Serenity Estates Of Lena
Inspection history, citations, penalties and survey trends for this long-term care facility in Lena, Illinois.
- Location
- 1010 South Logan Street, Lena, Illinois 61048
- CMS Provider Number
- 146114
- Inspections on file
- 40
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Serenity Estates Of Lena during CMS and state inspections, most recent first.
A resident with dementia and a right arm amputation was found to have dark purple bruising near the left eye and additional bruising on the left upper arm, with no witnesses and the resident unable to explain the injuries. An LPN documented the bruises as an injury of unknown origin and notified the DON, who completed a risk management report but deemed the bruising explainable, suggesting it was plausibly caused by the resident pulling on a door handle, despite no documented or witnessed behavior confirming this. Social services staff reported the resident sometimes held a door handle and flailed arms when redirected but had never seen the resident hit himself. The administrator later acknowledged that unexplained eye bruising without a known cause should have triggered an injury-of-unknown-origin abuse investigation, which was not done, contrary to the facility’s abuse policy requiring investigation and reporting of suspicious injuries of unknown origin such as an unexplained black eye.
An agency LPN administered a full set of medications prescribed for one resident to a different resident after failing to verify the resident’s identity and insisting the pills were correct despite the resident’s objections. The medications included multiple cardiac, supplement, and antipsychotic agents that were not ordered for the recipient. The facility’s error report cited inexperienced staff and an outdated resident photo as contributing factors, and leadership confirmed that required verification steps under the six rights of medication administration were not followed.
The facility failed to properly cool cooked foods, risking pathogen growth. Leftover items like spaghetti sauce and taco meat were stored without cooling logs, contrary to HACCP guidelines. The Dietary Manager confirmed these leftovers were served to residents, highlighting a lapse in food safety protocols.
A facility failed to conduct interdisciplinary care plan conferences for a resident with severe cognitive impairment and multiple diagnoses. The resident's power of attorney was not informed or invited to care plan meetings, despite expressing frustration over the lack of communication. The facility did not document invitations to these meetings, and no family attendance was recorded, highlighting a deficiency in involving family in the care planning process.
A resident with mild cognitive impairment and multiple diagnoses requiring assistance with ADLs was observed with wet clothing, indicating a need for incontinence care. A CNA changed the resident's brief and pants without performing necessary incontinence care. The resident continued to wear the same clothes for two days without documented refusal to change. The DON confirmed the need for assistance and adherence to facility policy for incontinence care.
A resident with a history of a Stage 3 pressure wound experienced a reopening of the wound due to inadequate monitoring and reporting by the facility staff. Despite the facility's policy to prevent pressure ulcers, the wound was not identified and reported in a timely manner, leading to its reopening and enlargement.
A resident with severe cognitive impairment and a history of falls was found without a functioning bed alarm, despite care plans and physician's orders requiring it. Staff were confused about the alarm's necessity, and the DON confirmed it should be in place. The facility's fall management policy was not followed.
The facility did not follow manufacturer instructions for insulin expiration, affecting two residents. One resident received expired insulin glargine, while another's insulin aspart pen lacked proper labeling to track expiration. The DON confirmed the importance of adhering to expiration guidelines to prevent contamination and potency issues.
A facility failed to follow infection control protocols during incontinence care for a resident with chronic kidney disease and a UTI. CNAs did not change gloves or perform hand hygiene after cleaning feces and before touching clean items. The CNAs were unable to state when glove changes and hand hygiene should occur, despite facility policies and training.
A resident, diagnosed with dementia but cognitively intact, was not offered the flu vaccine for the 2024/2025 season due to the facility's policy of requiring POA consent for dementia patients. The POA was unavailable, and the facility lacked a specific flu vaccination policy, leading to the resident contracting flu and COVID-19.
A facility failed to offer a COVID-19 vaccine to a resident with dementia who was cognitively intact and expressed a desire to make her own vaccination decisions. The facility's practice was to defer to the POA for consent, and the resident's POA was unavailable. The resident, who had a BIMS score of 15, was not offered the vaccine and later contracted COVID-19 and influenza. The facility lacked a specific COVID-19 vaccination policy.
