Sandwich Living & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sandwich, Illinois.
- Location
- 902 East Arnold Street, Sandwich, Illinois 60548
- CMS Provider Number
- 146133
- Inspections on file
- 30
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Sandwich Living & Rehab Center during CMS and state inspections, most recent first.
A resident with dementia, neuromuscular bladder dysfunction, a chronic indwelling urinary catheter, and a history of UTIs did not receive catheter care in accordance with facility policy and orders. During observed care, a CNA cleaned stool from the resident’s buttocks and then, without hand hygiene, glove change, or fresh water, used the same basins to cleanse the catheter tubing from the urethra downward. The DON later confirmed that staff are expected to change gloves, water, and equipment when stool is present, consistent with the facility’s catheter care policy, but this was not followed during the observed episode.
A resident with multiple health conditions and moderate cognitive impairment fell in the dining room after tripping on puckered laminate flooring and a sticky substance along floor seams. The unsafe floor condition, which included lifted seams and floor glue, had been reported by residents and observed by staff for at least a month without adequate repair, despite facility policy requiring prompt attention to hazards.
The facility did not maintain the dining room floor in a safe condition, resulting in puckered laminate seams, sticky glue patches, and exposed nails that created tripping hazards. Multiple ambulatory residents and staff reported incidents of tripping or getting caught on the floor, and at least one resident witnessed a fall. The Maintenance Director and staff acknowledged ongoing issues with the floor installation and repeated, unsuccessful attempts to repair it.
The facility failed to identify and manage a resident's heel wound, which developed into a deep tissue injury, and did not conduct required weekly wound assessments for another resident with a stage 4 pressure ulcer. Despite physician orders and facility policies mandating regular assessments, the facility did not update care plans or document interventions, increasing the risk of infection and delayed healing.
A resident with a history of cerebral infarction, Parkinson's disease, and dysphagia experienced a 7.98% weight loss over one month due to the facility's failure to implement dietary recommendations and monitor weight as ordered. Despite being provided with a pureed meal and nutritional supplements, the resident did not receive necessary assistance or cueing during meals, and there was a lack of documentation and follow-up on dietary interventions.
Two residents experienced discomfort during breakfast due to cold air entering the dining room when a resident opened patio doors to fill bird feeders. Staff did not intervene to close the doors, and the RN was busy with medication distribution. The Administrator was unaware of the situation and expressed concerns about safety and staff inaction.
The facility failed to safely transfer a resident requiring a mechanical lift, as CNAs were unaware of the updated transfer requirement due to an outdated electronic medical record. Additionally, a resident using smoking tobacco was not reassessed for smoking safety as per facility policy, indicating a lapse in adherence to safety protocols.
A resident with an indwelling catheter was observed with the drainage bag resting on the floor, and the tube uncovered and touching the floor. CNAs and the DON confirmed that the bag should not be on the floor due to infection risks and should be in a dignity bag.
A resident with multiple sclerosis and neuromuscular dysfunction of the bladder was discharged from the ER with an order for cefpodoxime to start immediately. The facility delayed inputting the order and administering the medication until the following day. The DON confirmed the importance of timely antibiotic administration, especially given the resident's susceptibility to sepsis. No documentation was found of pharmacy or physician notification regarding the delay.
A medication error rate of 8% was identified when an RN failed to administer pantoprazole and polyethylene glycol as ordered to a resident with alcoholic hepatitis and cirrhosis. The facility's policy requires verification of medication administration records against physician orders, which was not followed.
A facility failed to use the current EHR for medication administration, resulting in errors. An RN used an outdated MAR due to lack of training on the new system, leading to missed medications for residents. Despite the presence of an LPN to assist with the new EHR, the RN continued using the old system, causing discrepancies between the MAR and physician orders.
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents, leading to deficiencies in infection control. A resident with a stage 4 pressure injury and catheter, another with an indwelling catheter, and a third with a heel wound did not have EBP signage or PPE available. Staff were unaware of the need for EBP, and the Director of Nursing was not informed of the requirements, resulting in a lack of appropriate precautions.
A resident with a history of verbal aggression was punched by another resident with dementia, following ongoing antagonistic behavior. Despite staff awareness of the conflict, the facility failed to prevent the altercation, resulting in physical abuse.
A resident with severe cognitive impairment experienced significant weight fluctuations and a change in Lasix dosage without the Healthcare Power of Attorney (HPOA) being notified. The facility's staff failed to communicate these changes, despite policy requirements for prompt notification of significant changes in a resident's condition.
A resident's new wound on the right shin was not assessed or reported to the physician in a timely manner. The wound, first observed by the resident's HPOA, was not documented or treated according to the facility's policy. The DON confirmed that an assessment should have been conducted upon initial identification, but this was delayed by three days.
