Rock Falls Rehab & Hlth Care C
Inspection history, citations, penalties and survey trends for this long-term care facility in Rock Falls, Illinois.
- Location
- 430 Martin Road, Rock Falls, Illinois 61071
- CMS Provider Number
- 146157
- Inspections on file
- 14
- Latest survey
- November 8, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Rock Falls Rehab & Hlth Care C during CMS and state inspections, most recent first.
The facility failed to provide adequate notice to residents and their families before transferring them due to a sudden closure. Six residents, with various medical conditions, were given only two to three days to relocate, causing significant emotional distress. The facility's policy requires a 30-day notice, but the new owners mandated a rapid discharge, leading to confusion and upset among residents and their families.
A facility failed to administer prescribed fluoxetine to a resident with major depressive disorder, leading to suicidal ideation and hospitalization. Additionally, an LPN withheld lisinopril from another resident due to low blood pressure but failed to assess, re-check, or notify the physician, contrary to facility policy.
The facility did not maintain 8-hour consecutive RN coverage 7 days a week, impacting all residents. The DON often worked nights instead of days, leading to gaps in RN coverage, especially on weekends. Staffing records showed inconsistencies, and the BOM cited issues with the payroll system's reliability.
The facility failed to store medications safely, with unlabeled antibiotics found in a medication cart and improper temperature control in the medication refrigerator. The refrigerator contained morphine for two residents and other stock medications, with no recent temperature logs maintained. The DON acknowledged the importance of temperature checks but had not ensured compliance with the facility's policies.
The facility failed to ensure dietary staff completed food safety training, affecting all residents. The Dietary Manager acknowledged that two staff members alternated roles, but one was new and had not completed training, while the other's certification had expired. The Administrator expected staff to have current training, but it was the Dietary Manager's responsibility to ensure this. Job descriptions required food handler training within 30 days of employment, which was not met.
The facility failed to properly sanitize dishes and prevent chemical contamination of food, affecting all residents. The dishwasher did not reach the required temperature, and the chlorine sanitizer level was inadequate. The 3-compartment sink was improperly set up, leading to sanitizing liquid dripping into pureed food prepared for residents. This posed a potential health risk, as ingestion of the sanitizer could cause nausea.
The facility failed to maintain a safe and sanitary environment, with structural issues like ceiling holes and a leaking roof affecting all residents. Staff and residents reported prolonged inaction, and a resident with complex medical needs was exposed to a dusty fan due to unclear cleaning responsibilities.
A facility failed to follow infection control protocols, including improper cleaning of glucometers between residents, inadequate hand hygiene, and failure to adhere to Enhanced Barrier Precautions. An LPN used a glucometer on multiple residents without proper disinfection, and staff did not change gloves during incontinence care, risking cross-contamination.
A resident with multiple health conditions did not receive a bed hold notice after being hospitalized, as required by the facility's policy. The DON confirmed the absence of a signed notification in the resident's chart, despite the policy stating it should be issued at discharge or within 24 hours.
A resident with dysphagia was found feeding herself in bed at an improper angle, risking choking, due to lack of supervision and inadequate care planning. CNAs were not present to assist, and the care plan lacked necessary swallowing precautions. The facility's policies did not adequately address these needs, and no speech therapy evaluation was available.
The facility failed to manage tube feeding properly for two residents. One resident's feeding was not paused during a tracheostomy change, risking aspiration, while another resident's feeding tube site was not cleaned or dressed as required, leading to redness and drainage. Both residents have complex medical conditions requiring careful nutritional management.
The facility failed to provide adequate respiratory care for two residents. One resident with a tracheostomy did not have a smaller-sized trach tube at the bedside, which is necessary in emergencies. Another resident on oxygen therapy had outdated equipment and lacked oxygen saturation monitoring. The facility's policies on tracheostomy care and oxygen therapy were not properly followed, leading to these deficiencies.
A resident with multiple health conditions did not have an adequate supply of lactulose, leading an LPN to use another resident's medication to complete the dose. This was administered via gastric tube and documented, despite the DON stating that borrowing medication is unsafe and against proper medication administration practices.