The facility failed to ensure staff wore the required PPE when entering the rooms of three residents on droplet/contact isolation for influenza. Staff were observed not using full PPE, such as gowns, masks, eye protection, and gloves, despite signage indicating these requirements. The Director of Nursing confirmed the deficiency in PPE usage.
A resident's call light was removed by a CNA due to frequent activation, leaving it out of reach and violating the resident's rights. The resident, with conditions including cellulitis and COPD, expressed concern about not being able to call for help. The incident was confirmed by staff and the DON, highlighting a failure to adhere to the facility's policy on dignity and resident rights.
A significant medication error occurred when a nurse, distracted by giving a shift report, administered 40 units of unnecessary sliding scale insulin to a resident with a blood glucose level of 103. The resident, with a history of diabetes, congestive heart failure, and hypertension, appeared tired and vomited once the following day. The error was reported to the physician and Power of Attorney.
A resident with severe cognitive impairment and requiring two-person assistance for bed mobility was injured when a CNA attempted to provide care alone. The resident fell from a raised bed during a bed bath, resulting in a nasal bone fracture, femoral neck fracture, and a forehead laceration requiring sutures. The CNA did not seek help despite knowing the resident's needs and the availability of other aides.
The facility failed to ensure that the Director of Nursing (DON) and the Infection Preventionist attended the quarterly Quality Assurance and Performance Improvement (QAPI) meetings. The review of attendance sheets confirmed that the Infection Preventionist attended only two meetings, and the DON attended only one meeting out of four. This deficiency impacts the facility's adherence to its QAPI policy.
The facility failed to prevent a resident from falling from a broken beauty shop chair and did not implement fall prevention interventions for four residents. One resident fell due to a faulty chair, another lacked a required non-slip pad, and two others were without necessary bed and chair alarms.
The facility failed to obtain physician's orders for a resident on CPAP therapy and did not store nebulizer and CPAP masks in a sanitary manner for four residents. One resident had a CPAP machine without any physician's orders or documented settings, and three other residents had their nebulizer masks left uncovered and exposed to air on their bedside tables, contrary to facility policy.
The facility failed to reassess and update the dietary preferences and nutritional needs of a resident after readmission with a diet change to a full liquid diet. The care plan was not updated, and the dietary card did not include prescribed supplements. The Dietary Manager admitted to not reassessing the resident's needs, and the cook confirmed limited dietary options were provided.
The facility failed to ensure that two residents were assessed by a physician within the first 30 days after admission. Both residents were only seen by a Nurse Practitioner, and the facility staff misinformed one resident that a Nurse Practitioner is a doctor. The Clinical Coordinator confirmed the lack of physician assessments, which is against the facility's policy.
A resident with severe cognitive impairment and anxiety disorder did not receive 18 doses of Alprazolam over six days due to issues with medication availability and delays in receiving a new prescription. Despite multiple attempts by nursing staff to resolve the issue, the medication was not delivered in a timely manner.
The facility failed to ensure that vegetables served to residents were palatable and properly cooked. The vegetables were overcooked to a mushy texture and lacked flavor due to the omission of salt. Two residents expressed dissatisfaction, leading to uneaten portions on their trays.
A facility failed to ensure proper PPE was worn by a nurse while providing care to a resident in contact isolation for a MRSA infection. The nurse entered the room without a gown, despite clear signage and policy requirements, and performed tasks that involved contact with the resident's bedding.