The facility failed to perform weekly pressure wound assessments for two residents, as required by their policy. The DON stated that assessments should occur weekly, alternating between the wound care physician and the evening shift nurse. However, assessments were missing for a resident with a stage III pressure injury and another with an open heel wound. The facility lacked electronic reminders, relying on signs at the nurses' station, leading to incomplete documentation.
A facility failed to prevent residents from smoking inside and did not adequately supervise residents at risk for elopement. One resident, with a history of substance abuse, was found smoking inside despite the policy. Another resident with dementia frequently left the facility unattended, and a third resident with cognitive impairment also managed to elope. The facility's reliance on door alarms and lack of staff to monitor residents contributed to these deficiencies.
Two residents were involved in a physical altercation in their shared room, resulting in one resident sustaining a bloody nose and bruising. The incident occurred after one resident pulled back the privacy curtain, leading to a brief argument and physical confrontation. The facility's administrator confirmed the altercation, and the police were involved, with one resident receiving a citation. The facility's Abuse Prevention Program Policy was not effectively upheld, as the altercation was not prevented.
A resident with wounds did not receive prescribed Flagyl 500 mg for wound care as ordered by the physician. The DON was unaware of the order, and the MDS nurse found the missed order after the wound doctor mentioned it. Facility policy mandates that medications be administered as prescribed, which was not followed in this instance.
A facility failed to document a resident's change of condition and death. The resident, under hospice care, was unresponsive with periods of apnea and mottling. Despite these observations, no nursing assessments were documented on the day of death, including the time of death or body release details. The LPN admitted to forgetting to document due to an overwhelming day, and the DON confirmed that documentation should have been completed.
The facility failed to document a change in condition for a resident with multiple diagnoses, leading to an ER transfer without proper assessment records. Another resident with alcoholic cirrhosis and ascites did not have daily weights documented as ordered, and there was no care plan for monitoring his condition. The facility lacked a policy for daily weights, resulting in inconsistent monitoring.
A resident with dysphagia was not provided with the prescribed mechanical soft diet, leading to a choking incident. Despite a physician's order, the resident continued to receive a regular diet, resulting in a choking episode that required emergency intervention. The facility's lack of communication and adherence to dietary policies contributed to this deficiency.
The facility did not ensure menus were reviewed by a Registered Dietitian, impacting all 28 residents. The Dietary Manager rewrote menus without dietitian review due to time constraints after cooler issues and a health department inspection. The menus lacked serving sizes and recipes, and attempts to contact the dietitian were unsuccessful. Facility policy requires dietitian involvement in menu development and substitutions, which was not followed.
The facility failed to store food safely due to malfunctioning refrigeration units, with the walk-in cooler and freezer reaching unsafe temperatures. The Dietary Manager reported the cooler had been down for weeks, and domestic refrigerators were used temporarily, lacking proper thermometers. The County Health Department intervened, requiring food disposal and temporary meal solutions.
The facility failed to investigate an alleged drug diversion involving missing Norco tablets, affecting five residents on Schedule II narcotics. Despite staff reporting the missing narcotic card to the Regional Director, no investigation was conducted, contrary to the facility's abuse prevention policy. The Director of Nursing acknowledged the need for investigation, but no allegations were recorded, and the Regional Director denied awareness of the issue.
The facility failed to maintain accurate reconciliation and documentation of controlled substances, impacting six residents. Instances included missing witness signatures for wasted medications, excess dispensing of doses, and overlapping documentation. Interviews revealed non-adherence to policies, with staff expressing discomfort in discussing these issues, leading to a significant deficiency in pharmaceutical services.
A long-term care facility failed to prevent the diversion of Schedule II medication for two residents. Discrepancies in medication records and forged signatures indicated that a nurse may have diverted Hydrocodone/Acetaminophen. Staff interviews confirmed that some signatures were not authentic, and the Director of Nursing admitted to not checking for overlapping documentation. The facility's policy states residents have the right to be free from misappropriation, but inadequate monitoring led to medication diversion.
The facility failed to maintain a safe environment due to a long-standing roof leak affecting the South shower room and a resident room. Observations showed debris and moldy conditions, with staff confirming the issue has persisted for years despite multiple repair bids. The facility's policy stresses the importance of a safe environment, yet the problem remains unresolved.
Improper Catheter Care Technique Leading to Contamination Risk
Penalty
Summary
The deficiency involves failure to provide catheter care in a manner that prevented contamination for a resident with an indwelling urinary catheter and a history of urinary tract infections. The resident had diagnoses including dementia and neuromuscular dysfunction of the bladder, and physician orders and the active care plan required catheter care every shift and after each incontinent episode. Facility records showed the resident had UTIs requiring antibiotic treatment on two recent occasions. During observation, two CNAs provided care using a basin of soapy water and a basin of plain water, with one intended for washing and the other for rinsing. While providing care, one CNA cleaned stool from the resident’s buttocks using a washcloth, then, without washing her hands or changing gloves or water, obtained a new washcloth, dipped it into the same basin, and cleansed the urinary catheter tubing from the urethra downward. This sequence of actions occurred despite the resident’s chronic indwelling catheter and history of UTIs. The DON stated that when stool is present during catheter care, CNAs are expected to change gloves and water after cleaning the stool and before performing catheter care to prevent contamination of the catheter tubing. The facility’s catheter care policy also states that to prevent contamination when feces are present, staff should wash hands, change gloves, and use new equipment for catheter care.
