Rock River Health Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Rockford, Illinois.
- Location
- 707 West Riverside Boulevard, Rockford, Illinois 61103
- CMS Provider Number
- 145818
- Inspections on file
- 40
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 17 (1 serious)
Citation history
Health deficiencies cited at Rock River Health Care during CMS and state inspections, most recent first.
A quadriplegic resident, fully dependent for care and assessed as not capable of unsupervised outside pass privileges, was allowed to leave on a community pass with a man described as her boyfriend or ex-boyfriend. Staff helped her prepare to leave, observed her being taken to a city bus stop, and did not send medications or have a physician order authorizing community access. The sign-out documentation was incomplete and illegible, and there were no nursing notes detailing who she left with or her expected return time. When the resident did not return by the usual curfew, staff had inconsistent understandings of any extended return agreement, and there was no clear documentation that law enforcement or family were promptly notified. The resident did not return and was later admitted to an acute care hospital with fluid overload.
A resident with MS, neuromuscular bladder dysfunction, and an indwelling urinary catheter was discharged from the hospital with an order for a urology referral after hospitalization for sepsis due to UTI, but the facility did not ensure the consult occurred. The resident’s POA reported concerns about repeated UTIs and hospitalizations and stated she received no update about the specialist visit. An RN acknowledged that the local urology office did not accept the resident’s insurance and that neither the physician nor the family were informed that the ordered urology evaluation was not completed. The DON confirmed the resident had recurrent UTIs requiring hospitalizations and that the resident should have been referred to a urologist for bladder management and ongoing care.
A resident with MS, contractures, tremors, impaired cognition, impulsivity, psychiatric behaviors, and significant self-care deficits, who was care-planned as dependent in ADLs and requiring a mechanical lift with two staff for all transfers and repositioning, fell over bed side rails during morning care. An LPN reported being called to the room by a CNA who was alone attempting to get the resident up for breakfast, and observed the resident holding the side rails, turning to the side, and then falling over the rails. Facility documentation described the resident as resistant to care, weak, agitated, anxious, with involuntary movements and decreased strength, and the DON confirmed the resident was high fall risk and required two-person assistance for all care, indicating that required supervision and assistance were not provided at the time of the fall.
A resident with ESRD on dialysis, oral cancer, Type 2 DM, and a G-tube experienced significant weight loss after staff failed to obtain accurate and timely weights, did not follow the dietician’s recommendation for weekly weights, and did not notify the dietician or NP of refusals and missed bolus tube feedings. The resident’s tube feeding regimen was changed from continuous to bolus with added PO intake, but no readmission weight or weekly weight was documented as ordered, and multiple missed or refused feedings were not communicated. Later, previously recorded weights were crossed out and replaced with dialysis weights, and the NP reported not being informed of the significant weight loss until much later, all contributing to unaddressed, substantial weight loss.
Surveyors found that the facility did not employ a certified dietary manager as food service director, despite having over 80 residents. The food service director reported not being licensed as a certified dietary manager, having failed the certification exam years earlier and never retaking it, though he completed related college courses. He stated that he conducts initial and quarterly resident assessments, while a contract dietitian handles high-risk assessments. Verification with the national professional association confirmed there were no current certified dietary managers with his last name, and the facility’s own job description required specific education or completion of an approved food service supervision course that aligned with certified dietary manager qualifications.
A dietary aide failed to perform required hand hygiene while working in the kitchen, including after handling a garbage can lid and before handling clean, sanitized pans and other food service items. The aide repeatedly placed hands into a sweatshirt pocket, then performed additional tasks such as retrieving items from a cooler and preparing plastic bags to cover tray carts, without washing hands between tasks. The Food Service Director confirmed that staff are expected to wash hands after touching garbage and when changing tasks, and the facility’s handwashing policy requires handwashing before tasks, after handling garbage, and whenever hands are soiled.
The facility failed to prepare pureed pork to a smooth, pudding-like consistency for several residents on pureed diets. A cook blended cooked pork slices with broth and thickening powder, then served the product even though it remained chunky rather than smooth. When a test tray was evaluated by a surveyor and the Food Service Director, the pureed pork required chewing and was acknowledged as not being an appropriate texture. This did not comply with the facility’s policy requiring pureed foods to be the consistency of pudding or mashed potatoes.
A resident admitted with multiple mental health diagnoses, including schizoaffective disorder, dementia, major depressive disorder, PTSD, and generalized anxiety disorder, had a PASRR report indicating that a Level 2 PASRR evaluation was required. The facility requested the Level 2 evaluation, but it was canceled when the evaluator went to the resident’s previous facility, and there was no evidence that the evaluation was ever completed after admission. This occurred despite the facility’s policy requiring full PASRR materials, including Level 1 and Level 2, to be obtained from referral sources prior to or shortly after admission.
A resident with a diagnosis of bipolar disorder was admitted with a PASRR Level 1 screening that authorized a temporary stay of 60 days or less and required re‑screening by or before the end of that period. The facility’s records showed that no follow‑up PASRR was completed within the required timeframe, and the next available PASRR document was a Level 2 evaluation dated well after the 60‑day approval had expired. The Social Services Director reported that PASRRs are done on admission and after temporary approvals expire, often initiated by hospitals, and that a PASRR 2 is requested when a new mental illness diagnosis occurs, but there was no evidence of a timely re‑screening for this resident.
A resident with Type 2 DM, diabetic retinopathy, and visual impairment was examined by an in-house optometrist who diagnosed bilateral cataracts and directed staff to arrange an appointment with a glaucoma specialist, but no such appointment was scheduled or documented. The resident later reported worsening vision and that no specialist visit had been arranged. The Social Services Director stated she was unaware of the referral, and the Charge Nurse, who is responsible for making outside appointments once notified, reported not receiving any referral. The Administrator acknowledged there was no policy in place for scheduling outside appointments.
The facility did not properly program low air loss mattresses according to resident weights for three residents with existing pressure injuries. Each resident’s care plan identified a pressure-reducing low air loss mattress as an intervention, but there was no documentation that any resident requested a specific mattress setting. Despite recorded weights ranging from about 80 to just over 200 lbs, observations on multiple days showed mattresses set for 350–400 lbs. The wound care nurse confirmed that incorrect, higher weight settings prevent the mattress from effectively reducing pressure, and facility policy and the mattress manual required settings to match the patient’s actual weight.
Surveyors identified a 40% medication error rate when staff failed to follow physician orders and facility policy during a med pass. One resident received chewable aspirin instead of the ordered enteric-coated delayed-release aspirin 81 mg. For another resident, an LPN prepared 11 oral morning meds, left them on the breakfast tray, documented them as given, and left the area without observing the resident take them, even though there was no order for self-administration and the DON stated that staff must observe residents ingest their medications.