Failure to Investigate Unexplained Bruising as Possible Abuse
Penalty
Summary
The facility failed to investigate an injury of unknown origin as possible abuse for one resident with dementia and a right above-elbow amputation. The resident’s face sheet showed cognitive impairment, and progress notes documented bruising to the corner of the left eye, described as dark purple and approximately 3 cm by 0.5 cm, and additional bruising to the left upper arm measuring 10 cm by 5 cm, light purple/blue in color. The resident was alert and oriented to one sphere, confused, had impaired memory, and was unable to explain how either bruise occurred. No one witnessed how the bruising happened. The LPN who discovered the bruising stated she treated it as an injury of unknown origin and possible abuse, notified the DON, and completed a risk management/incident form that documented the unexplained bruising and the resident’s poor ability to report the cause. The DON acknowledged that a risk management form was completed but stated the bruising was considered explainable and therefore not treated as abuse, asserting it was plausible the resident sustained the bruise while swinging or forcefully pulling on a door handle, grab bar, or wheelchair component, despite there being no witnesses to such behavior and no behavior documented that corresponded with this explanation. The risk management/incident report signed by the DON characterized the bruising as plausibly self-inflicted based on behavioral observations, even though the resident was a poor historian, could not recall the cause, and there were no witnesses or prior safety alerts for that area. Social services staff reported the resident would hold the door handle and sometimes flail his arms when staff tried to remove his hands but had never seen the resident hit himself. The administrator later stated that unexplained bruising to the corner of a resident’s eye with no explanation and no witnesses should trigger an injury of unknown origin abuse investigation, and confirmed that no such abuse investigation was conducted, despite the facility’s abuse policy requiring investigation and reporting of suspicious injuries of unknown origin, including a black eye in a resident unable to communicate when no source is witnessed.
Significant Medication Error Due to Failure to Verify Resident Identity
Penalty
Summary
A resident received another resident’s medications, resulting in a significant medication error. On the morning of 1/29/26 at approximately 8:30 AM, an agency LPN administered a set of medications that were prescribed for a different resident. The medications given included Norvasc 5 mg, ferrous sulfate 325 mg, a fiber tablet, Lasix 10 mg, a multivitamin, potassium chloride 10 mEq, vitamin D3 25 mcg, Florastor, liquid protein, and risperidone 2 mg, none of which were prescribed for the resident who received them. The resident later reported that she tried to tell the nurse the pills were not hers, but the nurse insisted they were and did not ask her name or otherwise confirm her identity before administration. The resident stated she developed a severe headache and felt unwell afterward and noted she had never been prescribed risperidone before. The facility’s medication error report identified that the agency LPN gave the wrong medications and documented contributing factors as inexperienced staff and an old photo of the resident. The ADON confirmed that the resident received the wrong medications and that the LPN recognized the error immediately after administration. At the time of the incident, the resident remained alert and oriented x4, with no immediate symptoms documented other than later sleepiness. The facility’s medication administration policy required licensed nurses to follow the six rights of medication administration, including verifying the right resident, but this verification process was not followed when the LPN failed to properly identify the resident before giving the medications.
Improper Cooling of Leftover Foods
Penalty
Summary
The facility failed to ensure that cooked foods were cooled in a manner that limits the growth of potentially dangerous pathogens, which could affect all residents. During an inspection, it was observed that the facility's reach-in freezer contained several leftover food items, such as spaghetti sauce, taco meat, beef barley soup, and meatballs, with preparation and use-by dates indicating they were stored for extended periods. Additionally, leftover chicken noodle soup was found in the refrigerator. The Dietary Manager confirmed that these leftovers were served to residents and were part of the alternative menu. The Dietary Manager admitted that there were no cooling logs for the leftover items in the freezer, which should have been posted on the reach-ins. The facility's General HACCP Guidelines for Food Safety policy requires that cooked food be cooled from 135 degrees Fahrenheit to 70 degrees Fahrenheit within two hours and then from 70 degrees Fahrenheit to 41 degrees Fahrenheit within four hours. If these times and temperatures are not met, the food should be reheated to 165 degrees Fahrenheit, and the cooling process restarted. The absence of cooling logs and the improper cooling of food items indicate a failure to adhere to these guidelines, potentially allowing the growth of pathogens.