Unsafe Dining Room Flooring Creates Fall Hazard
Penalty
Summary
A deficiency was identified when the facility failed to maintain a safe walking environment for a resident at risk for falls. Observations revealed that the dining room floor had two visible seams running its length, with areas where the laminate flooring was puckering and lifting from the surface, creating a tripping hazard. Additionally, a brown, sticky substance, identified as floor glue mixed with debris, and tiny nails were present along the seams. Residents and staff reported that the floor had been in this condition for at least a month, and complaints had been made about the hazard, but the flooring had not been replaced or adequately repaired. One resident, who was cognitively intact, reported witnessing another resident fall due to the floor condition and expressed concern about the risk posed by the puckered flooring and sticky substance. Another resident, who had moderate cognitive impairment and multiple diagnoses including dementia, anxiety, diabetes, and reduced mobility, described a fall in the dining room where his foot got stuck on the sticky floor, causing him to trip and fall face-first, resulting in a bloody nose and bruising. This resident required hospital evaluation but did not sustain fractures. The resident's care plan had previously identified him as a fall risk, and after the incident, interventions included maintaining a safe environment. Interviews with facility staff, including the Maintenance Director, DON, and RN, confirmed ongoing issues with the dining room floor seams, with staff acknowledging that residents' walkers and wheelchairs sometimes got caught on the seams. The Maintenance Director stated that attempts had been made to repair the floor with glue and nails, but the problem persisted. The Administrator acknowledged awareness of the hazard and agreed that the condition of the floor could pose a problem for resident safety. Facility policy required malfunctioning equipment or hazards to be immediately addressed, but the unsafe floor condition remained unresolved at the time of the survey.
Unsafe Dining Room Flooring Creates Tripping Hazards for Ambulatory Residents
Penalty
Summary
The facility failed to maintain the dining room floor in a safe and functional condition for nine ambulatory residents. Observations revealed two visible seams running the length of the dining room laminate flooring, with random patches of a brown, sticky substance (identified as floor glue mixed with debris) and tiny nails along both sides of the seams. The laminate flooring was puckering at various points, causing the edges to lift from the surface and creating a tripping hazard. The surveyor confirmed that the puckered areas caught her foot, and the sticky substance posed an additional fall risk. Dining room tables were placed throughout the area, increasing the likelihood of residents encountering these hazards. Interviews with residents and staff confirmed ongoing issues with the floor. One resident reported witnessing another resident fall due to the floor condition and stated that her chair legs often got caught in the puckered areas. Another resident described tripping on the sticky floor while assisting another resident, attributing the incident to the glue applied to keep the floor down. The Maintenance Director acknowledged that the laminate was installed over existing vinyl against his advice, and that he had attempted to address the recurring seam issues by nailing or gluing them down. Staff also reported that the floor was poorly installed and that both residents and staff had experienced tripping or catching their feet on the seams. Facility records indicated that the floor had been problematic for at least a month, with multiple complaints from residents.
Failure to Conduct Regular Wound Assessments and Implement Interventions
Penalty
Summary
The facility failed to identify and properly manage a wound on a resident's right heel, which developed into a deep tissue injury (DTI). The resident, who had a history of peripheral vascular disease and was at moderate risk for pressure ulcer development, had a medical boot that caused a sore on her foot. Despite physician orders to monitor the area for complications, the facility did not conduct weekly wound assessments or update the care plan to include interventions for the wound. The wound was not assessed after its initial identification, and the care plan lacked focus areas or interventions related to the wound. Another resident with multiple sclerosis and a stage 4 pressure ulcer on the buttock also did not receive the required weekly wound assessments. The facility's wound assessment policy mandates weekly assessments for all wounds, but the last documented assessment for this resident was several weeks prior to the survey. This lack of regular assessment and documentation is contrary to the facility's policy and leaves the resident's condition inadequately monitored. The facility's failure to adhere to its own policies regarding wound assessment and care resulted in inadequate monitoring and management of pressure ulcers for both residents. This oversight increased the risk of infection and delayed wound healing, as the facility did not ensure that appropriate interventions were in place or that the wounds were regularly assessed and documented.