Surveyors found that two residents were keeping and using their prescribed medications at the bedside without required physician orders or documented self-administration assessments. One resident with Type 2 DM had opened Novolog and Ozempic pens on the bedside table and reported self-administering due to perceived delays in medication administration. Another resident had a Breo Ellipta inhaler at the bedside, had just used it, and was unsure about post-use instructions, with no related assessment or care plan focus. The DON, an LPN, and facility policies all confirmed that residents must be assessed and have a physician order before self-administering or storing medications at the bedside, which had not been done in these cases.
A resident with COPD experienced discomfort due to room temperatures consistently above 81°F, as confirmed by multiple temperature checks. The facility's air conditioning system was only partially operational, and no portable air conditioner was provided in the resident's room, despite high outdoor heat and the facility's policy to ensure comfort during hot weather.
A resident with a history of seizures did not consistently receive prescribed seizure medications, as evidenced by multiple missed doses and refusals documented in the MAR and discrepancies in medication card counts. Staff interviews revealed inconsistent documentation and re-approach practices, and there was no evidence of required physician notification or grievance documentation regarding the missed doses.
A resident with significant cognitive and physical impairments, including a history of traumatic brain injury and bilateral lower leg amputation, developed two new open areas on the lower buttocks that were not identified or documented by facility staff. Although these wounds were noted by an outside PCP nurse, the facility's records did not reflect the new skin issues, and required assessments and notifications were not completed according to the care plan.
The facility did not maintain or replace CPAP machines and supplies for five residents requiring respiratory care, resulting in the use of old, unclean, or ill-fitting equipment. Care plans and physician orders lacked instructions for CPAP supply replacement, and staff were unaware of appropriate cleaning and replacement schedules. Facility policies did not specify time frames for exchanging CPAP supplies, and supplies were only ordered when requested, contrary to manufacturer guidelines.
Two residents were involved in a physical altercation, resulting in one being kicked and the other sustaining a femur fracture. The incident involved a resident with no cognitive impairment and another with severe cognitive impairment and aggressive behavior. Staff noted the aggressive resident's tendency to become agitated, especially in the evenings, requiring intervention to prevent escalation. Despite the facility's policy to prevent abuse, the altercation occurred, indicating a failure to protect residents.
A facility failed to accurately document medication administration for three residents, resulting in blank spots on their MARs. An LPN admitted to administering the medications but neglected to document them, leading to potential confusion. The residents confirmed receiving their medications, and the facility administrator acknowledged the issue.
A facility failed to ensure staff followed enhanced barrier precautions for a resident with an indwelling urinary catheter. A CNA was observed emptying the catheter drainage bag wearing only gloves, without the required gown and splash guard. The resident was on enhanced barrier precautions due to the catheter and had a history of urinary tract infection. The facility's policy mandates gowns and gloves for high-contact activities, with additional PPE like a face shield when splashes are likely.
A resident with a left tibia and fibula fracture did not receive timely pain management due to the facility's failure to perform a pain assessment and provide prescribed oxycodone. The resident experienced severe pain and returned to the hospital for treatment. The facility's pharmacy delay and lack of available medication contributed to the deficiency.
The facility did not meet the requirement of having an RN on duty for 8 hours daily, affecting all 74 residents. On certain dates, either no RN was present, or the RN worked fewer than the required hours. The DON confirmed these staffing deficiencies, and the facility lacks a waiver for this requirement.
The facility did not follow the prescribed menu and recipe for the noon meal, affecting all 74 residents. The cook prepared a different meal for residents on puree diets and altered the recipe for regular diets by omitting green peppers and not baking the dish. The dietary manager confirmed that the menus and recipes should have been followed, indicating a failure to comply with the facility's policy.
The facility did not ensure controlled substances were double locked as required. An unlocked medication refrigerator was found containing liquid lorazepam, a Schedule IV controlled substance, prescribed to four residents. The DON confirmed the refrigerator should have been locked, violating the facility's policy for storing Schedule II-V medications.
The facility failed to provide residents with appetizing meals at the preferred temperature, with reports of cold food, lack of menu options, and insufficient portions. Residents expressed dissatisfaction with repetitive meals and poor communication about meal options, while an LPN confirmed the absence of steam tables contributed to cold food service.
The facility failed to provide requested milk to six residents during lunch, despite having sufficient milk available. An LPN reported that the kitchen limited milk supply, stating it was only for dinner. The dietary manager confirmed there was plenty of milk and no restrictions, yet the residents did not receive the milk they requested.
A resident was observed wearing ripped pants, causing embarrassment, which violated the facility's dignity policy. The resident, unable to dress himself, was dressed by staff in the torn clothing after a shower. A CNA confirmed the incident, and the DON stated that residents' clothing should be clean and free of holes, as per the facility's policy.
The facility failed to maintain a clean and clutter-free environment in a shower room and a resident's room. The shower room was found with items on the floor, cracked caulk, and a missing drain cover. Another resident's room had a baseboard pulling away, black substance in corners, and stained walls. The facility's policy emphasizes regular cleaning and maintenance, but these were not upheld.
A resident with a stage 4 pressure ulcer did not receive necessary wound care on weekends. The resident reported that the wound nurse provided care five days a week, but the dressing was not changed if it fell off over the weekend. The DON confirmed that the floor nurse was responsible for weekend care, but the MAR showed that wound care was not performed on several weekends.
A resident on a pureed diet due to swallowing difficulties was observed eating inappropriate snack cakes given by another resident, while an LPN did not intervene. The resident's medical condition required a pureed diet, confirmed by staff interviews, but the facility failed to supervise and adhere to dietary restrictions.
The facility failed to monitor a resident while taking medications and did not document medication administration for another resident. An LPN left medications with a resident without ensuring they were taken, and the resident lacked an order to self-administer. Another resident reported missing evening medications, which was confirmed by gaps in the MAR. The DON noted that nurses must sign the MAR when medications are given.
A resident reported the presence of wasps in their room, and black and red bugs were observed on the window over several days. Despite the facility's pest control policy, the maintenance staff was not informed, and the pest control company did not address the issue. The DON confirmed that resident rooms should be free of bugs.
The facility failed to administer and document medications properly for two residents. One resident did not receive a scheduled pain medication dose due to a misplacement in the narcotic overflow storage, and their MAR was blank for two days despite receiving medications. Another resident's MAR was also blank for two days, with the RN admitting to administering but not documenting the medications.
