemiplegia. Following the fall, the resident was assessed by a nurse and sent to the hospital for evaluation and treatment. Diagnostic imaging confirmed a posterior dislocation of the right tibial prosthesis, a proximal right tibial fracture, and a right periprosthetic femur fracture. The resident's care plan and CNA charting indicated that she was dependent on assistance for bed mobility, requiring two staff members for safe repositioning, which was not adhered to during the incident.
Failure to Follow Transfer Protocol Results in Resident Injury
Penalty
Summary
The facility failed to adhere to therapy's recommendations for the safe transfer of a resident, resulting in an injury. The resident, who had severe cognitive impairment and multiple diagnoses including dementia and peripheral vascular disease, required substantial assistance for transfers as per their care plan. The care plan specified the use of a mechanical lift with two staff members for transfers. However, on September 28, 2024, a CNA transferred the resident alone using a gait belt, contrary to the prescribed method. During this improper transfer, the resident's leg was scraped against the wheelchair, causing a laceration that required six sutures. Interviews with facility staff, including the Director of Rehab and a Nurse Practitioner, confirmed that the expectation was for staff to follow therapy's recommendations for safe transfers. The facility's policy also mandated the use of mechanical lifting devices for residents needing a two-person assist, except in emergencies. The incident report indicated that the resident was on anticoagulants, which could have contributed to the severity of the bleeding. The failure to follow the established transfer protocol directly led to the resident's injury.
Sanitary Practices Deficiency in Food Preparation and Service
Penalty
Summary
The facility failed to adhere to sanitary practices during food preparation and service, affecting 92 residents who receive meals from the facility kitchen. During an observation, a cook was seen washing a blender in a prep sink that contained food debris and a brownish substance. The cook, who had an uncovered beard, placed the washed lid inside the same dirty sink and used it on the blender, which still had food debris. The cook expressed frustration when informed that the blender and lid needed to be rewashed. Additionally, the cook's phone was on the main prep counter, which also had an opened box of cream of wheat. In the walk-in cooler, several bowls of pudding-like items were uncovered and stored on a rack, along with undated containers of various foods, some of which were past their use-by dates. The reach-in freezer contained an open packet of frozen breaded chicken. Multiple washed domed lids were stacked on a counter with dust and food debris, and some lids still had food and dust on them. A dietary aide with uncovered facial hair was also observed working in the kitchen, and the food service manager from another facility confirmed that dietary staff with facial hair should wear a beard cover. The facility's policies on food storage and preparation were not followed, contributing to the deficiency.
Infection Control and Water Management Failures in LTC Facility
Penalty
Summary
The facility failed to adhere to its Infection Prevention and Control Program, as evidenced by the lack of infection surveillance and documentation. The Assistant Director of Nursing (ADON), who assumed the role of Infection Preventionist on October 14, 2024, admitted to not having completed any infection surveillance tools since taking over the position. This lapse in surveillance was confirmed by the Regional Nurse Consultant, who noted the absence of Infection Screening Evaluations for resident infections from September 1, 2024, to the present. The facility's policy mandates a system for preventing, identifying, reporting, investigating, and controlling infections, which was not followed. The facility also neglected its water management plan for legionella, as the Maintenance Director, who started on October 7, 2024, was unaware of the plan and had not conducted any monitoring. The facility's water management plan requires daily temperature checks of the hot water tank and weekly checks of chlorine or bromine levels, none of which were documented. The Administrator confirmed that the previous maintenance director also did not perform these necessary checks, indicating a systemic failure in following the water management plan. Additionally, there were multiple instances of staff failing to follow hand hygiene and Enhanced Barrier Precautions (EBP) policies. Certified Nursing Assistants (CNAs) were observed providing care without performing hand hygiene between tasks or wearing the required personal protective equipment, such as gowns, when caring for residents on EBP. Specific cases included residents with conditions like ESBL resistance and Candida Auris, where staff did not adhere to the necessary precautions, potentially compromising infection control efforts.