Failure to Prevent Significant Weight Loss in Resident
Penalty
Summary
The facility failed to prevent a significant unplanned weight loss for a resident, identified as R8, who experienced a 7.98% weight loss over one month. R8 had a medical history that included cerebral infarction, Parkinson's disease, depression, vomiting without nausea, and dysphagia. Observations revealed that R8 was not consuming meals, as evidenced by an untouched lunch meal despite being seated with a pureed texture meal and a nutritional supplement. Staff members approached R8 during the meal but did not offer assistance or cueing. R8's care plan included dietary recommendations such as pudding, magic cup, mighty shake, benecalorie, and medpass, but there was no documentation of follow-up or administration of these recommendations, except for medpass and pudding. The facility's records showed a lack of adherence to the physician's order for weekly weights, with a two-week delay before the first weight was recorded. Interviews with staff, including a registered nurse and a registered dietitian, highlighted the importance of timely weight monitoring and implementation of dietary recommendations. The dietitian confirmed that R8's weight loss was significant and that the dietary recommendations should have been followed up on quickly. The facility's Unintended Weight Loss policy required monthly or weekly weights and physician notification of significant weight loss, but these protocols were not adequately followed, contributing to the deficiency.
Failure to Maintain Comfortable Dining Environment
Penalty
Summary
The facility failed to provide a comfortable and homelike dining experience for two residents, R21 and R7, due to cold air entering the dining room. On the morning of December 4, 2024, R21 and R7 were observed eating breakfast near sliding glass doors leading to the patio. Another resident, R5, opened the doors to fill bird feeders, allowing cold air to blow into the dining room. R21 expressed discomfort due to the cold and left his meal unfinished, while R7 also left the dining room with food still on his plate. Several staff members noticed the cold but did not intervene to close the doors. The weather was in the 20s with wind, exacerbating the cold conditions inside. R5 stated he fills the bird feeders independently and was not instructed by staff to keep the doors closed. The Registered Nurse, V6, was preoccupied with medication distribution and did not notice the residents leaving the dining room. The Administrator, V1, was unaware of R5's actions and expressed concerns about his safety and the staff's lack of intervention. The facility's policy emphasizes the residents' right to a safe and comfortable environment, which was not upheld in this instance.
Deficiencies in Resident Transfer and Smoking Safety Assessment
Penalty
Summary
The facility failed to ensure a resident was transferred safely, as evidenced by the improper handling of a resident with specific transfer requirements. The resident, diagnosed with conditions such as cerebral infarction and Parkinson's disease, was noted to require a mechanical lift for transfers due to full staff dependence. However, during an observation, two CNAs transferred the resident from bed to wheelchair without using a mechanical lift or a gait belt, contrary to the physician's order. The CNAs were unaware of the updated transfer requirement, as the electronic medical record banner did not reflect the need for a mechanical lift, indicating a lapse in communication and record updating. Additionally, the facility did not adequately assess a resident for safe smoking practices. The resident, who uses smoking tobacco, had not been reassessed for smoking safety since May, despite the facility's policy requiring quarterly assessments. The resident was observed with an unlit cigar and mentioned smoking outside at night. The social services staff confirmed that the resident should have undergone a quarterly safety assessment, highlighting a failure to adhere to the facility's smoking safety policy.
Failure to Maintain Catheter Bag Properly
Penalty
Summary
The facility failed to maintain an indwelling catheter drainage bag in a manner that prevents contamination for one resident. The resident, who was admitted with multiple diagnoses including multiple sclerosis, flaccid neuropathic bladder, acute kidney failure, and a history of urinary tract infections (UTIs), was observed with a catheter drainage bag resting on the floor. This observation was made on two separate occasions, and the drainage tube was also noted to be uncovered and touching the floor. Certified Nursing Assistants acknowledged that catheter drainage bags should not be on the floor due to infection risks and should be placed in a dignity bag. The Director of Nursing confirmed that the catheter drainage bag should not be on the floor and that the drainage tube should be covered and closed.
Failure to Timely Administer Antibiotic
Penalty
Summary
The facility failed to initiate an antibiotic as ordered for a resident reviewed for pharmacy services. The resident, who was admitted with multiple diagnoses including multiple sclerosis and neuromuscular dysfunction of the bladder, was seen in the emergency room for a fever and abdominal pain. He was given IV antibiotics and discharged with an order for cefpodoxime 200 mg twice daily for 10 days, starting on the same day. However, the facility did not input the order until the early hours of the following day, and the medication was not started until then. The Director of Nursing acknowledged that the medication should have been started the same day it was ordered, especially since the resident is very susceptible to going septic when ill. The facility's policy requires the charge nurse to notify the pharmacy if a drug is unavailable, but there was no documentation of any notification to the pharmacy or physician regarding the delay in administering the antibiotic.
Medication Administration Error Exceeds Acceptable Rate
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 8%, which exceeds the acceptable threshold of 5%. During a medication pass observation, a registered nurse (RN) did not administer pantoprazole 40 mg and polyethylene glycol 17 grams to a resident as per the physician's orders. The resident, who was admitted with alcoholic hepatitis, alcoholic cirrhosis, and esophageal varices, was supposed to receive these medications at 8:00 AM, but they were neither given nor offered. The facility's policy requires that the medication administration record be verified against physician orders, which was not adhered to in this instance. The Director of Nursing and a Nurse Consultant confirmed that medications should be administered as ordered by the physician.