The facility failed to reconcile and administer medications for four residents, leading to missed doses of critical medications. Observations revealed 20 packages of medications that were not given as scheduled. The DON confirmed that the responsible LPN had issues with medication pass responsibilities, and the facility's policies were not followed, resulting in significant lapses in care.
Failure to Safely Manage Community Pass for Dependent Quadriplegic Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure the safety and adequate supervision of a dependent resident during a community pass. The resident was a quadriplegic, paralyzed from the neck down, dependent on staff for all care, and required a mechanical lift for transfers. Her assessments documented extensive care needs, lack of cognitive impairment, and that she was not capable of unsupervised outside pass privileges. A Community Survival Skills assessment indicated she was not sufficiently able to navigate safely in the community, and several items related to self-harmful behavior, adherence to pass policies, and following rules could not be determined. The discharge planning review identified that her physical and mental health problems increased her vulnerability and that she would likely suffer from lack of proper care and could become a victim or perpetrator of abuse/neglect in a less structured setting. Despite these documented limitations, the resident left the facility on a community pass with a male individual described by staff as her boyfriend or ex-boyfriend, who had reportedly just been released from jail or prison. Staff accounts show that earlier in the day the resident repeatedly stated she was going to leave and that her boyfriend was coming to get her. In the evening, after dinner, the man arrived, and staff assisted the resident with putting on her coat and preparing to leave. Staff questioned whether the man understood that the resident was paralyzed from the neck down and required complete care, and he reportedly stated he was aware of her care needs. Staff observed him take her out of the building and wheel her across the street to a city bus stop, and they expressed concern among themselves about who would be caring for her once she left. No medications were sent with her, and there was no physician order in place authorizing community access. The facility’s documentation and communication around the resident’s departure were incomplete and inconsistent. The sign-out sheet at the facility entrance contained an undated sign-out for the resident with an illegible signature for the party accepting responsibility, and the resident’s record contained no notes on the day she left indicating that she was going out on pass, with whom she left, or when she was expected to return. Nursing staff reported varying understandings of curfew expectations, with references to an 8 p.m. return time and an alleged agreement with the Administrator for a midnight return, but there was no clear documentation of these arrangements. When the resident did not return, staff discussed among themselves that she had called saying she would be back by midnight and that if she did not return she should be admitted to a hospital, but there was no indication in the record that law enforcement or family were promptly notified. The Administrator and charge nurse later stated that staff should have contacted the non-emergency police line and family when the resident failed to return, but this was not documented as having occurred. The resident ultimately did not return to the facility and was later admitted to an acute care hospital with a diagnosis including fluid overload.
Removal Plan
- Re-educate all staff on ensuring the safety of a dependent resident during community pass.
- Re-educate all staff on notifying law enforcement when a resident fails to return to the facility at the designated time.
- Re-educate all staff on completing an audit of residents with pass privileges for appropriateness related to resident care needs while out on pass.
- Re-educate all staff on ensuring resident contact information is available prior to going out on pass.
- Re-educate all staff on ensuring residents are aware of expectations for return to the facility.
- Educate new hires on the community pass systems prior to starting on the floor.
- Provide on-the-spot education as needed regarding community pass processes.
- Re-educate staff not present in the facility via phone prior to the beginning of their next shift and obtain signed education sheets.
- Social Services/DON to complete an audit of residents with pass privileges for appropriateness related to resident care needs while out on pass, including an audit of contact information.
- Implement a QAPI audit tool to audit weekly the community survival skills assessment for appropriateness and safety related to care needs while out on pass.
- Implement a weekly audit of residents who sign out on pass to ensure they returned at the designated time or that police were called.
- Implement a weekly audit to ensure resident contact information is available prior to going out on pass.
- Ensure residents are aware of expectations for return to the facility via a resident handout and resident council meeting.
- Implement a weekly audit to verify residents received and understand expectations for return to the facility.
- Analyze audit results and present analysis through QAPI quarterly.
- Conduct a root cause analysis to identify barriers and further education needed.
- Complete an Ad Hoc QAPI to review systems and analyze the root cause analysis.
- Have the QAPI Committee determine whether audits will continue after the initial audit period.
Failure to Obtain Ordered Urology Consult for Resident With Recurrent UTIs
Penalty
Summary
The facility failed to ensure that a resident received a urology consultation as ordered following hospitalization for sepsis due to urinary tract infection (UTI). The resident had multiple sclerosis (MS), neuromuscular dysfunction of the bladder, and required an indwelling urinary catheter due to urinary retention. Hospital records from a stay ending on 12/19/25 documented that the resident was discharged back to the facility with an order for referral to a urologist. The resident’s power of attorney reported concerns about multiple UTIs and hospitalizations and stated that the resident was supposed to see a specialist but that she never received any update from the facility. A registered nurse stated that the local urology office did not accept the resident’s insurance and acknowledged that neither the physician nor the family were notified that the urology consultation ordered on 12/19/25 did not occur. The director of nursing confirmed that the resident had recurrent UTIs requiring hospitalizations and should have been referred to a urologist for bladder management and ongoing care due to these recurrent infections, but this referral and evaluation were not completed.
Failure to Provide Required Two-Person Mechanical Lift Assistance Resulting in Resident Fall
Penalty
Summary
The facility failed to ensure a resident’s safety during care by not providing adequate supervision and assistance during a transfer, resulting in a fall. On 11/21/25, an LPN (V3) reported that while passing morning medications, a CNA (V4) asked her to come to the resident’s (R1’s) room, where R1 was upset and angry as V4 was about to get him up for breakfast. When V3 entered the room, R1 was holding onto the side rails, turned over to his left side, and then fell over the side rails. The LPN stated she did not know why the CNA was alone attempting to get R1 up. R1’s fall incident report documented that R1 turned over too quickly and flipped himself over the side rails, and listed predisposing physiological factors including resistance to care, weakness, agitation, anxiety, involuntary movements, and decreased strength. R1’s care plan, which identified him as at risk for falls related to multiple sclerosis with contractures, tremors, impaired cognition, impulsivity, psychiatric diagnosis with behaviors, and self-care deficits, specified that he was dependent in ADLs, required total assistance with hygiene and dressing, needed two staff for turning and repositioning, and required transfers with a mechanical lift with two staff. The DON (V2) confirmed that R1 was at high risk for falls due to MS and required two staff assistance for all care for safety. The deficiency centers on the facility’s failure to follow the resident’s care plan and provide the required two-person assistance and mechanical lift during transfer activities, as evidenced by the CNA being alone with the resident at the time of the incident and the subsequent fall over the side rails.