Inadequate Notice for Resident Transfers Due to Facility Closure
Penalty
Summary
The facility failed to provide appropriate notice to residents and their representatives prior to transferring them to another facility. This deficiency affected six residents, leading to psychosocial harm, confusion, and distress. The facility informed residents and their families on November 4, 2024, that they had only two to three days to find alternative placements due to the facility's closure. This short notice was contrary to the facility's policy, which requires a 30-day notice for transfers or discharges initiated by the facility. The residents involved had various medical conditions, including Alzheimer's disease, schizoaffective disorder, anoxic brain damage, and cerebral palsy, among others. The abrupt transfer process caused significant emotional distress for the residents and their families. For instance, one resident's sister, who is also her power of attorney, reported that the resident was confused and scared after being moved to a new facility. Another resident's mother expressed distress over the short notice and the distance of the new placement from her home. The facility's administration and staff were informed of the closure by the new owners on November 4, 2024, and were instructed to discharge all residents by November 6, 2024. This rapid turnaround did not allow for adequate preparation or consideration of the residents' emotional and psychological needs. The facility's failure to adhere to its own transfer and discharge policy resulted in a chaotic and distressing experience for the residents and their families.
Medication Administration Failures Lead to Resident Safety Concerns
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of major depressive disorder received her prescribed medication, fluoxetine, which resulted in the resident experiencing suicidal ideation and being sent to a local emergency room for evaluation. The resident, identified as R8, had a history of depression and was supposed to receive an increased dose of fluoxetine from 60 mg to 80 mg daily as per the physician's order. However, due to a pending order status, the staff was unaware of the dose increase, and R8 did not receive the medication for six days. This lapse in medication administration was confirmed by the Director of Nursing, who acknowledged the potential for severe reactions, including increased depression and suicidal thoughts, if medications are not administered as ordered. Another deficiency involved the failure to notify a physician and assess a resident, identified as R21, after holding a blood pressure medication, lisinopril. An LPN, V3, decided to withhold the medication after observing a low blood pressure reading of 99/56, which was lower than the resident's usual range. Despite this, V3 did not perform any further assessment, re-check the blood pressure later, or notify the physician about the held medication. The Director of Nursing confirmed that without specific parameters set by the physician, the nurse should have re-checked the blood pressure, performed an assessment, and informed the physician of the held medication. The facility's Medication Administration Policy requires that physicians and licensed nursing personnel administer drugs and biologicals, and that the physician be notified as soon as practical when a scheduled dose of medication has not been administered. In this case, the LPN failed to document the low blood pressure, the decision to hold the medication, or any follow-up assessments, which was acknowledged by the Director of Nursing as a failure to adhere to the facility's policy.
Deficiency in RN Coverage at Facility
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours, 7 days a week, affecting all residents. The CMS 671 Form indicated that 21 residents were residing in the facility. The CMS PBJ Staffing Data Report for Quarter 2 revealed that the facility had no RN hours during this period. The Director of Nursing (DON) admitted to covering open shifts and call-offs, often working nights instead of days, and acknowledged that there might have been weekends without RN coverage. A review of the facility's monthly working schedule, timecards, and Labor Detail Report showed inconsistencies and confirmed the absence of 8-hour consecutive RN coverage on specific dates, primarily weekends. The Business Office Manager (BOM) noted the payroll system's unreliability, contributing to the confusion in staffing records.
Medication Storage Deficiency
Penalty
Summary
The facility failed to store medications safely and in accordance with professional principles, which could potentially affect all 21 residents. During an inspection, it was observed that a medication cart contained two cephalexin capsules without any resident or pharmacy identifiers, and a bottle of eye drops labeled for a specific resident with an opened date. Additionally, the medication refrigerator was found to have a temperature of 44 degrees, with ice buildup in the freezer section and melted popsicles, indicating improper temperature control. The refrigerator contained bottles of morphine labeled for two residents, along with stock medications such as tubersol, insulin, suppositories, and injectables. The facility's Director of Nursing acknowledged the importance of checking refrigerator temperatures twice daily to prevent damage or efficacy alteration of medications. However, the temperature log had not been completed since a previous date, and there were no complete logs for several months. The facility's policy requires medications to be labeled with specific information and for discontinued or expired medications to be removed from active storage. The failure to adhere to these policies and maintain proper storage conditions led to the deficiency.
Deficiency in Dietary Staff Training
Penalty
Summary
The facility failed to ensure that dietary staff completed the necessary food safety training, affecting all residents in the building. The CMS 671 form indicated that there were 21 residents in the facility. During the survey, the Dietary Manager (V7) acknowledged that two staff members, V8 and V9, alternated between cooking and dietary aide duties. However, V8, who was new to the facility, had not completed her food safety training, and V9's certification had expired. V8 mentioned that she informed the facility during her interview about her expired certification, but the facility had not arranged for her training. The Dietary Manager stated that it was the responsibility of the staff to keep their training up-to-date, and the facility did not pay for training. The Administrator (V1) expected the dietary staff to have current food handler training and indicated that the training could be completed online through the food service contractor's website. However, it was the Dietary Manager's responsibility to ensure that her staff's training and certifications were current. The job descriptions for both the Cook/Dietary Aide and Dietary Aide positions required food handler training within 30 days of employment, which was not adhered to in this case.