Failure to Conduct Interdisciplinary Care Plan Conferences
Penalty
Summary
The facility failed to conduct interdisciplinary care plan conferences for a resident, identified as R44, who was reviewed for care plans. R44 has multiple diagnoses, including cerebral infarction, hemiplegia, hemiparesis affecting the left dominant side, dementia with anxiety, and dementia with behaviors, and is noted to have severe cognitive impairment. Despite these conditions, the facility did not involve R44's family or power of attorney in care plan meetings. The power of attorney, V13, expressed frustration over the lack of communication and the absence of care plan meetings, stating that they had never been informed of such meetings. The facility's records showed that care plan meetings were held on three occasions, but no family attendance was recorded. The Social Service Director, V12, acknowledged the lack of family involvement and stated that invitations to care plan meetings are typically made by phone calls, which are not documented. Despite the family's recent increased involvement, they had not been invited to any care plan meetings, and no policy regarding family attendance or documentation of invitations was provided by the facility. The facility had contacted the family six times since R44's admission but failed to invite them to participate in care plan meetings.
Failure to Provide Incontinence Care and ADL Assistance
Penalty
Summary
The facility failed to provide adequate incontinence care and activities of daily living (ADL) assistance for a resident identified as R35. R35 has diagnoses including the need for personal care, muscle wasting and atrophy, morbid obesity, and edema, and requires partial to moderate assistance with toileting hygiene due to mild cognitive impairment. On March 25, 2025, R35 was observed with wet marks on the back of his pants, indicating a need for incontinence care. A Certified Nursing Assistant (CNA), identified as V14, assisted R35 by removing the wet pants and incontinence brief but failed to perform incontinence care before applying a clean brief and pants. V14 admitted to not offering incontinence care because R35 did not request it, despite acknowledging that it should have been offered. Further observations on March 26 and March 27, 2025, revealed that R35 continued to wear the same clothes from March 25, 2025, without any documented refusal to change clothes or receive incontinence care. The Director of Nursing (DON), identified as V2, confirmed that R35 requires assistance with personal care and emphasized the importance of providing incontinence care to prevent skin breakdown and ensure cleanliness. The facility's policy mandates providing incontinent care in a manner that ensures privacy, dignity, and no cross-contamination, which was not adhered to in this instance.
Reopened Pressure Ulcer Due to Inadequate Monitoring
Penalty
Summary
The facility failed to ensure that a healed pressure injury did not reopen for a resident with a history of multiple diagnoses, including congestive heart failure and moderate cognitive impairment. The resident, who required assistance with personal care and was occasionally incontinent of urine, was admitted with a Stage 3 pressure wound that had initially resolved. However, the wound reopened, as documented in a wound evaluation and management summary, with measurements indicating a significant size. Observations revealed that the wound had reopened and was covered with a white paste. The RN noted that the wound had originally been two open areas that merged into one. The Director of Nursing acknowledged that the wound should have been identified and reported before it reached its current size. The facility's policy mandates that residents at risk for pressure ulcers receive necessary treatment to promote healing and prevent new sores, which was not adhered to in this case.
Failure to Implement Fall Prevention Measures for a Resident
Penalty
Summary
The facility failed to ensure fall prevention measures were in place for a resident with severe cognitive impairment and a history of falls. The resident, who has diagnoses including a femur fracture, dysphagia, osteoarthritis, dementia with behaviors, and major depressive disorder, was observed without a functioning bed alarm. The resident's care plan and physician's orders indicated the need for a bed and chair alarm to be in place and functioning at all times due to a history of falls and attempted independent transfers and ambulation. On the day of observation, the bed alarm cord was found disconnected and placed in a basin, with the alarm box showing no signs of functioning. Staff interviews revealed confusion regarding the resident's need for a bed alarm, with a Licensed Practical Nurse unaware of the requirement and a Certified Nursing Assistant unsure why the alarm was not plugged in. The Director of Nursing confirmed that the resident should have the alarms plugged in at all times, especially after a recent fall incident. The facility's policy on fall management emphasizes evaluating residents for fall risk and developing preventive interventions, which was not adhered to in this case.