Failure to Monitor Tube Feeding, Weights, and Nutrition-Related Changes
Penalty
Summary
The deficiency involves the facility’s failure to obtain accurate and timely weights, follow dietician recommendations for weekly weights, and communicate nutrition-related issues for a cognitively intact resident with a G-tube, end-stage renal disease on dialysis, oral cancer, and Type 2 diabetes. The resident initially received continuous Nephro tube feeding at 40 ml/hr while NPO, then was hospitalized and later readmitted with orders for an oral diet plus bolus tube feedings four times daily. The dietician assessed the resident and documented that tube feeding provided approximately 88% of estimated caloric needs and recommended weekly weights due to changes in diet and tube feeding orders. However, no admission/readmission weight was obtained upon return, and no weight was documented for the week of the dietician’s assessment, contrary to facility policy and the dietician’s recommendation. Weight records showed a documented weight of 135 lbs early in the month, followed by a later documented weight of 101.4 lbs and then 101 lbs, reflecting a significant weight loss over a short period. The dietician stated she was not notified of these weights when they were first recorded and only discovered the 12/5 weight herself in the electronic record the day before the survey, at which point she requested a reweigh. The dietician also reported that she was not informed of the resident’s refusals or missed bolus tube feedings, even though the progress notes and MAR showed at least one documented refusal and multiple missed feedings without documentation of refusal or notification. The resident reported sometimes not receiving tube feedings when feeling too full and specifically stated that tube feedings were not given as supposed to be over a weekend. The restorative nurse later produced a revised weight report in which previously documented weights were crossed out and replaced with weights obtained from dialysis records, acknowledging that the CNAs’ earlier weights could not be verified and that the facility had been unaware of the dialysis weights until the night before. The nurse practitioner stated she was not notified of the resident’s significant and continued weight loss until the day before her exam, despite expectations that staff notify her promptly of excessive weight changes. Based on the combined original and revised weight records, the resident experienced a significant weight loss over a two-month period. These failures to obtain accurate and timely weights, follow ordered/ recommended monitoring, and notify the dietician and nurse practitioner of refusals, missed feedings, and significant weight loss contributed to the resident sustaining significant weight loss.
Lack of Qualified Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a qualified certified dietary manager as the food service director, as required for the food and nutrition service. CMS Form 671 dated 12/8/25 documented that 81 residents resided in the facility. During an interview on 12/8/25 at 9:31 AM, the food service director (V13) stated he was not licensed as a certified dietary manager, explaining that he had taken the relevant courses at a local community college 7 to 8 years earlier, failed the certification exam on his first attempt, and had not retaken it. V13 reported that he completes initial and quarterly assessments of residents, while a contract dietitian performs all assessments on high-risk residents. Course certificates provided by the facility showed that V13 completed coursework in food nutrition therapy, food safety sanitation and human resource management, and management of food service operations, but verification with the Association of Nutrition and Foodservice Professionals showed there were no current certified dietary managers in the nation with V13’s last name. The facility’s job description for the Food Service Supervisor required either a Bachelor of Science degree in Foods and Nutrition from an accredited college or university, or graduation from a qualifying food service supervision course with at least 90 hours of classroom instruction and on-the-job counseling by a dietitian, which V13 did not meet as a certified dietary manager.
Failure to Perform Hand Hygiene During Kitchen Food Service Tasks
Penalty
Summary
The deficiency involves failure to follow hand hygiene requirements in the kitchen during food service operations. Surveyors observed a dietary aide (V14) working in the dishwashing and food preparation areas who handled a garbage can lid, then immediately proceeded to handle clean and sanitized food service equipment without performing hand hygiene. After placing the lid onto the garbage can, V14 did not wash or sanitize their hands before picking up a clean, sanitized food service pan, carrying it to the storage rack, and placing it with other clean pans. During this time, V14 repeatedly placed their hands into the front pocket of a hooded sweatshirt and then removed them to perform additional tasks, still without any handwashing. Surveyors further observed that V14 continued to perform multiple tasks without hand hygiene, including responding to another staff member at the kitchen entrance, opening the cooler door, retrieving an item from the cooler, and handing it to the staff member. V14 then again placed their hands back into the sweatshirt pocket, took three large plastic bags, opened them to prepare for covering tray carts during service, and again returned their hands to the sweatshirt pocket, all without washing hands. The Food Service Director (V13) stated that kitchen staff are expected to wash their hands after touching the garbage can or lid and when completing different tasks. The facility’s kitchen handwashing policy dated 9/21/23 requires employees to wash hands before starting any task, after touching hair, face, or body, after taking out the garbage, and anytime hands are soiled.
Improper Preparation of Pureed Pork Resulting in Inappropriate Texture
Penalty
Summary
The facility failed to ensure pureed pork was prepared to a smooth, pudding-like consistency for four residents on pureed diets, resulting in food that was chunky and required chewing. A facility diet report dated 12/8/25 showed that four residents were ordered pureed diets. On that date at 11:45 AM, a cook (V15) removed a pot from the stove containing seven servings of pork slices cooked in chicken broth, placed all pork slices into a blender pitcher, and added additional chicken broth to puree. At 11:48 AM, V15 added thickening powder to the pureed pork, and by 11:52 AM had finished blending and transferred the product to a food service pan. The finished pureed pork appeared chunky and not smooth, despite V15 stating that pureed foods should have a pudding-like consistency and not be too thick or too runny. At 1:00 PM, a surveyor and the Food Service Director (V13) tested a pureed test tray and found the pureed pork was not smooth and required chewing; V13 acknowledged it could have been cooked longer, blended longer, or made thinner to be easier to swallow and that it was not an appropriate texture. The facility’s Pureed Food Preparation policy dated 9/26/23 states that pureed food must be the consistency of pudding or mashed potatoes, which was not met in this instance.
Failure to Ensure Completion of Required Level 2 PASRR Evaluation
Penalty
Summary
The facility failed to ensure completion of a required Level 2 Preadmission Screening and Resident Review (PASRR) evaluation for a resident admitted with known mental illness. The resident’s Facesheet documented an admission with multiple psychiatric diagnoses, including schizoaffective disorder, dementia, major depressive disorder, post-traumatic stress disorder, and generalized anxiety disorder. A PASRR report dated 10/2/24 indicated that a Level 2 PASRR evaluation was required for this resident, but the facility was unable to provide evidence that this Level 2 evaluation was ever completed. During an interview on 12/10/25, the Restorative Nurse stated that the facility had requested a Level 2 evaluation for the resident, but the evaluation was canceled when the evaluator went to the resident’s previous facility to conduct it. Despite this cancellation, there was no documentation showing that the Level 2 PASRR evaluation was subsequently completed after the resident’s admission. This failure occurred despite the facility’s own PASRR policy stating that it would request full and complete PASRR materials, including Level 1 and Level 2, from each referral source prior to or soon after admission.
