Serenity Estates Of Lincolnshire
Inspection history, citations, penalties and survey trends for this long-term care facility in Lincolnshire, Illinois.
- Location
- 150 Jamestown Lane, Lincolnshire, Illinois 60069
- CMS Provider Number
- 146028
- Inspections on file
- 41
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 15 (1 serious)
Citation history
Health deficiencies cited at Serenity Estates Of Lincolnshire during CMS and state inspections, most recent first.
A resident with multiple chronic conditions, including CKD, morbid obesity, gait abnormalities, depression, and anxiety, reported to her insurance case manager and later to staff that a CNA repeatedly called her “big” and “fat,” which she found abusive. She stated she had informed several CNAs and an LPN about these comments. The Administrator and identified staff denied receiving any such report, while another CNA acknowledged that the resident had told her about being called “fat” and feeling abused but admitted she did not report the allegation to anyone. This failure to report occurred despite a facility policy requiring all abuse allegations, regardless of source or severity, to be immediately reported and investigated.
Two residents with multiple chronic conditions, mobility limitations, and cognitive communication deficits reported that a CNA made demeaning comments about a resident’s weight, was rough and aggressive during care, jostled a resident "like a piece of meat," restricted a resident’s access to his remote and meals outside his room, and complained about assisting with leg positioning. The administrator stated she had not received prior reports of verbal abuse or rough care, yet time records showed the accused CNA continued working multiple shifts after these allegations arose, instead of being immediately removed from duty as required by the facility’s abuse policy.
A cognitively impaired, high elopement-risk resident with dementia, altered mental status, and multiple safety risk factors eloped from the facility in a wheelchair after an exit door alarm sounded during the night. Staff turned off the alarm, briefly checked outside, and inconsistently reported whether a full head count was completed or communicated to the nursing supervisor, who stated she was never notified of the alarm and did not perform a head count. The resident, whose wandering risk was documented but whose photo was not included in the facility’s wandering "Walkers" binder, was later found by police about a block away, disoriented, very cold, in urine-soaked clothing, and without appropriate winter gear. EMS documented cold exposure and hypothermia, and the ED later recorded a low rectal temperature before discharge. Interviews and record review showed the facility did not follow its elopement policy, did not effectively respond to the door alarm, and failed to ensure all residents were accounted for, resulting in the resident’s unsupervised exit and cold exposure.
The facility failed to ensure ordered medications were available and administered as prescribed for several residents. One resident repeatedly missed doses of ordered ophthalmic ointment and cough medication because they were not available, and an RN reported the eye ointment had not been on hand for weeks, yet she documented it as given based on a family supply. Another resident, who returned from the ER with a painful tongue injury, did not receive any doses of a prescribed compounded mouthwash, which pharmacy records show was never delivered. A third resident missed multiple bedtime doses of prazosin ordered for dreams, with documentation indicating the drug was still on order. The DON acknowledged that medications should be reordered with 2–3 days’ supply remaining and that residents should not go without ordered medications, as reflected in the facility’s medication administration policy.
Two residents did not receive multiple ordered doses of critical medications when drugs were not available and remained "on order." One resident with a history of pulmonary embolism missed several doses of enoxaparin 100 mg SQ BID, and reported that the facility frequently ran out of her medications. Another resident with a seizure disorder missed several doses of levetiracetam 500 mg (three tablets BID) because the medication was not available. The NP confirmed both medications were prescribed to prevent serious conditions and stated she was not notified of the missed doses, while the DON and facility policy indicated medications should be reordered with 2–3 days’ supply remaining so residents do not go without ordered medications.
A resident with an acute cough had a respiratory viral panel ordered by an NP, who entered the order into the computer and informed nursing staff, but the test was never completed. The DON later confirmed there was no documentation that a specimen was collected, no lab requisition was found, and no evidence the sample was sent to the lab, despite facility policy requiring nursing staff to carry out ordered lab tests and ensure results are obtained.
A resident with an acute cough and a history of chronic bronchitis and pneumonia had a STAT chest x-ray ordered by an NP, who entered the order into the computer and informed nursing staff. The DON reported that the facility’s protocol requires nursing staff to call the x-ray provider for STAT orders, which are typically completed within hours with same-day results, but no documentation or evidence of the x-ray being performed or results received could be found. This failure to carry out the STAT radiology order did not follow the facility’s policy requiring timely provision or procurement of ordered diagnostic services.
A resident with dementia and limited English proficiency, whose records specified Mandarin as the preferred language and a need for an interpreter, experienced a fall and later developed left hip and left elbow fractures. Staff and EMS reported that no formal translation services were used and that staff relied on English and interpreting the resident’s moans, including a repeated word later identified by family as meaning “ouch.” A night LPN found the resident on the floor, documented no pain, gave acetaminophen “just in case,” and moved her, but the fall note was entered more than two days later. The oncoming RN was told only that the resident was in pain, obtained stat X‑rays, and the NP was not informed of a recent fall at the time of consultation. EMS and hospital records documented fractures and noted that staff reported the fall had occurred several days earlier. These actions and omissions, including lack of effective communication, incomplete post‑fall assessment, and delayed documentation, led to the resident experiencing pain and a delay in treatment.
A resident with dementia, prior fracture, osteoarthritis, and spinal conditions experienced two documented falls, including one from bed with head impact and another where the resident was found on the floor and later diagnosed with a left hip and elbow fracture. In both events, nursing staff delayed or failed to notify the resident’s family and the NP, despite facility policy requiring immediate notification of physician and family after any fall. The daughter/POA reported learning of each fall well after the events, and both the DON and NP confirmed that timely notification is expected so they can be aware of changes and make informed decisions.
A resident with multiple serious diagnoses experienced respiratory distress and was unable to reach staff for 45 minutes, ultimately calling 911 for help. Emergency responders found the resident in distress with low oxygen saturation and no staff present for at least 10 minutes after their arrival. Documentation showed no recent vital signs or assessments, and staff interviews confirmed delayed response and lack of awareness of the resident's condition.
Two residents requiring substantial staff assistance for incontinence care and toileting did not receive timely support, resulting in prolonged periods without being changed or toileted. One resident remained in soiled bedding for hours despite repeated requests, while another, cognitively impaired, was left in a wheelchair for an extended period without incontinence care, contrary to facility policy.
A CNA transferred a resident alone using only a gait belt, despite the resident's updated care plan requiring a mechanical lift with two staff due to increased weakness. The CNA was unaware of the change in transfer status after returning from leave, leading to a transfer that did not follow the resident's current safety requirements.
Several residents requiring substantial assistance with ADLs and incontinence care did not receive timely care or medication administration due to insufficient nursing staff. Staff interviews and observations revealed that CNAs and nurses were stretched across multiple units, resulting in delayed incontinence care and late medication passes, contrary to facility policy and care requirements.