Failure to Maintain Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain a comfortable room temperature for residents, compromising their right to a safe and homelike environment. Six residents reported issues with heating and cooling in their rooms, with temperatures dropping as low as 58 degrees Fahrenheit at night. Residents resorted to using extra blankets and clothing to stay warm. Observations confirmed discrepancies in room temperatures, with facility thermometers showing different readings than residents' personal thermometers. The facility's Maintenance Director acknowledged that room temperatures should not fall below 70 degrees Fahrenheit. The facility's Administrator and Vice President of Operations explained that the issues stemmed from a previous contractor's error in stripping the electrical system, which required reinstallation. New heating and cooling units were being installed, but some rooms were not yet connected. The 100 hallway was particularly affected, with delays due to damaged heat pumps. The facility had a policy for loss of heat during cold weather, but it was not effectively implemented, leading to discomfort for the residents.
Failure to Follow Prescribed Portion Sizes for Pureed Diets
Penalty
Summary
The facility failed to adhere to the prescribed portion sizes for pureed diets as outlined in their menu spreadsheets. This deficiency was observed in six residents who were on pureed diets. The Spring Summer Menu 2024 specified the use of a #8 scoop for pureed carrot raisin rice and pureed broccoli, and a #6 scoop for pureed pork chop with apples. However, during meal preparation, the cook substituted pureed chicken for pork chop and mashed potatoes for pureed rice, citing resident preferences. The dietary aides used a #10 scoop, which was not in accordance with the menu specifications, to serve the pureed meat, broccoli, and mashed potatoes. The dietitian confirmed that the correct scoop size is crucial for ensuring the residents receive the appropriate amount of protein and nutrients. The facility's diet order listing confirmed that the six residents were on pureed diets, yet they received meals that did not match the planned menu in terms of both content and portion size. This deviation from the menu and portion guidelines led to the deficiency noted by the surveyors.
Deficiency in ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide necessary assistance with personal hygiene, grooming, and incontinence care for six residents who required such support. Resident 13, with severe cognitive impairment and limited mobility, was observed with dirty fingernails despite needing total assistance with personal hygiene. Similarly, Resident 25, also severely cognitively impaired, had long, jagged fingernails with black substances underneath and overgrown chin hair, indicating a lack of grooming assistance. Resident 76, who is cognitively intact but has impaired range of motion, reported requesting nail care assistance without receiving it, resulting in long, dirty fingernails. Resident 23, with severe cognitive impairment and hemiplegia, was found with overgrown, dirty fingernails and facial stubble, despite requiring total assistance for ADLs. Resident 56, who needs extensive assistance, was found in a room with a strong urine odor and expressed a desire for facial hair removal, which was not addressed. Resident 71, with cognitive impairment, was found tearful and improperly dressed, with dirty fingernails, overgrown facial hair, and fecal smears on her body. Despite being assisted with dressing and incontinence care, her grooming needs were not met. The facility's failure to provide adequate ADL care, including nail and facial care, was acknowledged by the Director of Nursing, highlighting a deficiency in maintaining residents' hygiene and dignity.