Failure to Complete Timely PASRR Re-Screening for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure timely resubmission of a Level 1 Preadmission Screening and Resident Review (PASRR) evaluation before the expiration of a 60‑day approval period for one resident with a mental health diagnosis. The resident’s facesheet showed admission with a diagnosis of bipolar disorder. A PASRR Level 1 screening dated 1/24/24 authorized a nursing facility stay of 60 days or less and explicitly required that a re‑screening be performed by or before the end of that 60‑day period. However, the next PASRR document available in the record was a Level 2 evaluation dated 2/26/25, which was completed well beyond the 60‑day timeframe specified in the initial Level 1 approval. During an interview, the Social Services Director stated that PASRR is completed on admission and after a temporary approval expires, that hospitals usually complete the 30‑ or 60‑day temporary assessments, and that a new PASRR 2 is requested when there is a new mental illness diagnosis, but there was no evidence that a timely re‑screening occurred within the required 60 days for this resident. This deficiency centers on the lapse between the expiration of the resident’s 60‑day PASRR Level 1 approval and the subsequent PASRR Level 2 evaluation, with no documented re‑screening by or before the required deadline.
Failure to Schedule Specialist Eye Appointment After Optometrist Referral
Penalty
Summary
The deficiency involves the facility’s failure to schedule a specialist appointment as ordered and indicated for a visually impaired resident with Type 2 Diabetes Mellitus and diabetic retinopathy. The resident’s care plan dated 6/27/25 documented visual impairment related to these diagnoses. On 11/24/25, an in-house optometrist examined the resident and diagnosed bilateral cataracts, documenting that facility staff were to make an appointment with a glaucoma specialist. Subsequent review of the physician order report printed 12/9/25 showed no scheduled appointment with an optometrist specializing in glaucoma, and progress notes from 11/24/25 through 12/8/25 contained no documentation that such an appointment had been scheduled. During an interview on 12/8/25, the resident reported that vision had significantly worsened over the past six months and stated that although an eye doctor had recommended seeing a specialist for cataracts or glaucoma, no appointment had been made. On 12/9/25, the Social Services Director stated she was not aware of the referral from the in-house optometrist. The Charge Nurse, who reported being responsible for making outside appointments once notified, stated she had not received a referral from the Social Services Director and was unaware of the need for a glaucoma specialist appointment. On 12/10/25, the Administrator stated the facility did not have a policy on scheduling outside appointments for residents.
Improper Programming of Low Air Loss Mattresses for Residents With Pressure Injuries
Penalty
Summary
The facility failed to ensure low air loss mattresses were correctly programmed according to residents' weights for multiple residents with pressure injuries. One resident with a Stage 4 pressure injury to the coccyx had a care plan listing a pressure-reducing low air loss mattress as an intervention, with no documentation that the resident requested a specific mattress setting. The resident’s recorded weight was 101 lbs, yet observations on two consecutive days showed the mattress programmed for a 350-lb setting. Another resident with a Stage 4 pressure injury to the medial right knee also had a care plan including a low air loss mattress, with no documentation of any resident request for a specific setting. This resident weighed 81.4 lbs, but observations on two days showed the mattress programmed for a 400-lb setting. A third resident with pressure injuries to the left ischium and coccyx had a care plan that included a low air loss mattress as a pressure-relieving intervention, again without documentation that the resident requested a specific setting. This resident weighed 205.3 lbs, but observations on two days showed the mattress programmed for a 400-lb setting. The wound care nurse stated that low air loss mattresses should be programmed to the correct resident weight so the mattress can help heal or prevent pressure injuries, and that if the weight is set too high, the mattress will not reduce pressure to wound areas and can impede wound healing. The facility’s pressure injury prevention policy required following the manufacturer’s instructions for low air loss mattress use, and the operator’s manual directed staff to determine the patient’s weight and set the control knob to that weight setting.
Failure to Administer Medications as Ordered and to Observe Ingestion
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered as ordered by the physician and in accordance with facility policy, resulting in a medication error rate of 40% (12 errors out of 30 opportunities) during a medication pass observation. For one resident, a registered nurse prepared and administered a chewable aspirin 81 mg tablet in the morning, despite the physician’s order specifying aspirin enteric coated delayed-release 81 mg once daily for heart health. The Director of Nursing later confirmed that chewable aspirin should not be given when the order is for enteric-coated aspirin. For another resident, an LPN prepared 11 oral morning medications and placed the medication cup on the resident’s breakfast tray while the resident was seated in a chair with breakfast at the overbed table. The LPN then administered the resident’s insulin, left the room, documented the medications as administered in the computer, and moved the medication cart to another area of the building without observing the resident take the medications. Several minutes later, the medications remained on the breakfast tray, and the resident stated she needed to eat before taking them. There was no physician order authorizing this resident to self-administer medications. The Director of Nursing stated that a complete medication pass includes preparing medications, bringing them to the resident, and watching the resident take them, and that medications should not be left at the bedside for residents to take on their own. The facility’s policy requires medications to be administered per physician orders with verification of the right medication, dose, route, time, and resident identity.
Failure to Secure Medications and Assess Residents for Self-Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were securely stored and that residents did not self-administer medications without appropriate physician orders and assessments. One resident with Type 2 Diabetes Mellitus had active orders for Novolog insulin and Ozempic, but no physician order permitting self-administration or in-room medication storage. Surveyors observed this resident seated in bed with opened and partially used Novolog and Ozempic pens on the bedside table on two consecutive days. The resident stated he kept the medications at his bedside and administered them himself because he felt his medications were sometimes given late. The DON confirmed that residents are not permitted to have medications in their rooms or self-administer unless there is a physician order and an assessment confirming it is safe, and the Administrator confirmed that no self-administration assessment had been completed for this resident. A second resident had an order for Breo Ellipta inhalation aerosol powder, to be taken once daily with instructions to rinse the mouth and spit after use, but there was no order for self-administration or in-room storage. Surveyors observed this resident sitting on the side of the bed with the Breo inhaler on the bedside table; the resident reported having just used it and was unsure if anything needed to be done after taking the medication. The medical record contained no self-administration assessments, and the resident’s care plan did not address any desire or attempts to self-administer medications. An LPN stated that residents who self-administer must be assessed and have an order. Facility policies on administering medications and self-administration specified that medications may only be self-administered upon assessment and physician order, and that bedside storage is not permitted unless the resident has been assessed and found safe to do so, which had not occurred for these residents.