Improper Dish Sanitization and Chemical Contamination of Food
Penalty
Summary
The facility failed to ensure proper sanitation of dishes and prevent chemical contamination of food, affecting all residents. During a kitchen tour, the Dietary Manager and Cook/Dietary Aide demonstrated improper use of the dishwasher and 3-compartment sink. The dishwasher was not reaching the required temperature of 135 degrees Fahrenheit, and the chlorine sanitizer level was consistently below the necessary 50-100 PPM, indicating inadequate sanitization of dishes. Despite multiple attempts to rectify the issue, the sanitizer was not being dispensed correctly due to a potential problem with the hose. Additionally, the 3-compartment sink was not set up correctly, with the sanitizer level exceeding the recommended 200 PPM, and there was no designated drying area. The Cook/Dietary Aide failed to submerge the blending container in the sanitizing sink for the required 30 seconds and did not allow it to air dry. This led to sanitizing liquid dripping into the pureed food prepared for residents, which could pose a health risk. The facility's policies for ware-washing and the use of the 3-compartment sink were not followed, resulting in potential chemical contamination of food. The Dietary Manager acknowledged that the sanitizing liquid should not be present in the food and that ingestion could cause nausea. The residents affected by this deficiency were those on pureed diets, specifically identified as R1, R6, and R17.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment, affecting all residents. Observations revealed significant structural issues, including a large hole in the ceiling of the main dining area and another in the activity room, both with plastic tunnels leading to garbage cans. The surrounding ceiling areas showed signs of water damage, such as bubbling and peeling drywall. The roof was in disrepair, with missing or damaged shingles, allowing water to enter the facility. The Maintenance Director, on his first day, acknowledged the leaks and suggested temporary fixes, but the issues had persisted for weeks to months without resolution. Interviews with staff and residents confirmed the prolonged nature of the problem. A CNA reported the holes had been present for weeks to months, and residents expressed concerns about the lack of communication and action from facility management. The Administrator admitted the roof was leaking and required replacement, but no maintenance policy or repair log was in place. An email from the Regional Maintenance indicated that temporary repairs had been made, but permanent solutions were pending. Additionally, a resident with complex medical needs, including a tracheostomy, was found in a room with a dusty fan blowing directly on them. The fan had not been cleaned in a long time due to staffing shortages and unclear responsibilities between housekeeping and maintenance. The resident's care plan highlighted their vulnerability due to multiple health conditions, yet the facility failed to ensure a clean environment, as required by their housekeeping job summary.
Infection Control Deficiencies in Glucometer Use and Hygiene Practices
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices, particularly in the use and cleaning of glucometers. An LPN was observed using a glucometer on multiple residents without adequately cleaning it between uses. The glucometer was loosely wrapped in a white wipe and not wiped with a bleach wipe before or after use, leading to potential cross-contamination. The facility's policy required the glucometer to be cleaned with a germicidal disposable wipe between each resident test, which was not followed. Additionally, the facility failed to maintain proper hand hygiene and G-tube positioning. An LPN was observed using excessive hand sanitizer and wiping it on her scrub pants instead of rubbing it in completely. During the administration of G-tube medications, the LPN placed the feeding tube directly on a resident's gown without a cap, increasing the risk of contamination. The facility's policy required hand sanitizer to be rubbed over all surfaces of the hands until dry and the feeding tube to be kept clean and off the resident. The facility also did not adhere to Enhanced Barrier Precautions (EBP) for residents requiring such measures. Staff were observed providing care to a resident with a tracheostomy without wearing gowns, despite the EBP sign on the resident's door. The facility's policy required gowns and gloves for high-contact care activities, which was not followed. Furthermore, during incontinence care, staff failed to change gloves between tasks, risking contamination. The facility's policy required gloves to be changed after incontinence care and before touching anything else.
Failure to Issue Bed Hold Notice
Penalty
Summary
The facility failed to issue a bed hold notice to a resident who was transferred to a hospital, as required by their policy. The resident, a cognitively intact [AGE] year-old female with multiple diagnoses including major depressive disorder, schizoaffective disorder, bipolar type, generalized anxiety disorder, osteoarthritis, hypertension, type 2 diabetes, and chronic obstructive pulmonary disease, reported not receiving a bed hold notice after her hospitalization. The Director of Nursing confirmed that there was no signed bed hold notification in the resident's chart and acknowledged the importance of issuing such notifications to inform residents of their bed status. The facility's policy mandates that a bed hold notice be given at the time of discharge or within 24 hours, but this was not documented in the resident's medical record.