Staff failed to administer and document medications as ordered for three residents, including missed doses of an antifungal for a resident with a skin rash and late administration of scheduled medications for two other residents. The DON confirmed that undocumented medications were not given, and facility policy requires timely and accurate medication administration and documentation.
Two residents did not receive their scheduled medications at the ordered times, with doses administered more than one hour late by nursing staff. This resulted in a medication error rate of 20%, surpassing the facility's acceptable threshold, as confirmed by the DON and facility policy.
Two residents with PICC lines did not receive timely dressing changes or proper labeling of IV tubing, as required by facility policy. Staff demonstrated inconsistent knowledge and practices regarding the frequency of dressing and tubing changes, and documentation was lacking for required procedures. These failures resulted in missed dressing changes and unlabeled IV tubing for residents receiving IV antibiotics.
Two residents did not receive scheduled IV antibiotics as ordered because the medication was not available, and staff documented the missed doses and contacted the pharmacy, but the medication was not administered as required by physician orders and facility policy.
A resident's family member filed a grievance regarding care concerns, but the facility failed to maintain the written grievance and did not follow its policy for tracking and resolving grievances. The grievance form was submitted to the receptionist and placed in the DON's mailbox, but was not found in facility records, and staff could not account for its whereabouts. This resulted in a failure to honor the resident's right to voice grievances without discrimination or reprisal.
A dependent resident with severe cognitive impairment and multiple medical conditions was not safely positioned during a meal, resulting in her contracted shins being pressed against the edge of a dining table. This improper positioning led to linear, reddened wounds on both shins, as observed by the wound care nurse. The care plan did not address the skin concerns from the incident, and the facility's policy to provide a safe environment and prevent skin injuries was not adequately followed.
Surveyors found that food items in storage were not properly labeled, dated, or sealed, including opened bags of vegetables, hot dogs, and rice, as well as an improperly closed tub of ice cream. A dietary aide was observed with hair not fully restrained by a hair net, and a sanitation bucket was found to contain soap instead of sanitizer, failing to meet required concentration levels. These actions did not comply with facility policies for food safety and hygiene.
Two residents did not receive proper pressure ulcer prevention interventions as required by their care plans and physician orders. One resident's low air loss mattress was set incorrectly, leading to the development of a new pressure ulcer, while another resident did not have both feet properly offloaded despite multiple wounds and immobility. Staff failed to consistently follow established protocols for pressure ulcer prevention and management.
A resident with multiple medical and psychiatric conditions, including paraplegia and nicotine dependence, was allowed to smoke unsupervised in the courtyard on several occasions, despite requiring substantial assistance for daily activities. The resident kept cigarettes and a lighter accessible in her room and was observed calling for help with shaky hands while smoking, with no staff present to assist. Another resident was able to access her smoking materials, and staff did not respond to her distress, contrary to facility policy and the DON's statements regarding supervision and safety.
A resident with a history of malnutrition and special dietary needs was not served lunch while others at her table were eating. Staff served meals in a random order and failed to notice the omission until another resident brought it to their attention. The resident remained without food for an extended period, despite having a meal ticket indicating her required diet.
Three residents were found with medications left in their possession or self-administering without nurse supervision, including oral pills and topical cream, despite not being assessed or care planned for self-administration. Staff confirmed that no residents on the unit were authorized for self-administration, and a pill was also found unattended in a dining area.
Staff failed to consistently wear required PPE, such as gowns and gloves, when providing direct care to multiple residents on enhanced barrier precautions due to wounds. In several cases, CNAs provided wound care, hygiene, and linen changes without proper PPE, and soiled linens were carried without being bagged, contrary to facility policy and care plans.
A resident with dementia and high fall risk was found on the floor with her arm trapped between a bed rail and mattress, resulting in a comminuted humerus fracture. Staff provided inconsistent supervision and did not individualize fall interventions, and the bed rails were installed with a gap wide enough for entrapment, contrary to facility policy. The resident's care plan relied on reminders to use the call light, despite her cognitive deficits and history of not using it.
A resident with an LVAD did not receive daily sterile wet kit dressing changes as ordered, and staff used inappropriate supplies and monitoring methods, including missed dressing changes and use of an automatic blood pressure machine instead of manual checks. Documentation and staff interviews confirmed multiple lapses in following prescribed LVAD care and monitoring protocols.
A facility failed to assess and monitor a resident's skin integrity and did not obtain a physician's order for wound care. The resident, with a history of multiple health issues, was found with reddened areas and scabs on her forearm, but no documentation or treatment orders were present. The Wound Nurse had not noted any issues in a prior assessment, and the DON emphasized the need for treatment orders and documentation, as per facility policy.
A resident with a hearing impairment was excluded from her care plan meeting, despite being cognitively intact and able to express her needs. The facility's social services staff discussed her care with her daughter without her consent, citing HIPAA concerns. The resident had explicitly requested to be included in all meetings, and the facility's policy mandates resident participation in care planning.
The facility did not provide pressure relieving mattresses for two residents with severe pressure ulcers, despite having orders for such equipment. One resident had a Stage 4 ulcer on the sacrum and a Stage 3 ulcer on the ischial tuberosity, while another had a Stage 3 ulcer on the sacrum. The wound care nurse confirmed the need for low air loss mattresses, which were not supplied, contrary to the facility's policy on pressure ulcer management.
A resident with severe cognitive impairment and a history of wandering fell in the hallway due to inadequate supervision. The resident, who required supervision for walking, was found with a bruise on her forehead after the fall. At the time, only one RN was present on the unit, as other staff were unavailable, leading to insufficient supervision.
A resident with stomach cancer experienced severe pain due to the facility's failure to manage her Norco medication supply. Despite the facility's policy for timely medication refills and access to emergency medication, the resident faced delays and had to seek specific nurses for assistance. The resident's medical records confirmed a gap in receiving Norco, highlighting ongoing issues with medication availability and administration.
A facility failed to administer a resident's prescribed Flonase nasal spray due to it being unavailable. The medication was not given on multiple occasions, and it was incorrectly marked as administered once. An LPN discovered the issue and learned from the pharmacy that the medication was not sent because an over-the-counter form was missing. The DON stated that timely follow-up on unavailable medications is required, as per facility policy.
A facility failed to obtain physician orders for a resident upon admission, despite the presence of wounds. An LPN admitted to not calling a provider for necessary wound care orders, and the DON confirmed that the protocol requires obtaining appropriate orders upon admission. A review showed no active orders for wound care were entered, contrary to the facility's policy.
A resident admitted with wounds did not receive appropriate wound care assessment and treatment. The LPN did not change the resident's dressing upon admission, and the facility failed to follow its wound care protocol. The Wound Nurse was not contacted for recommendations, and no wound care orders were obtained from the physician. The resident's TAR lacked documentation of wound care, and the admission assessment was incomplete.