Failure to Use Current EHR Leads to Medication Errors
Penalty
Summary
The facility failed to utilize the current electronic health records (EHR) medication administration record (MAR) for administering medications to residents, leading to medication errors. On December 3, 2024, the facility transitioned to a new EHR system. However, on December 4, 2024, a registered nurse (RN) was observed administering medications to three residents using the outdated EHR's MAR. The RN admitted to not being trained on the new system and continued using the old system despite the presence of a licensed practical nurse (LPN) who was there to assist with the new EHR. This resulted in the RN administering medications based on potentially outdated information. The failure to use the current EHR led to specific medication errors. For instance, a resident did not receive pantoprazole and polyethylene glycol as prescribed, as these medications were not listed on the old MAR used by the RN. The current EHR's MAR and the physician's order sheet (POS) indicated these medications should have been administered. Similarly, another resident's medications, divalproex and levothyroxine, were not listed on the old MAR but were current on the new EHR's MAR and POS. This discrepancy highlights the facility's failure to ensure staff were adequately trained and using the correct system for medication administration, as per the facility's updated policy from September 2023.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents, leading to deficiencies in infection control practices. Resident R19, who had a stage 4 pressure injury and an indwelling urinary catheter, did not have a sign indicating EBP on his door, nor was personal protective equipment (PPE) readily available. Certified Nursing Assistants (CNAs) V11 and V12 entered R19's room without donning gowns, and V12 handled the urinary drainage bag without gloves. Despite R19's care plan indicating the need for EBP due to his wounds and catheter, the staff was unaware of the requirement, and no isolation measures were in place. Similarly, Resident R4, who had an indwelling urinary catheter and was at risk for urinary tract infections, did not have EBP signage or PPE near his room. The Director of Nursing (V3) was unaware that residents with catheters required EBP, leading to a lack of appropriate precautions. Additionally, Resident R11, who had a wound on her heel and required assistance with transfers and toileting hygiene, did not have EBP signage or PPE available until after CNAs V11 and V12 had already provided care. The facility's policy required EBP for residents with devices like urinary catheters and skin openings, but this was not consistently implemented, resulting in a failure to adhere to infection control protocols.
Resident Conflict Leads to Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident, R1, from physical abuse, resulting in R1 being punched in the face by another resident, R2. R1, who has a history of paranoid thoughts and verbal aggression, was observed with a bruise on his face and reported being punched by R2. R1's care plan indicated a history of verbal aggression and potential for self-injury, with behaviors such as waving arms and stomping feet when angry. R1 was known to antagonize R2, including yelling and making inappropriate gestures. R2, who has dementia and a history of criminal behavior, was involved in an altercation with R1. On the day of the incident, R2 was outside with a CNA when R1 began yelling and making gestures at him. Despite attempts by the CNA to redirect R2, he became angry and struck R1. R2's care plan noted potential for verbal and physical aggression, and staff were aware of the ongoing conflict between R1 and R2. The facility's abuse investigation confirmed that R2 struck R1, and staff interviews revealed that R1 had been antagonizing R2 for some time. The facility's policy on abuse prevention emphasizes the right of residents to be free from abuse and outlines measures to prevent such occurrences. However, the facility failed to effectively manage the conflict between R1 and R2, leading to the physical altercation.
Failure to Notify HPOA of Medication and Weight Changes
Penalty
Summary
The facility failed to notify a resident's Healthcare Power of Attorney (HPOA) regarding significant changes in medication and weight, which is a requirement for maintaining informed decision-making about the resident's health care. The resident in question, identified as R4, was admitted with diagnoses including dementia with behaviors, seizures, and depression. The resident's records showed a change in Lasix dosage from 40 mg to 80 mg, and significant weight fluctuations, with a 6.4 percent weight loss followed by an 11.4 percent weight gain over a few months. However, there was no documentation of re-weights or notifications to the HPOA regarding these changes. Interviews with the HPOA and facility staff confirmed the lack of communication. The HPOA was not informed about the weight changes or the increase in Lasix dosage, learning about the weight loss from a hospice nurse weeks later. A registered nurse admitted to not notifying the HPOA about the medication change, and the Director of Nursing acknowledged that the HPOA should have been informed about both the weight changes and the medication adjustment. The facility's policy requires prompt notification of significant changes in a resident's condition, including a 5 percent weight gain or loss in 30 days, which was not adhered to in this case.