Failure to Follow Insulin Expiration Protocols
Penalty
Summary
The facility failed to adhere to manufacturer instructions regarding the expiration date of in-use insulin for two residents. For one resident, insulin glargine was found in the medication cart with an open date and a discard date that had already passed. Despite this, the insulin was documented as being administered to the resident after the expiration date. The Director of Nursing acknowledged that the expired insulin should not have been used, as the manufacturer's instructions specify that insulin vials should be discarded 28 days after opening due to potential contamination and decreased potency. For another resident, an insulin aspart pen was found in the medication cart without any dates documented on the facility-applied label, which is intended to track the date of opening and the discard date. The Director of Nursing confirmed that insulin pens should be dated once removed from the refrigerator to ensure proper tracking of expiration. The facility's Insulin Administration policy requires checking expiration dates and recording the expiration date and time on new vials, following manufacturer recommendations.
Infection Control Breach During Incontinence Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices during incontinence care for a resident with chronic kidney disease stage 4, urinary tract infection, and anxiety disorder. The resident, who has moderate cognitive impairment and is dependent on staff for personal hygiene, was provided incontinence care by two Certified Nursing Assistants (CNAs). During the care, the CNAs did not change their gloves or perform hand hygiene after cleaning feces from the resident's buttocks and before touching clean items such as a new incontinence brief, a mechanical lift remote, bed controls, and the resident's wheelchair. The CNAs were unable to articulate when gloves should be changed and when hand hygiene should be performed, despite the facility's policy requiring glove changes and hand hygiene to prevent cross-contamination. The Director of Nursing confirmed that staff are taught the correct procedures during training and competencies.
Failure to Offer Flu Vaccine Due to Consent Policy
Penalty
Summary
The facility failed to offer a resident the flu vaccine for the 2024/2025 flu season, which was identified during a survey. The resident, who was part of a sample of 26, was diagnosed with dementia but was cognitively intact, as evidenced by a BIMS score of 15 out of 15 and multiple medical notes indicating she was alert and oriented. Despite this, the facility's Director of Nursing (DON) stated that they do not allow residents with a dementia diagnosis to sign consents, relying instead on the Power of Attorney (POA). However, the POA was unavailable due to being in the Intensive Care Unit, and the resident's family was unwilling to make decisions on her behalf. Consequently, the resident did not receive the flu vaccine and subsequently contracted the flu and COVID-19 early in 2025. The facility did not have a specific policy in place for flu vaccinations, and the DON expressed concerns about allowing residents with dementia to sign consents, fearing they might later claim they did not sign the paperwork. The resident's POA documentation allowed her to make her own decisions while she was still capable, but the facility did not assess her cognitive ability at the time of signing consents. The Ombudsman noted that dementia is a spectrum, and individuals with the diagnosis can vary significantly in their decision-making capabilities. The lack of a specific flu vaccination policy and the facility's approach to consent for residents with dementia contributed to the deficiency.
Failure to Offer COVID-19 Vaccine to Cognitively Intact Resident
Penalty
Summary
The facility failed to offer a COVID-19 vaccine to a resident for the 2024/2025 season, despite the resident being cognitively intact and expressing a desire to make her own vaccination decisions. The resident, who was diagnosed with dementia but had a BIMS score of 15 out of 15, indicating full cognitive function, was not offered the vaccine because the facility's practice was to defer to the power of attorney (POA) for consent. The resident's POA was unavailable due to being in the ICU, and the facility did not have a policy in place to assess the resident's cognitive ability to consent at the time of vaccination. The Director of Nursing (V2) stated that the facility's practice was to rely on the POA for consent if a resident had a dementia diagnosis, regardless of their cognitive status. The resident's medical records and interviews confirmed her cognitive awareness and ability to make informed decisions about her health. Despite this, the facility did not offer the COVID-19 booster, and the resident subsequently contracted COVID-19 and influenza. The facility lacked a specific COVID-19 vaccination policy, contributing to the oversight in offering the vaccine to the resident.