A resident with severe cognitive impairment and a history of falls was not adequately supervised while ambulating, leading to a fall and serious injuries. Despite the care plan requiring supervision and assistance, the resident was found on the floor after an unwitnessed fall, resulting in a subarachnoid hemorrhage and a subdural hematoma.
The facility failed to conduct quarterly care plan conferences for three residents, leading to a deficiency in care planning. One resident reported never having a conference, and another's son requested one due to dissatisfaction with care. Documentation was delayed or missing, and the facility did not adhere to its policy supporting resident participation in care planning.
A facility failed to implement contact isolation precautions for a resident with scabies, leading to potential cross-contamination. The resident was not isolated, and a communal shower room was not disinfected after use. Housekeeping staff did not wear required PPE when cleaning isolation rooms. The facility lacked a specific scabies prevention policy during a change in ownership.
A resident with dementia and aggressive behaviors attacked another resident, causing a facial fracture. The incident occurred when the aggressive resident was left unsupervised, despite known risks. The injured resident was hospitalized for treatment.
A resident reported an alleged sexual abuse incident to a CNA, who failed to immediately report it to the appropriate authorities as required by the facility's policy. The Director of Nursing confirmed that all abuse allegations should be reported to the Administrator or the DON, but this protocol was not followed, resulting in a delay in reporting and investigation.
A resident left the facility on a community pass without staff awareness or a physician order. The receptionist did not inform the nursing staff, and the resident was reported missing later that evening. The resident was found safe the next day.
The facility failed to ensure medications were administered according to professional standards for two residents. One resident's medications were left on a table while he was asleep, and another resident's medications were left on her bedside table at her request, including a controlled substance and blood pressure medications. The facility's policy requires that medications be administered in a safe and timely manner, which was not followed.
Failure to Report Resident’s Allegation of Verbal Abuse
Penalty
Summary
The facility failed to ensure staff reported an allegation of verbal abuse to the abuse coordinator for one resident. The resident was recently admitted with multiple diagnoses including chronic kidney disease stage 3, gait and mobility abnormalities, depression, anxiety disorder, cognitive communication deficit, morbid obesity, type II diabetes mellitus, anemia, and chronic peripheral venous insufficiency. A facility assessment showed she was cognitively intact, had no range of motion impairment, used a walker and wheelchair for mobility, and required substantial/maximal assistance with most ADLs. During a visit, the resident’s insurance case manager reported that the resident, who is overweight and sensitive about her weight, stated that a CNA had verbally abused her by calling her “fat” and “big” on several occasions, and that this upset her. In a subsequent interview, the resident stated that on her first day in the facility the CNA told her “You’re so big,” and on days three, four, and five the CNA told her “You’re so fat.” She reported that she told two CNAs and an LPN about these comments but did not recall if she told anyone else. The Administrator stated she had been in communication with the resident since admission and had not received any reports of verbal abuse from the resident or staff. The CNAs and LPN identified by the resident denied that the resident had reported these comments to them. Another CNA later reported that a couple of weeks earlier the resident had told her that the same CNA was calling her “fat,” that the resident felt abused, and that the CNA had not apologized. This CNA acknowledged she did not report the allegation to anyone, despite knowing she should report when someone says they are being abused. The facility’s abuse policy required that all allegations, regardless of source or perceived severity, be immediately reported, thoroughly investigated, and addressed, but this did not occur in this case.
Failure to Immediately Suspend CNA After Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to immediately suspend a CNA who was the subject of abuse allegations, as required by its abuse policy. One resident with multiple chronic conditions, including chronic kidney disease, gait abnormalities, morbid obesity, and cognitive communication deficit, but assessed as cognitively intact, reported to an insurance case manager that a CNA had verbally abused her by calling her “fat” and “big” on several occasions. In a subsequent interview, the resident stated that on her first day in the facility the CNA told her, “You’re so big,” and on days three, four, and five the CNA told her, “You’re so fat.” The resident also reported that some staff, identified by name, complained about their backs when assisting her with lifting and positioning her legs in bed. The administrator stated she had been in communication with this resident since late February but had not received any reports from the resident or staff about the CNA making comments about the resident’s weight or staff complaining about back pain when assisting her. Another resident with Parkinson’s disease, diabetes, unsteadiness on feet, muscle weakness, cognitive communication deficit, anxiety, depression, and other chronic conditions, and who required staff assistance for transfers, toilet hygiene, bathing, and lower body dressing, reported aggressive and rough care by an unidentified female CNA from the midnight shift, described as a large, full-figured African American woman. He stated that when he was incontinent, this CNA would enter and ask, “What do you want,” jostle him around “like a piece of meat,” tell him to go to sleep, and accuse him of abusing call-light privileges. He further alleged that the same CNA who verbally abused the first resident confiscated his remote, restricted him to eating in his room, and was rough when helping him. The administrator reported having no prior reports of verbal abuse or rough care. Despite these allegations, time clock records showed the accused CNA continued to work, including double shifts on two consecutive weekend days and part of a weekday shift, before being suspended, contrary to the facility’s abuse policy that requires immediate separation of the alleged victim and accused staff and placing the accused on administrative leave pending investigation.