Inadequate Perineum and Catheter Care Leading to Potential UTI Risk
Penalty
Summary
The facility failed to provide adequate perineum and catheter care to prevent potential urinary tract infections (UTIs) for four residents. One resident, who is cognitively impaired and requires assistance with toileting, was found with fecal matter on her hands and thighs. The CNA assisting her did not clean the frontal perineum and left fecal matter on her thigh. Another resident, who is cognitively impaired and requires total assistance for toileting, was not properly cleaned as the CNA did not retract his uncircumcised penis or clean the inner folds of his groins. A third resident, who is alert and oriented but requires total assistance for toileting, was not properly cleaned as the CNA did not clean the pubic area or the inner folds of the labia. Lastly, a resident with a suprapubic catheter due to neurogenic bladder was not provided with proper catheter care, as the CNA did not clean the catheter tube. The facility's guidelines for incontinence and catheter care were not followed, contributing to the potential risk of UTIs.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to properly label and date medications once they were opened, which is necessary to determine their expiration dates. This deficiency was observed in several residents' medications, including Insulin Lispro Kwik Pen, Insulin Glargine-YFGN, and Novolin R Flex Pen, which were opened but not dated. Additionally, Incruise Ellipta inhalers for two residents were also opened and not dated, contrary to the manufacturer's guidelines that specify a discard period after opening. These lapses in labeling and dating medications were identified during inspections of the medication room and carts in various halls of the facility. Furthermore, the facility did not appropriately handle narcotic medications with broken seals. During the inspection, it was found that several narcotic medications, such as Norco and Tramadol tablets, had broken seals that were taped over instead of being discarded as per the facility's policy. The Director of Nursing confirmed that staff are required to discard narcotic medications with broken seals to prevent medication diversion and ensure infection control. The facility's policy mandates the immediate removal and proper disposal of medications in containers that are cracked, soiled, or without secure closures, which was not adhered to in these instances.
Failure to Address Resident's Dental Pain and Required Extractions
Penalty
Summary
The facility failed to follow up on dental care recommendations for a resident experiencing tooth pain for over six months, requiring tooth extractions. The resident, an elderly female with a history of cerebral infarction, rheumatoid arthritis, and polyneuropathy, reported persistent mouth and tooth pain. Despite being seen by a dentist three times, no action was taken to address her broken teeth, which caused her significant discomfort and difficulty chewing. Observations noted that the resident had few teeth remaining, with black substance around the base of her upper teeth and a stub on her lower gum. The resident's diet was downgraded to a mechanical soft diet due to her chewing difficulties, as noted in an email from the Social Service Director. A dental assessment recommended extractions of specific teeth due to pain and inflammation, but no extractions were performed. Communication between the Director of Nursing and the business office manager highlighted ongoing concerns about the resident's dental issues and financial considerations for treatment. Despite the resident's repeated complaints and a nursing note indicating her desire to visit the dentist, the facility's administrator was unaware of any extractions in the past six months. The resident's daughter was informed of the situation but declined to pay for the extractions, seeking alternatives covered by insurance.
Failure to Provide Splint and Therapy Services for ROM Maintenance
Penalty
Summary
The facility failed to assess and provide necessary splint and therapy services to residents, leading to a deficiency in maintaining or improving their range of motion (ROM). One resident, with a history of hemiplegia and hemiparesis following a cerebral infarction, was observed without the prescribed splint for her left hand and wrist over several days. Despite having an active order for a hand orthotic to manage contracture, the resident reported not wearing the splint for at least two days, and staff did not apply it during the observed period. The occupational therapist later confirmed a decline in the resident's ROM, indicating a need for further evaluation and therapy. Another resident, with multiple medical diagnoses including hemiplegia and muscle atrophy, was observed with severe contractures in the right upper extremity, including the shoulder, elbow, and wrist. The resident's hand was flaccid, and fingernails were digging into the skin, yet no splint was applied. An occupational therapist evaluated the resident and noted severe contractures, recommending gentle splinting and an orthopedic consult for potential surgical intervention. These observations and evaluations highlight the facility's failure to provide appropriate care and interventions to prevent further reduction in ROM for these residents. The lack of timely application of prescribed splints and the absence of necessary therapy services contributed to the decline in the residents' conditions, as documented by the occupational therapist.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to adhere to its policy for antibiotic stewardship, affecting all 92 residents. The Assistant Director of Nursing, who assumed the role of Infection Preventionist on October 14, 2024, acknowledged that she had only just begun reviewing which residents were on antibiotics. The Regional Nurse Consultant confirmed that the Infection Preventionist nurse is responsible for the Infection Prevention and Control Program, including the antibiotic stewardship program. However, the facility lacked documentation to demonstrate tracking of antibiotic use from September 1, 2024, to the present.