Failure to Assess and Notify Physician of New Wound
Penalty
Summary
The facility failed to assess and notify the physician of a new wound on a resident's right shin, which was first observed by the resident's Healthcare Power of Attorney (HPOA) on a visit. The HPOA, who is a nurse, discovered a 1.5-inch round wound with a white/yellow slough wound bed and yellow drainage, covered by a gauze dressing. Despite the wound being present since at least the Friday before the HPOA's visit, there were no treatment orders for the wound, and the physician had not been notified. The Registered Nurse (RN) who was informed of the wound did not perform an initial assessment or notify the physician, as required by the facility's policy. On a subsequent visit, another RN removed the dressing and confirmed the presence of the wound, which had not been properly assessed or documented until three days after it was first observed by the HPOA. The Director of Nursing (DON) confirmed that an assessment should have been conducted upon the initial identification of the wound, even if it initially appeared as a blister. The facility's Skin Condition Monitoring policy mandates that any skin abnormality should be assessed, documented, and have a specific treatment order, which was not followed in this case.
Failure to Perform Weekly Pressure Wound Assessments
Penalty
Summary
The facility failed to perform weekly assessments for pressure wounds for two residents, R5 and R6, as required by their Decubitus Care/Pressure Areas policy. The Director of Nursing (V2) stated that the wound care physician assesses wounds every other Friday, and the opposite week, the evening shift nurse is responsible for completing the assessments. However, for R5, the facility was unable to locate the wound assessment for 9/13/24, despite the presence of a stage III pressure injury on her right shin that had not resolved. V2 acknowledged the absence of electronic charting reminders and relied on signs at the nurses' station to remind staff to complete assessments, which were not documented in the residents' electronic charting. Similarly, for R6, the facility could not produce a wound care physician note for 9/6/24 or a facility assessment from 9/13/24. R6 had an open pressure injury on his right heel. V2 admitted that the assessments were not completed and emphasized their importance for ensuring correct treatments and tracking wound progression. The facility's policy mandates documentation of pressure areas upon identification and at least once each week, which was not adhered to in these cases.
Inadequate Supervision and Smoking Policy Enforcement
Penalty
Summary
The facility failed to prevent residents from smoking within the premises and did not adequately supervise residents at risk for elopement. Resident 1, who has a history of psychoactive substance abuse and unsteadiness on feet, was observed with cigarettes and a vaping device in his room, contrary to the facility's smoking policy. Despite being educated on the smoking policy, Resident 1 continued to smoke both cigarettes and marijuana inside and outside the facility. Staff reported that the administrator instructed them to overlook such behaviors, and there was a lack of enforcement of the smoking policy. Resident 2, diagnosed with dementia and severe cognitive impairment, exhibited frequent exit-seeking behaviors. Despite being identified as high risk for wandering, Resident 2 repeatedly left the facility unattended, reaching as far as the parking lot and the street. The facility's interventions, such as door alarms, were insufficient to prevent these incidents, and staff reported being unable to constantly monitor the resident due to staffing limitations. Resident 3, with moderate cognitive impairment, also managed to elope from the facility. On one occasion, the resident was found outside after triggering a door alarm and was difficult to redirect back inside. The facility did not employ additional measures such as wander guards, relying solely on responding to door alarms, which proved inadequate in preventing the resident from leaving the premises.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to ensure residents were free from physical abuse, as evidenced by an incident involving two residents, R1 and R2. According to the facility's incident report, R1 claimed that R2 pulled back the privacy curtain in their shared room and, following a brief argument, struck him in the face. Conversely, R2 stated that after pulling back the curtain, R1 struck him twice in the face before he retaliated by hitting R1 once. There were no eyewitnesses to the altercation. Observations noted R1 with a small yellow/purple bruise on the left side of his nose and under his right eye, while R2 reported being hit on both sides of his jaw. The facility's administrator confirmed that both residents were involved in a physical altercation, with R1 sustaining a bloody nose. The police were called, and both residents declined hospital visits. The following day, R1 decided to press charges against R2, resulting in R2 receiving a citation. The facility's Abuse Prevention Program Policy emphasizes the commitment to protecting residents from abuse by anyone, including other residents. However, the incident indicates a failure to uphold this policy, as the altercation between R1 and R2 was not prevented.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to ensure that a resident's physician orders were followed, specifically for a resident with wounds who was prescribed Flagyl 500 mg to be crushed and applied to each wound bed twice daily with every dressing change. On August 5, 2024, the resident was observed in the dining room, and during an interview, he mentioned having wounds that the wound doctor examines. A progress note from July 29, 2024, indicated that orders were received from the primary care physician to follow the wound care recommendations made on July 19, 2024. However, the Director of Nursing (V2) was unaware of the order, and the Minimum Data Set nurse (V3) discovered the missed order only after the wound doctor brought it to her attention. The facility's policy requires that all medications be given as prescribed by the physician and at the designated time, which was not adhered to in this case.