Failure to Prevent Elopement and Account for Cognitively Impaired Resident After Door Alarm
Penalty
Summary
The deficiency involves the facility’s failure to prevent the elopement of a cognitively impaired resident and to ensure that all residents were accounted for after a door alarm sounded. The resident had multiple diagnoses including dementia, altered mental status, anxiety disorder, unsteadiness on feet, malnutrition, alcohol abuse, pulmonary fibrosis, and a left femur fracture. An elopement risk assessment identified the resident as high risk for elopement, and the Minimum Data Set documented that the resident was not cognitively intact. CNA documentation on two dates in January showed elopement behaviors, and a nurse practitioner documented severe cognitive impairment and disorientation in late January and early February. The resident’s care plan noted cognitive impairment and multiple fall and safety risk factors, including poor safety awareness and dementia. Despite this, the resident’s picture was not included in the facility’s “Walkers” binder used to identify residents who wander. On the night of the incident, staff reported that the resident was last seen in bed asleep between approximately 3:45 AM and 4:00 AM. The RN on duty stated that the main exit door alarm sounded around 3:00–3:20 AM; she turned off the alarm, looked outside, and did not see anyone, but did not notify the nursing supervisor on other units. She reported that a resident head count was performed after the alarm, but this was not communicated consistently, as the nursing supervisor stated she was never notified of an alarm and did not perform a head count on her units. Another CNA gave conflicting statements about whether she recalled an alarm and whether a head count was done, but confirmed that she believed all residents were present at that time. The facility’s policy on elopement and wandering residents states that alarms are not a replacement for necessary supervision, that staff must respond to alarms in a timely manner, and that a systematic approach to monitoring and managing residents at risk for elopement is required. At approximately 5:42–5:43 AM, police responded to a 911 call from a passerby reporting a person in a wheelchair sitting outside in the cold. The police officer found the resident about a block away from the facility, in a wheelchair, wearing only a thin sweater with no winter gear, with a sweater on the ground nearby. The officer observed that the resident was very cold, shivering, had a shaky voice, smelled strongly of urine, and had wet pants in the groin area. The resident was disoriented, did not know where she lived or where she was going, and stated she had been outside all night. EMS arrived and documented cold exposure, chills, confusion, and cold skin, with an impression of hypothermia and emergent acuity. The resident was transported to the emergency department, where she was monitored and later documented to have a rectal temperature of 95.9°F at discharge. The police officer subsequently went to the facility and learned from staff that they had not known the resident had left the building until he informed them. He also reported that staff told him an exit door alarm had gone off around 3:30 AM but they were unable to confirm the cause, and he later observed wheelchair tracks in the snow near an employee exit door with an unshoveled sidewalk, suggesting a potential route of exit. These events demonstrate that the facility did not ensure adequate supervision and monitoring of a known high elopement-risk, cognitively impaired resident and did not effectively account for all residents after a door alarm sounded, resulting in the resident’s elopement and exposure to cold. The Immediate Jeopardy was determined to have begun when the resident was found outside in the cold in her wheelchair by herself and was transferred to the hospital for cold exposure. The administrator was notified of the Immediate Jeopardy several days later. Interviews with nursing staff, the nursing supervisor, the police officer, and the resident, along with review of clinical records, EMS and hospital documentation, and facility policies, confirmed that the facility failed to follow its own elopement and wandering policy, failed to ensure that a high-risk resident was properly identified in the wandering binder, and failed to ensure that all residents were accounted for when an exit door alarm sounded. These failures led directly to the resident’s unsupervised exit from the facility and subsequent cold exposure. The sidewalk route the resident likely used included broken and uneven concrete and led around the facility to a shopping plaza parking lot. The police officer believed the resident left near the employee exit door because the sidewalk there was not shoveled and he observed wheelchair markings in the snow. The resident later told EMS that she had been outside all night and had been living outside for a couple of months, although she had in fact been residing in the facility. When interviewed by the surveyor, the resident could not recall going outside in the cold or speaking with a police officer, and inaccurately reported that she went out the front door to smoke a couple of times a day, despite not having smoked since admission. These observations further illustrate the resident’s cognitive impairment and confusion at the time of the elopement and underscore the facility’s failure to provide adequate supervision and monitoring for a resident known to be at high risk for elopement.
Removal Plan
- All residents were reassessed for elopement risk.
- All residents identified as high risk for elopement had care plans reviewed for accuracy.
- Elopement binder reviewed and updated to reflect high risk residents.
- An emergency QAPI was held to review policies/procedures.
- Daily door alarm audits began.
- Door alarm added to interior door leading to staff entrance.
- Second door alarms added to reception door as well as the exit between two units in order to double alarm all exits.
- Additional speakers added so alarms are more audible.
- In-Service/Education was initiated on the facility's door alarm protocol, responding to alarms, and completing head counts.
- R1 was moved to a secured unit.
- The Administrator or designee will perform elopement risk assessment audits to ensure compliance with transfer protocols; findings will be reviewed during Quality Assurance and Performance Improvement meetings monthly; noncompliance will result in immediate corrective action and additional staff training; monitoring will continue until the QAPI committee determines sustained compliance has been achieved.
- The Administrator or designee will perform door alarm response audits to ensure compliance with transfer protocols; findings will be reviewed during Quality Assurance and Performance Improvement meetings monthly; noncompliance will result in immediate corrective action and additional staff training; monitoring will continue until the QAPI committee determines sustained compliance has been achieved.
Failure to Ensure Availability and Administration of Ordered Medications
Penalty
Summary
The facility failed to provide pharmaceutical services and administer medications as ordered for multiple residents when medications were unavailable or not obtained in a timely manner. One resident had an order for Muro 128 ophthalmic ointment to be instilled in the right eye twice daily beginning in early December, but the January and February MARs show multiple missed doses with administration notes stating the medication was not available. A registered nurse reported that during her two weeks at the facility the ointment was never available until recently, that she had called the pharmacy but it never arrived, and that she signed the medication as administered despite not having it because the resident’s mother had a supply. The same resident also had an order for dextromethorphan for cough, with the MAR showing missed doses and notes indicating the medication was not available. Another resident returned from the emergency room with new orders, including a compounded “Magic Mouthwash” for pain control after biting her tongue and having blood in her mouth. The MAR shows that this resident did not receive several ordered doses, and the pharmacy proof of delivery list indicates the mouthwash was never delivered. A nurse practitioner confirmed that the mouthwash was ordered for pain control and did not believe the resident ever received it. A third resident, who was ordered prazosin 2 mg at bedtime for dreams, missed several doses on the January and February MARs, with order-administration notes stating the medication was on order. The DON stated that all medications should be administered as ordered, that medications should be reordered when there is a 2–3 day supply remaining, and that residents should not have to go without their ordered medications, consistent with the facility’s medication administration policy.
Missed Doses of Anticoagulant and Anticonvulsant Due to Medication Unavailability
Penalty
Summary
The facility failed to ensure that ordered medications were administered as prescribed, resulting in missed doses of significant medications for two residents. One resident with a history of pulmonary embolism, diagnosed on 11/4/25, had an order for enoxaparin 100 mg subcutaneously twice daily starting 1/2/26 to treat and prevent blood clots. The January MAR shows this resident did not receive the PM dose on 1/2/26, both AM and PM doses on 1/19/26, the PM dose on 1/20/26, and both AM and PM doses on 1/26/26. The administration notes for these dates document that the medication was "on order." The resident reported that the facility was constantly running out of her medications and that she had missed multiple doses, and the nurse practitioner confirmed that the resident was on enoxaparin to prevent additional blood clots and to keep the previous clot from worsening, and that it was important she receive the doses as ordered. Another resident with a seizure disorder had an order for levetiracetam 500 mg, three tablets twice a day as an anticonvulsant. The January MAR shows this resident did not receive either the AM or PM dose on 1/20/26 and did not receive the AM dose on 1/21/26, with administration notes indicating the medication was not available. The nurse practitioner stated that the resident is on levetiracetam to prevent seizures, that it should be given as ordered, and that missing too many doses could result in a seizure. The nurse practitioner also stated that if a medication is not available, staff should call her for direction, and she was not aware that this resident had missed any doses. The DON stated that all medications should be administered as ordered, that medications should be reordered when there is a 2–3 day supply remaining, and that residents should not have to go without their ordered medications. The facility’s Medication Administration Policy, revised 9/1/24, directs staff to reorder medications from the pharmacy when there is a 2–3 day supply remaining.