Failure to Maintain Comfortable Room Temperature for Resident
Penalty
Summary
The facility failed to maintain a comfortable temperature in a resident's room, resulting in the room temperature remaining above 81 degrees Fahrenheit for several hours. The resident, who had a diagnosis of chronic obstructive pulmonary disease and intact mental status, reported feeling uncomfortably hot for several days. Multiple temperature checks by both the surveyor and the facility administrator confirmed that the room temperature and the air coming from the wall air conditioner were consistently above 81 degrees Fahrenheit. The room did not have a portable air conditioner, and the built-in unit was not effectively cooling the space. The administrator stated that two out of four compressors for the facility's air conditioning system were not working, causing the system to operate at only 50% capacity. The facility was awaiting parts to repair or replace the compressors and was using portable air conditioning units in some areas to help maintain comfort. However, a portable unit was not present in the affected resident's room. The outside heat index was forecasted to be 104 degrees Fahrenheit on the day of the observations. The facility's policy indicated a commitment to ensuring resident comfort during hot weather.
Failure to Ensure Consistent Administration of Seizure Medications
Penalty
Summary
A resident with a history of post-traumatic seizures, COPD, major depressive disorder, anxiety, and traumatic brain injury experienced a significant medication error related to the administration of seizure medications. On the morning of the incident, the resident exhibited unusual behavior by requesting to return to bed after breakfast, which was not typical for him. Shortly after being transferred to bed, the resident began experiencing seizure activity, prompting staff to call emergency services. Review of the resident's medication administration records (MAR) for June and July revealed multiple missed doses and refusals of prescribed seizure medications, including Phenytoin, Divalproex, Levetiracetam, and Aptiom. The medication cards also showed discrepancies between the number of tablets dispensed and those remaining, indicating that several doses were not administered as ordered. Interviews with nursing staff confirmed that the resident could be non-compliant with medication administration depending on his mood, and that staff would attempt to re-approach him if he initially refused. However, documentation practices were inconsistent, with staff acknowledging that if a medication was not signed off in the MAR, it was not given. The facility's policy required physician notification if three consecutive doses or a pattern of frequent refusals occurred, but there was no documentation of such notifications or grievances related to the resident's medication administration. The failure to ensure consistent administration and documentation of seizure medications resulted in a significant medication error for the resident.
Failure to Identify and Document New Pressure Ulcers in High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to identify and document new skin alterations for a resident at risk for developing pressure wounds. The resident, a cognitively impaired male with a history of traumatic brain injury, bilateral lower leg amputation, lack of coordination, and unspecified dementia, was dependent on staff for most activities of daily living. During a skin check performed by the DON, two open areas were found on the resident's lower buttocks, both over previously healed pressure wounds. These areas were not listed on the facility's current list of residents with pressure wounds, and there was no documentation in the medical record of new skin assessments, orders, or progress notes related to these open areas. The resident had recently attended an appointment with a new primary care provider, during which two open areas were also identified by the provider's office nurse. However, the facility's records, including a shower sheet from the same day, only noted discoloration on the buttocks and did not document any open areas. The resident's care plan required daily and weekly skin checks, with instructions to notify the charge nurse of any new skin issues for further assessment and treatment. Despite these protocols, the new skin alterations were not promptly identified or communicated, resulting in a failure to provide appropriate pressure ulcer care and prevention.
Failure to Maintain and Replace CPAP Supplies for Residents
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care by not maintaining or replacing CPAP machines and supplies for all five residents reviewed who required respiratory treatments. Observations revealed that residents were using old or unclean CPAP masks, tubing, and water tanks, with some equipment showing visible signs of wear, discoloration, or contamination. Residents reported that they had not received new supplies since admission, and some had to clean their own equipment with tap water, while others stopped using their CPAP machines due to ill-fitting masks provided by the facility. Record reviews showed that care plans and physician orders did not include specific instructions or time frames for replacing CPAP supplies. In several cases, there were no orders for CPAP devices or supplies at all, and care plans lacked any focus on respiratory device use. Staff interviews indicated a lack of knowledge regarding the appropriate cleaning and replacement schedule for CPAP equipment, and the facility's policies did not specify time frames for exchanging supplies. The infection control policy referenced the need to prevent and control infections but did not address CPAP supply management. The third-party medical equipment company's replacement schedule recommended regular replacement of masks, tubing, and water chambers, but this guidance was not reflected in facility practice or policy. Interviews with clinical staff, including nurse practitioners and the infection control preventionist, confirmed that supplies should be exchanged according to manufacturer guidelines to reduce infection risk, but acknowledged that this was not being done. The administrator stated that supplies were only ordered when requested by residents or staff, and was unaware of recommended replacement intervals.
Failure to Prevent Resident Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse, resulting in one resident being kicked in the genitals and another being pushed to the ground, sustaining a fracture of the left femur. Resident 1, who has no cognitive impairment, was involved in an altercation with Resident 2, who has severe cognitive impairment and exhibits hallucinations and delusions. The incident occurred after Resident 2, who is known to become verbally aggressive and agitated, allegedly kicked Resident 1, prompting Resident 1 to push Resident 2, causing him to fall and fracture his femur. Staff interviews revealed that Resident 2 often becomes confused and aggressive, particularly in the evenings, and requires intervention to prevent escalation. On the day of the incident, staff heard yelling and found Resident 2 on the floor in pain, while Resident 1 claimed he acted in reaction to being kicked. The facility's policy emphasizes the residents' right to be free from abuse, yet the staff's inability to prevent the altercation indicates a failure to adhere to this policy.