Failure to Document Change of Condition and Death
Penalty
Summary
The facility failed to document a change of condition and death for a resident who was under hospice care. The resident was admitted to the facility and later to hospice, receiving morphine and Ativan as ordered. On the day of the resident's death, nursing progress notes indicated that the resident was unresponsive, with periods of apnea, no urine output, and mottling of the skin. Despite these observations, there were no nursing assessments documented for the day of death, including the time of death or details about the release of the body. The hospice nurse assessed the resident earlier in the day, noting a decline in condition, but the facility's LPN did not document these changes or the notifications made to the family and physician. The LPN admitted to forgetting to document due to an overwhelming day. The Director of Nursing confirmed that the agency nurse had access to the electronic record and should have documented the resident's condition changes, notifications, and time of death, as per the facility's policy.
Failure to Document Change in Condition and Monitor Daily Weights
Penalty
Summary
The facility failed to properly assess and document a change in condition for a resident (R1) and did not obtain daily weights as ordered for another resident (R2). R1 was admitted with multiple diagnoses, including sepsis and cognitive communication deficit. On a specific date, R1 was sent to the emergency room due to a change in condition, but the nurse (V2) did not document any assessments, vital signs, or reasons for the transfer. R1's guardian was informed of the transfer but was not provided with detailed information about R1's condition. The nurse acknowledged the importance of documenting assessments to provide a clear picture of the resident's condition. For R2, who was admitted with alcoholic cirrhosis of the liver and ascites, there was an order for daily weights to monitor fluid retention. However, weights were not documented for two consecutive days, and there was no care plan for monitoring R2's condition. The facility lacked a policy for daily weights, and the staff did not consistently follow the order for daily weight monitoring. R2 reported discomfort due to fluid retention and went to the emergency room for a paracentesis, highlighting the importance of monitoring his condition.
Failure to Provide Altered Diet Leads to Choking Incident
Penalty
Summary
The facility failed to provide an altered diet for a resident with dysphagia, leading to a choking incident. The resident, who had a history of oropharyngeal phase dysphagia and other medical conditions, was supposed to be on a mechanical soft diet as per a physician's order dated April 26, 2024. However, the resident continued to receive a regular diet, which resulted in a choking episode on June 16, 2024, requiring the Heimlich Maneuver and abdominal thrusts to dislodge the food. The resident's care plan and dietary assessments were not updated to reflect the necessary dietary changes, and there was a lack of communication between the nursing and dietary staff. The dietary manager indicated that diet changes are made only when a paper order is received from the nurse, and there was no tracking system for when dietary cards were updated. The resident was served a regular diet despite the order for a mechanical soft diet, and the dietary manager was unaware of when the dietary card was changed. Interviews with staff revealed that the resident was served inappropriate food, leading to the choking incident. The CNA who was feeding the resident reported that the resident was eating regular food and began choking, turning blue before the food was expelled. The facility's policies and procedures for diet orders and quarterly assessments were not followed, contributing to the failure to provide the appropriate diet for the resident.
Removal Plan
- In house audit of all diet orders to ensure accurate reconciled with dietary cards.
- IDT will review Speech Therapy recommendations daily in morning meeting.
- Regional Director in-serviced Dietary Supervisor on quarterly and annual dietary assessments.
- Staff in-serviced on appropriate diets by Regional Director and Administrator.
- Compliance will be monitored through the QA process.
- Speech orders will be reviewed daily during morning meeting by the IDT.
- DON/Designee will ensure all new diet orders are communicated to dietary.
- DON/Designee will in-service on diet orders once a month.
Failure to Review Menus by Dietitian
Penalty
Summary
The facility failed to ensure that menus were reviewed by a Registered Dietitian, affecting all 28 residents. The Dietary Manager, identified as V12, admitted to rewriting the facility's dining menus without having them reviewed by the Registered Dietitian due to time constraints, following issues with the cooler and an inspection by the County Health Department. The handwritten menus provided by V12, covering the period from June 19th through June 30th, lacked serving sizes and recipes. Attempts to contact the Registered Dietitian, identified as V30, were unsuccessful. The facility's policy requires the Dietitian to assist in menu development and sign off on all menu substitutions, which was not adhered to in this instance.
Improper Food Storage Due to Malfunctioning Refrigeration
Penalty
Summary
The facility failed to store food in a safe and sanitary manner, as evidenced by the malfunctioning of the walk-in cooler and freezer. The County Health Department documented that during an onsite visit, the walk-in cooler was at 55 degrees and the freezer at 73 degrees, leading to the disposal of all food stored in these units. The Dietary Manager, V12, confirmed that the cooler had been down for 6-7 weeks and that the freezer was also failing, with temperatures recorded as high as 80 degrees. Despite these issues, food was still stored in the malfunctioning freezer for several days before being discarded. The facility resorted to using domestic refrigerators, which were not equipped to handle the cooling needs of a commercial kitchen. These units lacked proper thermometers, and the County Sanitarian noted that they were only a temporary solution. The facility's policy required frozen foods to be at 0 degrees or lower and refrigerated foods at 41 degrees or lower, which was not adhered to. The Dietary Manager also reported being short-staffed, which may have contributed to the oversight in addressing the refrigeration issues promptly.