Failure to Complete Ordered Respiratory Viral Panel
Penalty
Summary
The facility failed to ensure that an ordered respiratory viral panel was performed for one resident. A nurse practitioner documented an acute cough for Resident R4 and entered an order for a respiratory viral panel on 2/5/26, also verbally informing the nurse of the order. During a later interview, the nurse practitioner stated she had not seen any test results and did not know whether the test had been completed. The Director of Nursing explained that when a provider orders a respiratory viral panel, nursing staff are responsible for collecting the specimen, notifying the laboratory for pickup, and completing a lab requisition form, but she was unable to find any evidence that a specimen had been collected or sent. This failure occurred despite a facility policy requiring that laboratory and diagnostic services ordered by authorized providers be obtained to meet residents’ needs and that nurses carry out such orders per facility protocol.
Failure to Obtain Ordered STAT Chest X-Ray
Penalty
Summary
The facility failed to obtain a STAT chest x-ray as ordered for one resident, resulting in noncompliance with its policy to provide or obtain timely diagnostic services. A nurse practitioner documented on 2/5/26 that the resident had an acute cough and, due to a history of chronic bronchitis and pneumonia, ordered a STAT chest x-ray, entering the order into the computer and verbally informing the nurse. The nurse practitioner later stated she had not seen any x-ray results and did not know if the x-ray had been completed. The DON explained that the facility’s process for a STAT x-ray requires the nurse to call the x-ray provider, who typically performs the x-ray within four hours with same-day results, but she was unable to find any evidence that the x-ray had been performed. The facility’s Laboratory and Diagnostic Services and Reporting Policy requires that laboratory and diagnostic services, including radiology, be provided or obtained when ordered and that nurses carry out such orders per facility protocol.
Failure to Assess Post-Fall Injuries and Provide Translation, Resulting in Delayed Fracture Treatment
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary care, services, and effective translation for a resident after a fall that resulted in hip and arm fractures. The resident had dementia, prior fractures, osteoarthritis, and spinal stenosis, required substantial/maximal assistance for most ADLs, and used a wheelchair. Her MDS documented Mandarin as her preferred language and that she wanted an interpreter to communicate with health care staff, and also showed she had no range of motion limitations prior to the events. Despite this, multiple staff and responding paramedics reported that the facility did not use translation services and instead relied on speaking English and interpreting the resident’s moans and groans, with staff and paramedics unsuccessfully attempting to use phone-based translation on their own. On one date, the resident fell from bed while attempting a self-transfer, landing on her left side and bumping a dresser, with a small bruise to the left forehead documented and no pain or functional change reported at that time. The NP note for that fall described no change in mental status, pain, or ADL function post-event. Over the following weekend, the resident’s daughter and primary nurse reported that the resident was walking, using both arms, and not exhibiting pain. However, the roommate later reported hearing a loud fall on a subsequent night, describing the resident crawling to her side of the room, wedging herself by the door, and moaning and yelling in apparent pain. The roommate stated she activated the call light, staff had difficulty entering due to the resident’s position, and the resident was taken out in a chair and later returned to bed, with the roommate noting that the resident was in pain when moved. The roommate, who was cognitively intact per her MDS, also reported that staff did not use translator services and that she sometimes used Google Translate herself and had learned from the daughter that certain commonly used words meant “pain” and “bathroom.” The night LPN later stated she found the resident on the floor around 12:30 a.m. during rounds, assessed her, and documented no pain or abnormal findings, gave acetaminophen “just in case,” and moved her to a wheelchair near the nurses’ station before she was later returned to bed. This fall note, however, was not entered until more than two days later and after the survey began, and the NP indicated she would not have seen a fall note in the chart at the time she was consulted. The day RN reported being told only that the resident was in pain and pointing to her hip, not that a fall had occurred, and obtained stat X‑ray orders for the left hip and forearm. CNAs reported that on the morning after the undocumented fall the resident remained in bed, ate in her room, and repeatedly said “Iyo” during care, a word they did not understand; the daughter later explained that “Iyo” meant “ouch” or pain. When EMS arrived for transfer after X‑rays showed fractures, paramedics found the resident in bed, noted bruising to the left side of her face and guarding of the left arm, and documented that staff reported a hip and left forearm fracture from a fall five days prior and that the resident only spoke Chinese. Paramedics reported that facility nurses told them they had no translator and that they communicated with the resident in English and interpreted her needs from sounds. Hospital evaluation confirmed a left hip fracture and displaced left elbow fracture, with the orthopedic note stating that staff reported the resident had started moaning the prior night and that X‑rays at the facility showed the fractures. The facility’s own policies required effective communication and language assistance services, as well as thorough assessment, documentation, and post‑fall procedures after any fall or change in condition, but the record and interviews showed gaps in timely fall documentation, incomplete communication of the fall and pain to the NP and oncoming staff, and lack of effective translation services, resulting in the resident experiencing pain and a delay in treatment.
Failure to Promptly Notify Family and NP After Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a resident’s family and nurse practitioner after two separate falls. The resident had dementia, a prior pubic fracture, osteoarthritis, a right shoulder bone density disorder, and spinal stenosis. On one occasion, a nurse documented that the resident fell from bed while attempting a self-transfer, landing on her left side and bumping a small dresser, resulting in a small bruise on the left side of the forehead. The nurse later stated she did not notify the resident’s family of this fall until the following day, despite recognizing that the resident must have hit her head due to the mark and bruise. The resident’s daughter/POA confirmed she was not notified of this fall until the next day and stated she expected to be called right away. On another occasion, a nurse documented that during routine rounds around 12:30 a.m., the resident was found lying supine on the floor in her room wearing non-skid socks and gesturing to staff to get her up. Less than 24 hours after this fall, the resident was diagnosed with a fractured left hip and left elbow. The LPN who authored the note stated she did not notify the family or the nurse practitioner after this fall. The resident’s daughter/POA reported she was not informed of this second fall until two days later by the DON. The DON stated that staff are expected to notify the family and provider after a resident falls so they can be aware of changes and make informed decisions, and the nurse practitioner stated she had not been notified of the fall and would have seen the resident if she had known. The facility’s Fall Prevention Program policy, reviewed 9/1/24, requires that after any resident fall, staff assess the resident, complete a post-fall assessment and incident report, notify the physician and family, and document all assessments and actions, which did not occur as required in these instances.