Medication Administration Record Documentation Failure
Penalty
Summary
The facility failed to ensure the accuracy of medication administration records (MAR) for three residents, leading to blank spots on their MARs for specific dates. Resident 1's MAR had blank spots for multiple medications on two consecutive days, although the resident recalled receiving the medications. Resident 2's MAR also showed blank spots for the same dates, despite documentation indicating receipt of a controlled drug and the resident's confirmation of receiving medications. Resident 3's MAR had a blank spot for one day, with the resident confirming medication receipt. All three residents had varying mental statuses, with two being intact and one moderately impaired. The deficiency was attributed to a Licensed Practical Nurse (LPN) who admitted to administering the medications but failing to document them on the MAR. A Registered Nurse (RN) emphasized the importance of documenting medication administration as proof of delivery, noting that blank spots could cause confusion. The facility administrator acknowledged that blank spots on a MAR suggest that medications were not given, highlighting the critical nature of accurate documentation in medication administration.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff adhered to enhanced barrier precautions when providing care to a resident with an indwelling urinary catheter. Specifically, a Certified Nursing Assistant (CNA) was observed emptying the urinary catheter drainage bag of a resident without wearing the required personal protective equipment (PPE). The CNA was only wearing gloves and did not have on a gown or a splash guard, which are mandated by the facility's Enhanced Barrier Precautions policy for high-contact activities involving indwelling medical devices. The resident in question was on enhanced barrier precautions due to the presence of an indwelling urinary catheter and had a history of receiving antibiotics for a urinary tract infection, as noted in the December 2024 infection control log. The facility's policy, revised in August 2024, clearly states that gowns and gloves are the minimum PPE required during high-contact activities, with additional PPE such as a face shield recommended when there is a risk of splashes. The Infection Control Nurse confirmed that the staff should have worn gloves, a gown, and a splash guard when emptying the catheter drainage bag.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to perform a pain assessment and provide appropriate pain management for a resident admitted with a left tibia and fibula fracture. Upon admission, the resident did not receive her prescribed pain medication, oxycodone, as the facility's pharmacy was located two hours away, and the medication had not arrived. The resident reported severe pain, rated 10/10, and was not provided with the prescribed medication, leading to her return to the hospital for pain management. The facility had hydrocodone/acetaminophen available, but it was not administered until after the resident's hospital visit, despite the resident's report that it was less effective than oxycodone. The resident's pain assessment was not completed upon admission, and the first recorded pain assessment showed severe pain the following day. The Nurse Practitioner was aware of the situation and had written prescriptions for both hydrocodone/acetaminophen and oxycodone, but the facility did not have the oxycodone on hand. The resident's pain was not adequately managed, resulting in her request for emergency room transport due to uncontrolled pain. The facility's delay in obtaining and administering the appropriate pain medication contributed to the resident's distress and need for additional medical intervention.
Failure to Maintain RN Staffing Requirements
Penalty
Summary
The facility failed to comply with the requirement of having a Registered Nurse (RN) on duty for at least 8 hours per day, 7 days a week, affecting all 74 residents. The CMS-671 application confirmed the presence of 74 residents in the facility. On specific dates, including April 28, June 2, and October 6, 2024, the facility's daily assignment sheets revealed that there was either no RN present or the RN was present for less than the required 8 hours. Specifically, on April 28, 2024, an RN was only present from 7:00 AM to 11:00 AM, totaling 4 hours. On June 2 and October 6, 2024, there were no RNs working at all. The Director of Nursing (DON) confirmed these findings and acknowledged the failure to meet the staffing requirement. The facility's policy, dated January 2024, mandates the presence of an RN for at least 8 consecutive hours daily, which was not adhered to, and the facility does not have a waiver for this requirement.
Failure to Follow Prescribed Menu and Recipe for Noon Meal
Penalty
Summary
The facility failed to adhere to the prescribed menu and recipe for the noon meal, affecting all 74 residents. On October 7, 2024, the facility's menu specified cheesy chicken baked penne, Italian blend vegetables, and mandarin oranges for the noon meal. However, the cook prepared a different meal for residents on puree diets, consisting of chicken, noodles, and broth, along with pureed carrots, instead of the specified menu items. For residents on regular diets, the cook served penne pasta in a red sauce with chicken, onion, and some cheese, but omitted green peppers due to unavailability and did not bake the dish as required by the recipe. The facility's standardized recipes, dated October 2, 2023, mandate that all recipes be followed as written to ensure consistent quality, portion size, and cost control. The dietary manager acknowledged that the menus and recipes should have been followed for all meals. The discrepancy between the prepared meals and the standardized recipes indicates a failure to comply with the facility's policy, resulting in a deficiency in meeting the nutritional needs of the residents as outlined in the menu.
Failure to Double Lock Controlled Substances
Penalty
Summary
The facility failed to ensure that controlled substances were double locked, as required by their medication storage policy. During an observation on October 7, 2024, at 10:09 AM, it was noted that the medication refrigerator in the second-floor medication room was unlocked, with the lock placed on top of the refrigerator. This refrigerator contained liquid lorazepam, a Schedule IV controlled substance, prescribed to four residents. The Director of Nursing acknowledged that the refrigerator should have been locked. The facility's policy mandates that Schedule II-V medications must be stored in separately locked, permanently affixed compartments, which was not adhered to in this instance.
Deficiency in Meal Quality and Service
Penalty
Summary
The facility failed to provide residents with meals that were appetizing, appealing, and served at the preferred temperature. Multiple residents reported dissatisfaction with the food, noting that hot items were served cold and cold items were warm. There was a lack of menu options and alternatives, with some residents expressing frustration over the inability to request substitutions or receive meals that accommodated their dietary preferences or restrictions. For instance, a resident allergic to pork was only offered peanut butter and jelly as an alternative, while another resident who preferred vegetables over meat found the vegetables too poorly cooked to consume. Additionally, the facility's food service practices contributed to the deficiency. Residents reported receiving repetitive meals with little variety, and the portions were often insufficient, leaving them hungry. The absence of steam tables, which were previously used to keep food warm, resulted in meals being served cold, as confirmed by an LPN. The lack of communication about meal options and the inability to provide requested items further exacerbated the residents' dissatisfaction with the dining experience.
Failure to Provide Requested Drinks to Residents
Penalty
Summary
The facility failed to provide requested drinks to six residents during their noon meal, despite having sufficient milk available. On the specified date, six residents requested milk, but the facility only provided milk to five residents, citing a kitchen policy that milk was not for lunch, only dinner. The LPN confirmed that the kitchen staff limited the milk supply to five, despite the dietary manager stating there was plenty of milk available and no restrictions on providing it. The residents' diet orders allowed for thin liquids with no dairy restrictions, yet they did not receive the milk they requested.
Resident Dressed in Ripped Clothing, Violating Dignity Policy
Penalty
Summary
The facility failed to dress a resident, identified as R2, in a dignified manner, which is a violation of the resident's rights to dignity and self-determination. On October 7, 2024, R2 was observed sitting in a wheelchair near the nursing station wearing pants with a 4-5 inch rip on the left inner thigh and a 2-inch rip on the right inner thigh. R2 expressed embarrassment about the condition of his pants. A Certified Nursing Assistant (CNA), identified as V7, confirmed that R2 was dressed by facility staff in the ripped pants after receiving a shower that morning. V7 stated that R2 is unable to dress himself and requires moderate to maximum assistance with dressing and grooming tasks, as noted in his current care plan. The Director of Nursing (DON), identified as V2, stated that residents' clothing should be clean, well-kept, comfortable, and free of holes, in accordance with the facility's dignity policy dated January 2023.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and clutter-free environment in the shower room on the second floor, as observed on October 7, 2024. A resident reported the shower room was dirty and cluttered, which was confirmed by observations that included a towel and a pink basin on the floor, a razor face down in the corner, a rolled-up blue gown on the floor, cracked or peeling caulk, and a missing drain cover. The Director of Nursing acknowledged that the shower room should be organized, clutter-free, and clean, with no towels on the floor or old clothing present. Additionally, another resident's room was found to be dirty and in need of repairs. The baseboard was pulling away from the wall, and there was a black substance lining the corners of the room and baseboard. The wall appeared heavily stained with spilled liquids. The resident mentioned that cleaning was infrequent, and the room had been in this condition for a long time. The Administrator and Maintenance Director stated that they wait for rooms to become empty before conducting repairs. The facility's policy on maintaining a safe, clean, and comfortable homelike environment was not dated but emphasized regular cleaning, preventative maintenance, and timely repairs.