Failure to Use Required PPE for Residents on Isolation
Penalty
Summary
The facility failed to ensure that staff wore the required personal protective equipment (PPE) when entering the rooms of residents who were on isolation for influenza. This deficiency was observed in three residents who were diagnosed with influenza and placed on droplet/contact isolation. For Resident 1, there was confusion regarding the isolation status, and the appropriate signage was not initially displayed on the door. An activity aide was observed in the room wearing only a surgical mask, without the full PPE required for droplet/contact isolation. The Director of Nursing confirmed that Resident 1 was to remain on isolation due to worsening symptoms. For Resident 2, a certified nursing assistant entered the room wearing only a surgical mask, despite the presence of a droplet/contact isolation sign indicating the need for full PPE, including a gown, mask, eye protection, and gloves. Similarly, for Resident 3, a certified nursing assistant entered the room with gloves, gown, and mask but lacked eye protection. The Director of Nursing confirmed that all three residents were on droplet/contact isolation and that the required PPE was not consistently used by staff, as indicated by the isolation signage.
Resident's Call Light Removed, Violating Dignity and Rights
Penalty
Summary
The facility failed to treat a resident with respect and dignity by not ensuring the resident's call light was within reach, which is a violation of resident rights. A certified nursing assistant (CNA), identified as V5, removed the call light from the resident's reach because it was frequently activated, sometimes accidentally. The resident, a male with diagnoses including cellulitis, COPD, weakness, and dehydration, expressed concern about not being able to call for help if needed. The incident was confirmed by another CNA, V7, and the CNA Supervisor, V6, who found the call light under the resident's bed. The Director of Nursing (DON), V2, was notified of the incident and confirmed through interviews with the resident and staff that the call light had been removed from the resident's reach. The facility's incident report documented that V5 admitted to moving the call light due to its sensitivity and frequent activation. The facility's policy on dignity and resident rights emphasizes that residents should be treated with respect and have their rights maintained, which was not adhered to in this case.
Significant Medication Error Due to Distraction During Medication Pass
Penalty
Summary
The facility failed to administer a physician-prescribed medication as ordered, resulting in a significant medication error for one resident. The resident, who was admitted with diagnoses including Type 2 Diabetes Mellitus, congestive heart failure, and hypertension, was cognitively intact and required moderate assistance with daily activities. On the night of the incident, the Director of Nursing (V2) was working a busy shift and mistakenly administered 40 units of regular sliding scale insulin to the resident, despite the resident's blood glucose level being 103, which did not require any sliding scale insulin. The error occurred while V2 was distracted, attempting to give a shift report to the oncoming nurse while preparing medications. The facility's policy for insulin administration requires checking the blood glucose level and ensuring the correct type and amount of insulin is administered. However, V2 admitted to being distracted and not focusing solely on the medication pass, leading to the error. The following day, the resident appeared tired and experienced one episode of emesis but did not report feeling unwell. The incident was promptly reported to the physician and the resident's Power of Attorney. The facility's administrator emphasized the importance of undivided attention during medication administration.
Failure to Provide Adequate Assistance Leads to Resident Injury
Penalty
Summary
The facility failed to ensure safe bed mobility for a resident, resulting in significant injuries. The resident, who had severe cognitive impairment and required assistance from two or more staff members for bed mobility, was being cared for by a single Certified Nursing Assistant (CNA). During a bed bath, the resident experienced a jerking movement, causing her to fall from the bed, which was raised to waist level. This incident led to the resident sustaining a nasal bone fracture, a femoral neck fracture, and a laceration on her forehead that required nine sutures. The CNA involved admitted to providing care alone despite knowing the resident required two-person assistance. The CNA did not request help, even though other aides were available in the building and communication devices were accessible for such purposes. The Director of Nursing and Assistant Director of Nursing confirmed that the CNA should have sought assistance, as the resident's assessment clearly indicated the need for two-person support for bed mobility. This oversight in following the resident's care plan and facility policy resulted in the resident's injuries.