Failure to Assess and Respond to Resident's Change in Condition
Penalty
Summary
The facility failed to identify and assess a resident experiencing a change in condition that required medical intervention. The resident, who had diagnoses including esophageal cancer, lung cancer with brain metastasis, anxiety, COPD, and dyspnea, called 911 himself after reportedly attempting to contact nursing staff for 45 minutes without success. Upon arrival, emergency responders found the resident in his bed, alert but in obvious respiratory distress, with an oxygen saturation of 88% on room air and labored respirations. The ambulance crew noted that the resident's abdomen was distended and rigid, and his respiratory effort improved only after oxygen was administered. The paramedics and police reported that no staff were present in the area for at least 10 minutes after their arrival, and the resident was loaded onto the cot before any staff appeared. Documentation in the resident's electronic medical record showed no recorded vital signs or assessments between the evening prior to the incident and the time of transfer to the hospital. The last documented vital signs were from the previous day, and there was no evidence of staff response to the resident's attempts to seek help during his respiratory distress. Interviews with staff indicated that the nurse was occupied on another unit and did not hear calls for assistance, while another resident reported hearing the affected resident yelling for help. The assigned CNA could not be reached for comment prior to the survey exit.
Failure to Provide Timely Incontinence Care and ADL Assistance
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADLs), specifically incontinence care and toileting, for two residents who required substantial staff support. One resident, who was incontinent of urine and stool and required significant help with personal hygiene and toileting, was observed with a call light on for over two hours while requesting to be changed due to being soaked in urine. Despite repeated requests and staff acknowledgment of the need, the resident was not provided incontinence care until nearly ten hours after the last change, resulting in saturated bedding and a wet mattress. Another resident, cognitively impaired due to dementia and also requiring substantial assistance for hygiene and toileting, remained in a wheelchair in a common area for several hours without being toileted or changed. Staff were unable to confirm when incontinence care was last provided, and the assigned CNA reported not having had time to attend to the resident since the start of the shift. Facility policy requires incontinence care at least every two hours, but this standard was not met for either resident.
Unsafe Transfer Performed Without Required Equipment and Assistance
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident from a wheelchair to bed using only a gait belt and without assistance, despite the resident's care plan requiring a mechanical (hoyer) lift with two staff for all transfers. The resident's transfer status had been updated in May to require the use of a hoyer lift due to declining strength and inability to use a sit-to-stand lift. The CNA, who had recently returned from medical leave, was unaware of the change in the resident's transfer requirements and performed the transfer alone. Interviews with facility staff confirmed that the resident was too weak to be safely transferred by one person with a gait belt.
Failure to Provide Sufficient Nursing Staff for Resident Care and Timely Medication Administration
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of several residents, as evidenced by direct observations, interviews, and record reviews. One resident, who required substantial assistance with personal hygiene and toileting due to incontinence, was left with a call light on for over an hour and a half without receiving incontinence care. The resident reported that their incontinence brief had not been changed since the previous night, and staff confirmed that there was inadequate staffing on the unit, with only one nurse and 1.5 CNAs available for a heavy long-term care unit. The resident's medications were also administered over an hour late due to staffing shortages. Another resident, who was cognitively impaired and required substantial assistance for personal hygiene and toileting, remained in a wheelchair in the dining room for several hours without being changed or toileted. The CNA responsible for this resident was also assigned to another unit and had not yet provided incontinence care, stating that he had been too busy with other residents. Staff interviews confirmed that residents were not being toileted or changed every two hours as required. A third resident did not receive scheduled medications on time, with administration occurring nearly two hours late. The LPN responsible stated she was the only nurse on the unit and was unfamiliar with the residents, working on a PRN basis. The Director of Nursing confirmed that medications should be administered within one hour of the scheduled time and that the goal was to meet state staffing requirements and resident care needs. The facility's policy requires sufficient staff to ensure resident safety and well-being, but observations and staff statements indicated that staffing levels were inadequate to meet these standards.
Failure to Accurately Administer and Document Medications as Ordered
Penalty
Summary
The facility failed to accurately administer medications as ordered for three residents. For one resident with a skin rash, family reported that staff were not applying an antifungal medication daily as prescribed. Review of the Medication Administration Records (MAR) confirmed that several doses were missed over two months. The Director of Nursing confirmed that if a medication was not documented as given in the MAR, it meant the medication was not administered. For another resident, medications including Lyrica, Rifaximin, Senna, and Sodium Chloride were scheduled to be given at specific times, but were observed being administered outside of the scheduled time. Similarly, a third resident was prescribed Metoprolol Tartrate and Apixaban to be administered via gastrostomy tube at set times, but these were also given late. The DON stated that medications should be administered within one hour of the scheduled time, and the facility's policy requires adherence to the six rights of medication administration, including right time and right documentation.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 20%, which exceeds the acceptable threshold of 5%. Specifically, two residents were observed receiving their scheduled morning medications significantly late. One resident was prescribed Lyrica, Rifaximin, Senna, and Sodium Chloride to be administered at 9:00 AM, but these were given at 10:23 AM. Another resident was prescribed Metoprolol Tartrate and Apixaban for administration at 9:00 AM, but these were given at 10:47 AM. According to the facility's policy and the Director of Nursing, medications are considered late if administered more than one hour after the scheduled time. The survey identified 30 medication administration opportunities with 6 errors, all related to late administration, during the observed medication pass.
Failure to Ensure Timely and Documented PICC Dressing and IV Tubing Changes
Penalty
Summary
The facility failed to ensure proper infection control practices related to dressing changes and intravenous (IV) tubing changes for two residents with peripherally inserted central catheters (PICCs). Observations revealed that one resident's PICC insertion site was dressed but not labeled with a date or time, and the IV tubing was also unlabeled. The resident reported that staff did not change his PICC dressing weekly as required. Another resident had antibiotics infusing via a PICC line with tubing that was not labeled, and reported that his PICC dressing had not been changed for almost two weeks, with IV medication tubing in use for four days instead of the required 24 hours. Interviews with nursing staff revealed inconsistent knowledge and practices regarding the frequency of IV tubing and PICC dressing changes, as well as documentation requirements. Some staff stated that IV tubing should be changed every 24 hours, others said every 72 hours or three days, and there was confusion about labeling and documentation. Review of treatment administration records confirmed that required dressing changes were missed and not documented as completed. Facility policies required IV tubing to be labeled with date, time, and initials, and for PICC dressings to be changed weekly and documented, but these procedures were not consistently followed.