Inadequate COVID-19 Infection Control Measures
Penalty
Summary
The facility failed to implement proper infection control practices following a COVID-19 exposure, affecting 55 residents. On multiple occasions, residents reported not being tested for COVID-19 despite being informed of positive cases within the facility. The facility did not display a sign indicating outbreak status at the entrance, and the Infection Preventionist Nurse admitted to prematurely removing the outbreak status sign. The facility's COVID-19 policy, which mandates testing and precautions following exposure, was not adhered to. A certified nursing assistant (CNA) who tested positive for COVID-19 had been in contact with residents and staff without appropriate precautions being taken. The CNA reported feeling unwell during her shift and later tested positive for COVID-19. Despite this, the facility did not conduct timely testing of residents and staff who were potentially exposed. The Infection Preventionist Nurse acknowledged the failure to test all potentially exposed residents and staff, citing difficulties in tracking and documentation. The Director of Nursing and Acting Administrator confirmed that the facility's policy required testing and transmission-based precautions for exposed individuals, which were not implemented. The facility lacked documentation of testing and tracking for the affected residents and staff, and the testing that was conducted was insufficient and delayed. The facility's failure to follow its COVID-19 policy and state guidelines resulted in inadequate infection control measures during the outbreak.
Facility Fails to Maintain Safe Environment Due to Malfunctioning Air Conditioning
Penalty
Summary
The facility failed to maintain a safe and comfortable environment for its residents due to a malfunctioning air conditioning system. The issue began when the facility was notified by their HVAC contractor that there would be no heating or cooling capacity without necessary repairs. Despite this notification, the facility did not take timely action to address the problem, resulting in room temperatures reaching as high as 91 degrees Fahrenheit. Residents expressed discomfort and distress due to the heat, with some removing clothing to cool off and others complaining of difficulty sleeping. The facility did not follow its own hot weather policy, which required measuring room temperatures and humidity levels every two hours when the air conditioning was not functioning properly. Instead, the Maintenance Director used an infrared temperature gun, which is not suitable for measuring air temperature, leading to inaccurate assessments of the indoor environment. Additionally, staff did not ensure that residents had access to adequate fluids, further compromising their comfort and safety. The facility's failure to address the air conditioning issues promptly and effectively affected all 98 residents. The HVAC contractor had informed the facility of underground pipe leaks that prevented the system from functioning, but the facility delayed authorizing temporary cooling solutions. The facility's lack of proper monitoring and failure to implement high-temperature procedures as outlined in their policies contributed to the ongoing discomfort and potential health risks for the residents.
Failure to Adhere to Hot Weather Policies During AC Malfunction
Penalty
Summary
The administration of the facility failed to provide adequate oversight and leadership to ensure compliance with hot weather policies and procedures when the air conditioning system was not functioning properly. The facility's administrator, V1, was aware of the malfunctioning air conditioning but did not ensure that temperature and humidity levels were being monitored as required by the facility's policy. The facility did not have the necessary equipment to measure air temperatures and humidity, and the staff was not informed about the need to check these levels every two hours during the malfunction. Observations revealed that room temperatures in the facility were consistently above 85 degrees Fahrenheit, with some areas reaching as high as 91 degrees. Residents expressed discomfort due to the heat, and there were instances where residents were in common areas without access to water, and no staff was present to assist them. The facility's policies required that temperatures and humidity be monitored regularly and that residents be relocated to cooler areas if necessary, but these procedures were not followed. The facility's failure to adhere to its hot weather and extreme high temperature guidelines resulted in prolonged exposure of residents to excessive heat. The administration did not notify the State Agency about the air conditioning issues, and the facility continued to use common areas like the dining room despite high temperatures. The lack of proper monitoring and response to the heat conditions posed a risk to the health and well-being of the 98 residents in the facility.
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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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