Failure to Provide Weekend Wound Care
Penalty
Summary
The facility failed to provide adequate wound care for a resident with a stage 4 pressure ulcer on the weekend shift. The resident, who had a wound on the left upper buttocks, reported that the wound nurse attended to the dressing five days a week, but if the dressing fell off over the weekend, it was not changed by the floor nurse. The Director of Nursing confirmed that wound care was documented in the Medication Administration Record (MAR) and that the floor nurse was responsible for dressing changes on weekends. However, the MAR for September 2024 showed empty boxes indicating that wound care was not performed on several weekends, specifically on Saturday 09/07/24, Sunday 09/08/24, Sunday 09/15/24, Saturday 09/21/24, and Sunday 09/22/24.
Failure to Supervise Resident on Pureed Diet
Penalty
Summary
The facility failed to adequately supervise residents to prevent a resident on a specialized diet from consuming inappropriate food. A resident, identified as R38, who was on a pureed diet due to swallowing difficulties, was observed eating snack cakes with a doughnut-like consistency. This occurred while an LPN was present but did not intervene or express concern. The resident reported that another male resident had given her the snack cakes. R38's medical records indicated she was placed on a pureed diet due to issues with swallowing and phlegm in her throat, which had previously necessitated an emergency room visit. Interviews with facility staff, including an LPN, a dietitian, and a speech therapist, confirmed that R38 was on a pureed diet due to her medical condition, which included spinal stenosis and difficulty swallowing. The dietitian and speech therapist both acknowledged that the snack cakes were not suitable for R38's diet. The facility's documentation on pureed diets indicated that cake consistency desserts should be soaked in milk, which was not done in this case, further highlighting the lack of supervision and adherence to dietary restrictions.
Medication Administration and Monitoring Deficiencies
Penalty
Summary
The facility failed to properly monitor a resident while taking medications and did not document the administration of medications for another resident. In the first instance, a Licensed Practical Nurse (LPN) was observed administering morning medications to a resident by placing them in a cup and leaving them on the resident's meal tray without ensuring the medications were taken. The LPN left the room without monitoring the resident, who did not have an order to self-administer medications. The Director of Nursing confirmed that residents should be observed while taking medications unless they have a physician's order to self-administer, which this resident did not have. In the second instance, a resident reported not receiving their evening medications on specific dates. The Medication Administration Record (MAR) confirmed that several medications, including those for hypertension, edema, and diabetic polyneuropathy, were not documented as administered on multiple occasions. The Director of Nursing stated that nurses are required to sign the MAR when medications are provided, indicating a failure in documentation and potentially in medication administration for this resident.
Failure to Address Pest Issue in Resident's Room
Penalty
Summary
The facility failed to maintain a resident's room free of pests, specifically bugs, as observed in the case of one resident. On multiple occasions, black and red bugs were observed on the interior portion of the resident's room window. The resident reported the presence of wasps to an LPN, but the issue was not addressed promptly. The Director of Nursing acknowledged that resident rooms should not have bugs. However, the maintenance staff was not informed of the pest issue in the resident's room, and the pest control company present on-site did not address this specific room. The facility's pest control policy requires employees to report pest observations to their department heads, which was not followed in this instance.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure that a resident received their scheduled pain medication and did not document the administration of medications on the Medication Administration Record (MAR) for two of the three residents reviewed. One resident, identified as R3, did not receive a scheduled dose of hydrocodone-acetaminophen because the medication was reportedly unavailable. The Licensed Practical Nurse (LPN) responsible for R3's care on the night in question stated that the medication was not included in the pharmacy delivery and was later found in the narcotic overflow storage area. Additionally, R3's MAR was blank for two days, although the resident confirmed receiving all medications, and the Controlled Drug Receipt indicated the medications were administered. Another resident, R1, had blank entries on their MAR for two separate days, despite the resident confirming receipt of all medications. The Registered Nurse (RN) responsible for R1's care admitted to administering the medications but failing to document them on the MAR. The facility's policy requires that medications be checked off on the MAR as given or indicate why they were not given, which was not adhered to in these instances.
Failure to Reconcile and Administer Medications
Penalty
Summary
The facility failed to ensure medications were reconciled for four residents, leading to missed doses of critical medications. On 5/21/24, a surveyor observed 20 individual packages of various medications in the second-floor medication room that were supposed to be administered on 5/12/24. The medications included seizure prevention drugs, antidepressants, and other essential medications. Licensed Practical Nurse (LPN) V6 confirmed that these medications should have been given at bedtime on 5/12/24 but were not. Resident R2 reported not receiving his seizure medications on multiple occasions, while R3, R4, and R5 also had medications that were not signed off as given on the same date. R5 had already been discharged and was unavailable for an interview. None of the residents' care plans indicated any refusals of medications, suggesting that the medications were simply not administered as required. The Director of Nursing (DON), V2, verified that LPN V5 was responsible for administering the evening and bedtime medications on 5/12/24. V2 acknowledged receiving a report from RN V4 on 5/13/24 about the medications still in the cart. V2 contacted V5, who admitted to possibly missing a few medications but claimed to have passed most of them. V2 also noted that V5 was new to the facility and had issues understanding her medication pass responsibilities. V4, who followed V5 on 5/13/24, confirmed finding numerous medications still in the cart from the previous evening and reported the incident to V2. V4 also mentioned that duplicate medications were not a factor in this case, as the pharmacy had not sent any duplicates for these 20 residents. The facility's policies and procedures require that medications be signed off in the Medication Administration Record (MAR) immediately after administration. However, V2 admitted that there were ongoing issues with nurses not signing off medications in the MAR, particularly with V5. The facility's pharmacy director, V11, confirmed that no duplicate medications were sent for the 20 residents in question. Despite the facility's policy and the pharmacy's procedures, the failure to administer and sign off medications as required led to significant lapses in care for the affected residents.
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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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