Failure to Administer IV Antibiotics as Ordered Due to Medication Unavailability
Penalty
Summary
The facility failed to administer intravenous (IV) antibiotics as ordered by the physician for two residents receiving IV therapy. One resident reported missing an entire day of IV antibiotics because the medication was not ordered, and this was confirmed by nursing staff who noted that the medication was not available and had not been administered. Documentation on the electronic medication administration record (EMAR) and progress notes indicated missed doses, with staff marking codes to indicate the medication was not available and noting communication with the pharmacy regarding the delay in delivery. The medication, Vancomycin, was not available for scheduled doses on multiple occasions, and staff confirmed that the missed doses were not given due to the unavailability of the medication. Nursing staff described their process for handling unavailable medications, which included checking the convenience box, contacting the pharmacy, and documenting the issue in the resident's records. However, there was no evidence that the physician was notified in all instances when the medication could not be obtained, as required by facility policy. The facility's Medication Administration Policy requires medications to be administered as ordered by the physician, and the MAR to be signed after administration, but the records showed that the IV antibiotics were not administered as scheduled for both residents due to medication unavailability.
Failure to Maintain and Track Resident Grievance Documentation
Penalty
Summary
The facility failed to maintain a written record of a grievance and did not follow its own grievance policy for one resident. The resident's daughter filed a grievance after observing her mother in pain, with her legs pressed against the edge of a table, resulting in wounds on her shins. The daughter completed the facility's grievance form and submitted it to the receptionist, who placed it in the DON's mailbox. However, the grievance form was not included in the facility's records when requested by the surveyor, and staff were unable to locate it. Interviews with staff revealed that the receptionist confirmed receiving the grievance form and placing it in the appropriate mailbox, but was unaware of what happened to it afterward. The Social Services Director stated that grievances are typically relayed to the appropriate department and that the Administrator should be aware of all grievances. However, the Social Services Director did not receive the form and only became aware of the concern after speaking with the resident's daughter days later. The Director of Nursing and Administrator also could not account for the missing grievance form. The facility's policy requires that the Administrator oversee the grievance process, track grievances through to their conclusion, and issue written decisions to the resident. The policy also states that staff receiving a grievance must record the specifics on the designated form and that all actions taken to resolve the grievance should be documented. In this case, the facility did not maintain the required documentation or follow the established grievance process, resulting in a failure to honor the resident's right to voice grievances without discrimination or reprisal.
Failure to Safely Position Dependent Resident Results in Skin Injury
Penalty
Summary
A dependent resident with severe cognitive impairment and multiple medical conditions, including cerebral atherosclerosis, peripheral vascular disease, multiple sclerosis, abnormal posture, dementia, diabetes, and dysphagia, was not safely positioned during a meal. The resident was placed in a reclining wheelchair at a 45-60 degree angle, causing her contracted knees and shins to be elevated above the dining table. Staff parked her diagonally next to the table, resulting in her shins being pressed against the table edge. This positioning led to linear, reddened areas and small wounds on both shins, as observed by the wound care nurse. The resident's daughter reported that during a visit, she found her mother with her shins pressed tightly against the table, causing pain and deep indents. The daughter released the wheelchair brakes and moved her mother away from the table, noting the marks and reporting the incident to staff. The CNA assigned to the resident stated that she had positioned the resident at the table with a nurse and believed the resident's legs were not touching the table when she left. However, it was acknowledged that the table may have been moved by another resident, resulting in the injury. Documentation showed that the resident was dependent on staff for all activities of daily living and had severe cognitive impairment, making her unable to communicate her needs effectively. The care plan did not address the skin concerns resulting from the incident. The facility's policy required interventions to provide a safe environment and prevent skin injuries, but these were not adequately implemented in this case, leading to minor traumatic wounds on the resident's shins.
Deficient Food Storage, Labeling, and Sanitation Practices
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage and handling practices. During a kitchen tour, an undated and opened bag of mixed vegetables, an undated and improperly sealed box of frozen hot dogs with visible frost, and an undated, improperly closed tub of chocolate ice cream with ice crystals were found in the walk-in freezer. In the dry storage room, an undated and opened box of parboiled rice was also observed. The Dietary Manager confirmed that all food items should be properly dated and sealed to maintain quality and prevent contamination. Additionally, a dietary aide was seen wearing a hair net that did not contain all of her hair, contrary to facility policy requiring all hair to be restrained for sanitation purposes. Further, a sanitizer test in the kitchen revealed that a sanitation bucket near the dish machine contained soap instead of sanitizer, as indicated by the test strip not changing to the required color for proper sanitizer concentration. The Dietary Manager acknowledged that the sanitizer concentration should be within the appropriate range to prevent bacterial growth. These observations were inconsistent with the facility's policies on food safety, labeling and dating foods, storage of dry goods, and staff hygiene practices.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to ensure appropriate pressure-relieving interventions were in place for two residents at risk for or with a history of pressure ulcers. For one resident with a history of sacral deep tissue injury and a current moderate risk for pressure ulcers, the low air loss mattress was set incorrectly at a setting far above the resident's actual weight. The wound care nurse confirmed that the mattress setting was too high, making it overly firm and increasing the risk of skin breakdown. The resident was found lying on her back, incontinent, and refusing to be repositioned, and a new stage 1 pressure ulcer was identified on her coccyx. The care plan required the mattress to be checked every shift, but this was not done appropriately, and the mattress was adjusted based on the resident's preference rather than clinical guidelines. For another resident with multiple wounds and a care plan requiring offloading of the feet with heel protectors or pillows, staff failed to ensure both feet were properly offloaded. The resident was observed in bed with only one offloading boot in place, while the other boot was not on the resident and was found on the nightstand. The CNA responsible for the resident was unaware of the need for both boots and did not notice the missing boot until it was pointed out. The resident's care plan and physician orders indicated the need for offloading due to immobility and existing wounds, but this intervention was not consistently implemented. Both cases demonstrate a lack of adherence to established care plans and physician orders regarding pressure ulcer prevention and management. Staff failed to ensure that pressure-relieving devices were used correctly and consistently, and did not follow facility policy requiring regular assessment and implementation of interventions to prevent the development or worsening of pressure ulcers.
Failure to Supervise Resident During Smoking Activities
Penalty
Summary
A deficiency occurred when the facility failed to ensure the safety of a resident while smoking. The resident, who had multiple diagnoses including anxiety disorder, major depressive disorder, chronic pain syndrome, paraplegia, and nicotine dependence, was assessed as a safe smoker and allowed to keep her cigarettes and lighter in her possession. Observations showed the resident smoking outside in the courtyard on multiple occasions without staff supervision, despite her care plan indicating she was at high risk for falls and required substantial to maximal assistance for activities of daily living. The resident reported that staff did not check on her while she was outside smoking, and she was observed with other residents, with no staff present, for extended periods. During one observation, another resident accessed the first resident's bag and took a cigarette, and the resident was seen crying out for help with shaky hands while holding a lit cigarette. No staff responded to her calls for help, and she remained unsupervised. The facility's policy required residents to be reassessed for safe smoking if there was a decline in condition or cognition and stated that smoking supplies should not be left accessible to other residents. The DON confirmed that residents exhibiting distress or changes in condition while smoking should be reassessed and that smoking materials should not be left out. Despite these policies, the resident was left unsupervised with smoking materials accessible to others, and her distress went unaddressed by staff.