Failure to Ensure Required Attendance at QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) and the Infection Preventionist attended the quarterly Quality Assurance and Performance Improvement (QAPI) meetings. The CMS 671 dated 4/11/24 shows 56 residents residing in the facility. The Administrator (V1) acknowledged that the DON had to cover the floor during some meetings and did not attend. The Assistant Director of Nursing (V2), who is also the Infection Preventionist, mentioned that she attended the meetings only when she was in the building and was off for a while on maternity leave. The review of the quarterly QAPI Agenda - Attendance sign-in sheets for 4/27/23, 8/30/23, 11/27/23, and 3/19/24 confirmed that the Infection Preventionist attended only two of these meetings, and the DON attended only one meeting. The previous DON (V10) also confirmed that she missed some meetings due to working the floor or night shifts. The facility's Quality Assurance and Performance Improvement (QAPI) policy mandates that the QAPI Committee must include the Director of Nursing, the Medical Director or designee, at least three other staff members including the administrator, and the infection preventionist. The policy also states that QAPI meetings should be held monthly but at a minimum of quarterly. The failure to ensure the required attendance of the DON and Infection Preventionist at these meetings constitutes a deficiency in the facility's adherence to its QAPI policy, potentially impacting the quality of care for all residents in the facility.
Failure to Prevent Falls and Implement Safety Interventions
Penalty
Summary
The facility failed to prevent a resident from falling from a broken beauty shop chair and did not implement interventions to prevent falls for four residents reviewed for falls. Resident R43, who has moderate cognitive impairment and a history of falls, fell backward and hit her head on the floor when a beauty shop chair broke. The beautician had previously reported the chair's potential mechanical failure to maintenance, but it was deemed functional. The chair was later found to recline completely backward without pulling the lever, indicating it was not safe for use. The facility's investigation into the incident was incomplete and lacked proper documentation. Resident R3, who has severe cognitive impairment and a history of falls, was found without a non-slip pad in her recliner, despite it being a documented intervention to prevent falls. Multiple staff members confirmed that R3 should have a non-slip pad in her recliner at all times, but it was not in place during the surveyor's observations. This failure to follow the care plan put R3 at risk for further falls. Residents R20 and R50, both of whom require bed and chair alarms due to their high fall risk, were observed without these alarms in place. R20 was transferred to bed without the alarm being activated, and R50 was seen in his wheelchair without the alarm on multiple occasions. Staff acknowledged the necessity of these alarms to alert them when residents attempt to get up, but they were not consistently used, increasing the risk of falls for these residents.
Failure to Obtain Physician's Orders and Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to obtain physician's orders for a resident on CPAP therapy and did not store nebulizer and CPAP masks in a sanitary manner for four residents. Specifically, one resident with a history of pneumonia and COVID-19 had a CPAP machine from home without any physician's orders or documented settings. The CPAP mask was left uncovered on the bedside table, and there was no care plan or facility assessment completed for this new admission. Additionally, the facility's policy required respiratory equipment to be stored in plastic bags to prevent bacterial contamination, which was not followed for this resident. Three other residents with various diagnoses, including dementia, upper respiratory infections, and RSV, also had their nebulizer masks left uncovered and exposed to air on their bedside tables. The facility's policy mandated that respiratory equipment be stored in plastic bags marked with the date and resident's name, which was not adhered to. Interviews with the facility's staff confirmed the importance of proper storage to prevent bacterial contamination and the necessity of having physician's orders for respiratory treatments like CPAP therapy.
Failure to Reassess Dietary Needs After Readmission
Penalty
Summary
The facility failed to reassess and update the dietary preferences and nutritional needs of a resident (R22) after a readmission with a diet change to a full liquid diet. R22, who has diagnoses including dementia, gastro-esophageal reflux disease, and a non-pressure chronic ulcer, was readmitted with a new diet order for a full liquid diet. Despite this significant change, the care plan was not updated to reflect the new dietary requirements, and the dietary card did not include the prescribed dietary supplements. The resident expressed confusion about the reason for the liquid diet and mentioned only being able to consume liquids and tomato soup. The Dietary Manager (V5) admitted to not reassessing R22's dietary needs or preferences since the readmission and was unaware of the specific dietary requirements for a full liquid diet. The cook (V6) confirmed that R22 was primarily receiving chicken broth, tomato soup, and occasionally pudding, but noted that R22 had refused pudding and yogurt. The facility's policy mandates that residents at nutritional risk be monitored and assessed by a consultant dietitian within 72 hours of a significant change, which was not adhered to in this case.