Failure to Investigate Alleged Drug Diversion
Penalty
Summary
The facility failed to investigate an allegation of drug diversion involving missing narcotic medication, specifically Norco tablets, which are Schedule II narcotics. This issue affected five residents who were on Schedule II narcotics during the time of the alleged incident. The report indicates that a missing narcotic card was reported by two staff members, V18 and V8, to V19, the Regional Director of Clinical Operations, over the phone. However, V19 allegedly dismissed the report and did not initiate an investigation. The staff members involved could not recall which resident's medication was missing due to the time elapsed since the incident. The facility's policy on abuse prevention requires immediate reporting and investigation of discrepancies in controlled substance inventories. Despite this policy, the report highlights that the administration did not investigate the missing narcotic card. The Director of Nursing, V2, acknowledged the importance of investigating such allegations to prevent ongoing theft. However, the report notes that no allegations of misappropriation were recorded for the relevant months, and V19 denied any awareness of the drug diversion allegations.
Deficiency in Controlled Substance Reconciliation and Documentation
Penalty
Summary
The facility failed to maintain accurate reconciliation and documentation of controlled substances, impacting six residents. The report highlights multiple instances where controlled substances, such as Hydrocodone/Acetaminophen and Morphine, were not properly accounted for, with discrepancies in count sheets and missing witness signatures for wasted medications. For instance, one resident had 41 tablets of Norco wasted without a second nurse's signature, contrary to the facility's policy requiring two nurses to witness and document the destruction of controlled substances. The report also details specific cases where medications were dispensed in excess of the prescribed amounts or without proper documentation. One resident's count sheets showed overlapping and duplicate documentation, while another resident's sheets indicated more doses were dispensed than ordered. Additionally, there were instances where medications were documented as dropped or wasted without a second nurse's cosignature, raising concerns about potential diversion of narcotics. Interviews with staff, including the Director of Nursing and Licensed Practical Nurses, revealed a lack of adherence to established policies and procedures for handling controlled substances. The facility's pharmacist noted numerous instances of undocumented waste and expressed concerns about the discomfort and unease among nursing staff when discussing these issues. Despite these observations, the facility failed to identify and address the discrepancies, leading to a significant deficiency in pharmaceutical services.
Medication Diversion in LTC Facility
Penalty
Summary
The facility failed to prevent the diversion of Schedule II medication, specifically Hydrocodone/Acetaminophen, for two residents. For one resident, discrepancies were found in the Medication Administration Record (MAR) and Controlled Substance Proof of Use records, indicating that more tablets were dispensed than should have been administered. The records showed overlapping dates and forged signatures, suggesting that a nurse may have diverted the medication. Interviews with staff revealed that some signatures on the count sheets were not authentic, and the Director of Nursing (DON) admitted to not checking for overlapping documentation, which allowed the issue to go undetected. For the second resident, similar issues were identified with the administration of Hydrocodone/Acetaminophen. The MAR and count sheets showed duplicate administrations and inconsistencies in signatures, indicating that the medication was likely diverted by a nurse. The Regional Director of Clinical Operations noted that the signatures and handwriting on the count sheets appeared to be from the same person, further supporting the suspicion of medication diversion. The facility's Abuse Prevention Program policy states that residents have the right to be free from misappropriation of their property, including medications. However, the facility's failure to properly monitor and document the administration of controlled substances led to the misappropriation of medications for both residents. The lack of oversight and verification of count sheets allowed the diversion to occur without detection.
Facility Fails to Address Long-Standing Roof Leak, Compromising Safety
Penalty
Summary
The facility failed to maintain a safe and comfortable environment for its residents, as evidenced by the condition of the South shower room and a resident room that was taken out of service. Observations revealed insulation and debris from the ceiling on the floor and hanging from the ceiling in the South shower room, with an area measuring approximately 10-12 feet by 3-4 feet directly above the shower. Additionally, a resident room not in service had a section of the ceiling that had fallen, with peeling wallpaper and apparent mildew or mold around the top of the wall. Interviews with staff, including the Maintenance Director, indicated that there has been an ongoing leak in the South shower room and another area of the facility for the last three years, with multiple bids submitted to fix the roof issue, but no action taken by corporate. The Maintenance Director reported that the roof is made of fabric layers, and a leak at one of the seams worsens with heavy rain. Despite submitting multiple bids for repairs over the past three years, the issue remains unresolved. Staff members, including CNAs, confirmed the long-standing nature of the problem, describing the ceiling as moldy, cracked, and sagging. The facility's policy emphasizes the importance of maintaining a safe and clean environment, yet the ongoing issues with the roof and ceiling have not been addressed, leading to unsafe conditions for residents and staff.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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