Failure to Supervise and Position Resident with Dysphagia
Penalty
Summary
The facility failed to ensure proper supervision and positioning for a resident with dysphagia who was on a pureed diet. On the observed date, the resident was found lying in bed with the head of the bed at 45 degrees while feeding herself, which is contrary to the requirement of sitting upright at 90 degrees to prevent choking. The resident expressed awareness that her bed should be higher but continued eating regardless. Certified Nursing Assistants (CNAs) were present in the hallway and not supervising the resident, and upon inquiry, one CNA adjusted the bed to the correct position, acknowledging the resident should be sitting upright to avoid choking. Further investigation revealed that the resident's care plan did not include specific swallowing precautions or positioning needs for eating, despite her history of dysphagia and a stroke. The Dietary Manager confirmed the absence of a speech therapy evaluation and noted issues with therapy services at the facility. The Director of Nursing also confirmed the resident's need to be upright while eating to prevent aspiration. The facility's policies on swallow evaluation and therapeutic diets did not adequately address swallowing or aspiration precautions, contributing to the oversight in the resident's care plan.
Deficiencies in Tube Feeding Management and Site Care
Penalty
Summary
The facility failed to ensure proper management of tube feeding for a resident, R11, during a tracheostomy change. On the morning of September 3, 2024, R11's tube feeding was observed to be infusing at 60 ml per hour while the head of the bed was flat, contrary to aspiration precautions. The Licensed Practical Nurse (LPN) and Respiratory Therapist involved did not pause the tube feeding during the procedure, which is a necessary step to prevent aspiration when the resident's head is not elevated. The Director of Nursing later confirmed that tube feeding should be paused during such care activities. The care plan and physician orders for R11 did not specify the need to keep the head of the bed elevated during tube feeding, contributing to the oversight. Another deficiency was identified with resident R14, whose feeding tube site care was neglected. On September 4, 2024, R14 was found without a dressing at the feeding tube site, which exhibited serous fluid, redness, and a dried, caked substance. The Director of Nursing acknowledged the site was not clean and lacked a dressing, as required by the physician's orders. The LPN admitted to not having cleaned the site, despite a reminder in the medical record to perform this task daily. The care plan for R14 indicated the need for daily cleaning and dressing of the g-tube site, which was not adhered to. Both residents, R11 and R14, have complex medical histories that necessitate careful management of their nutritional needs through tube feeding. R11's conditions include anoxic brain damage, chronic respiratory failure, and cerebral palsy, while R14 has multiple sclerosis and other significant health issues. The facility's failure to follow proper procedures for tube feeding management and site care for these residents highlights a lapse in adhering to established care protocols, potentially compromising their health and safety.
Deficiencies in Respiratory Care for Residents with Tracheostomy and Oxygen Therapy
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents, R11 and R6, who required tracheostomy and oxygen therapy, respectively. For R11, the facility did not have a smaller-sized tracheostomy tube at the bedside, which is crucial in case of an emergency where the current trach might not fit due to swelling. During a trach change, it was observed that only size 6 tracheostomies were available, and the required size 4 was missing. The facility's policy did not specify the need for a smaller trach at the bedside, and R11's care plan lacked details on the trach size, type, and emergency procedures. For R6, the facility did not change the respiratory care equipment weekly as required. The nasal cannula and oxygen humidifier bottle were dated several weeks prior, indicating they had not been changed. Additionally, there was no monitoring of oxygen saturations for R6, who was on as-needed oxygen therapy. The staff, including a Registered Nurse and Certified Nursing Assistants, confirmed that oxygen was used regularly at night and during naps, but no oxygen saturation readings were recorded in September, and the last recorded reading was in early August. The facility's policies on tracheostomy care and oxygen therapy were not adequately followed, leading to deficiencies in the care provided to R11 and R6. The lack of a smaller trach at the bedside for R11 and the failure to change respiratory equipment and monitor oxygen saturations for R6 highlight significant lapses in ensuring safe and appropriate respiratory care for residents.
Inadequate Medication Supply and Improper Administration
Penalty
Summary
The facility failed to maintain an adequate supply of medication for a resident, leading to inappropriate medication administration. A male resident with multiple sclerosis, gastrostomy status, severe sepsis, and major depressive disorder was prescribed lactulose concentrate, 60 ml twice daily. During medication preparation, an LPN discovered that the resident's lactulose bottle was empty and no additional supply was available in the medication cart. The LPN then used another resident's lactulose bottle to complete the dose for the first resident, which was administered via gastric tube. This action was verbally confirmed by the LPN and documented in the medication administration record. The Director of Nursing later stated that borrowing medication from another resident is not acceptable practice, as it is unsafe and does not adhere to the five rights of medication administration.
Latest citations in Illinois
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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