Failure to Ensure Physician Assessment Within 30 Days of Admission
Penalty
Summary
The facility failed to ensure that two residents were assessed by a physician within the first 30 days after admission. Resident R22 was admitted 65 days ago with diagnoses including dementia without behavioral disturbance, atherosclerosis, and a non-pressure chronic ulcer of part of the foot. R22's records showed visits by a Nurse Practitioner on three occasions, but no visit by a physician. R22 expressed frustration about not being seen by a doctor and was misinformed by facility staff that a Nurse Practitioner is a doctor. The Clinical Coordinator confirmed that R22 had not been seen by a physician since admission. Similarly, Resident R9, admitted with diagnoses including anxiety, mood disorder, bipolar disorder, hydrocephalus, gastro-esophageal reflux disease, constipation, spinal stenosis, urinary tract infection, and chronic kidney disease, had not been seen by a physician since admission. R9's records showed visits by a Nurse Practitioner but no evidence of a physician's assessment. The facility's policy mandates that a physician must see each resident within the first 30 days of admission, which was not adhered to in these cases.
Failure to Administer Scheduled Medication
Penalty
Summary
The facility failed to ensure a scheduled medication was available for administration for a resident with severe cognitive impairment and multiple diagnoses, including anxiety disorder. The resident's care plan required the administration of Alprazolam three times daily to manage anxiety. However, from 8/25/23 to 8/31/23, the medication was not administered due to various issues, including a malfunctioning narcotic box, unavailability of the medication, and delays in receiving a new prescription from the pharmacy. This resulted in 18 missed doses of Alprazolam over the course of six days. Despite multiple attempts by the nursing staff to resolve the issue, including contacting the pharmacy and the Nurse Practitioner, the medication was not delivered in a timely manner. The Assistant Director of Nursing acknowledged that the medication should have been documented as missed and that follow-up actions should have been taken to ensure its availability. The facility's policy stated that medications should be administered and documented as ordered by the physician, but this was not adhered to in this case.
Failure to Ensure Palatable and Properly Cooked Vegetables
Penalty
Summary
The facility failed to ensure that vegetables served to residents were palatable and prepared according to acceptable standards. During an observation, the surveyor noted that the mixed vegetables were overcooked to the point of being mushy and bland. The cook admitted to boiling the vegetables for 45 minutes and then keeping them warm in the oven, which resulted in the undesirable texture. Additionally, the dietary manager confirmed that salt was omitted from the recipe due to many residents being on a low sodium diet, further contributing to the bland taste. Residents R1 and R13 both expressed dissatisfaction with the vegetables, stating they were too soft and flavorless, leading to uneaten portions on their trays. The dietitian confirmed that vegetables should not be boiled until mushy, and the recipe for mixed vegetables indicated the addition of salt, pepper, and margarine, but did not specify cooking times. The care plans for R1 and R13 indicated that they should consume 75% of their ordered diet daily and that their diets should be modified according to their food preferences. However, the overcooked and bland vegetables did not meet these preferences, resulting in the residents not eating the vegetables as part of their meals.
Failure to Adhere to Contact Isolation Protocols
Penalty
Summary
The facility failed to ensure the correct personal protective equipment (PPE) was worn while providing care for a resident in contact isolation with a multi-drug resistant organism (MDRO). Specifically, a registered nurse entered the resident's room without wearing a gown, despite signage indicating that gown and gloves were required. The nurse performed tasks such as checking the resident's blood sugar and administering insulin, during which her scrub pants came into contact with the resident's bedding. This occurred even though the resident's care plan and room signage clearly indicated the need for contact precautions due to a MRSA infection in an abscess on the resident's back. The infection preventionist confirmed that gown and gloves are required whenever staff enter a contact isolation room to prevent the spread of infection. The facility's infection control policy also mandates the use of contact precautions for residents known or suspected to be infected with transmissible microorganisms. The failure to adhere to these precautions was observed and documented, highlighting a significant lapse in infection control practices within the facility.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