Resident Missed Meal Due to Inadequate Meal Service System
Penalty
Summary
The facility failed to ensure that all residents received their meals as required, resulting in one resident not being served lunch while others at her table were eating. During the lunch service, staff were observed serving meals in a random order, and a resident with a mechanical soft diet and a history of significant weight loss was left without food for an extended period. Despite having a meal ticket indicating her dietary needs, the resident repeatedly stated she had not received her meal and appeared visibly upset and hungry. It was only after another resident alerted staff that the oversight was addressed. The affected resident had multiple medical diagnoses, including moderate protein-calorie malnutrition, heart disease, and dysphagia, and was at risk for fluctuating weights as documented in her care plan. The facility's policy required staff to ensure all components of the meal matched the diet card and resident preferences, but this process was not followed, leading to the resident missing her meal. Staff interviews confirmed the failure to serve the meal and acknowledged the lapse in the meal service system.
Failure to Ensure Safe Medication Administration and Adherence to Self-Administration Policy
Penalty
Summary
The facility failed to ensure that physician-prescribed medications were administered as ordered for three residents. One resident with multiple diagnoses, including osteoarthritis and dysphagia, was observed self-administering a cup of assorted pills at lunch without any nurse present. The resident stated that he usually takes his noon medications by himself in the dining room. Another resident with conditions such as rhabdomyolysis, hypothyroidism, and dementia was found with a medication cup containing an orange fluid on his bedside table, which he identified as his blood pressure medication. He reported that the nurse leaves the medication with him, and he takes it when he feels like it. A third resident with a history of cystitis, dementia, diabetes, and kidney transplant was found alone in her room with a tube of topical arthritis pain cream on her bedside table. An LPN acknowledged that the resident was not supposed to have the cream in her possession and that it should be kept in the medication cart. Additionally, an unidentifiable white pill was found on the counter in the group dining room, within easy reach of residents. The Assistant Director of Nurses identified the pill as acetaminophen but was unsure how it ended up there. Interviews with nursing staff and review of records revealed that no residents on the unit were assessed or care planned for self-administration of medications, despite facility policy requiring an interdisciplinary team assessment and care plan documentation before allowing self-administration. The Director of Nurses confirmed the absence of such assessments or care plans for the involved residents.
Failure to Ensure Proper PPE Use and Linen Handling for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff consistently wore appropriate personal protective equipment (PPE) when providing care to residents on enhanced barrier precautions (EBP) or transmission-based precautions. In one instance, a CNA entered a resident's room, which was marked with an EBP sign, and provided direct care involving wound dressings and offloading boots without wearing a gown or gloves, only a mask. The CNA was unaware of the resident's EBP status, believing the sign was left from a previous room assignment, despite the resident's care plan and physician orders indicating multiple wounds requiring EBP. Another incident involved a CNA providing peri-care and transferring a resident with multiple wounds while only wearing gloves and not a gown, despite an EBP sign posted outside the room. The CNA was unsure of the reason for the precautions, although documentation confirmed the resident was on EBP due to wounds. The care plan specified the need for gown and gloves during high-contact care activities, which was not followed during the observed care. A third case involved two CNAs changing the incontinence brief and bed linens of a resident with a stage 4 sacral pressure injury, both wearing only gloves and not gowns. One CNA carried soiled linens against her body and dropped a sheet in the hallway, and did not use a linen bag as required by facility policy. The Assistant Director of Nursing confirmed that gowns and gloves are required for EBP and that soiled linens should be bagged before removal from the room. Documentation for all three residents indicated the need for EBP due to wounds, and the facility's policy required proper handling of soiled linens to prevent contamination.
Failure to Prevent Accident Hazards and Ensure Safe Bed Rail Installation
Penalty
Summary
The facility failed to ensure that a resident at high risk for falls received adequate supervision and individualized fall interventions, and also failed to ensure that bed rails were installed in a manner that would prevent entrapment. The resident, an elderly female with multiple diagnoses including dementia with agitation, atrial fibrillation, diabetes, and hypertension, was assessed as a high fall risk with poor safety awareness and cognitive deficits. Despite her care plan indicating the need for partial to moderate assistance with transfers and toileting, staff reported inconsistent understanding of her needs, with some stating she could transfer independently and others noting she required extensive assistance and supervision. On the day of the incident, the resident was found kneeling on the floor next to her bed, with her right arm trapped between the side rail and the mattress, and her wheelchair positioned behind her. She was unable to explain what had happened and was experiencing significant pain in her right arm. The call light in the room had been activated by her roommate, not the resident herself, as she did not typically use the call light for assistance. Staff interviews revealed that the resident was forgetful, did not remember to use the call light, and would attempt to get up without assistance if left unsupervised. Observations confirmed that there was a gap between the mattress and the side rail wide enough for entrapment, and the bed rails were in the upright position at the time of the incident. Review of facility policies showed that bed rails should only be used after appropriate alternatives have been attempted, with informed consent and a physician's order required. The policy also mandates that installation must prevent gaps that could lead to entrapment. The resident's care plan interventions were not individualized, with repeated instructions to use the call light despite her cognitive deficits and history of non-compliance. The facility's failure to provide adequate supervision, individualized interventions, and safe installation of bed rails resulted in the resident sustaining a comminuted fracture of the right humerus.
Failure to Follow LVAD Care Orders and Monitoring Protocols
Penalty
Summary
The facility failed to consistently implement prescribed treatments and assessments for a resident with a Left Ventricular Assist Device (LVAD). The resident was observed with an undated dressing on the LVAD site, and reported that the dressing was not being changed daily as required, leading to concerns about infection and pain. Staff interviews revealed confusion regarding the frequency and type of dressing changes, with some staff using dry kits instead of the ordered sterile wet kits, and a lack of appropriate supplies on the unit. Documentation showed multiple missed dressing changes and incomplete monitoring of the LVAD and vital signs as ordered by the LVAD clinic. The resident had a history of LVAD infection and required daily sterile wet kit dressing changes to prevent further infection. Upon arrival at the facility, the resident's dressing had not been changed for 11 days, and the correct supplies were not readily available. Additionally, staff used an automatic blood pressure machine, which is not appropriate for LVAD patients, instead of the required manual method. These failures were confirmed through record review, staff interviews, and direct observation, indicating that the facility did not follow the physician's orders or the resident's care plan for LVAD management.
Failure to Document and Obtain Orders for Wound Care
Penalty
Summary
The facility failed to adequately assess and monitor a resident for skin integrity issues and did not obtain a physician's order for wound care. The resident, who has a medical history including anorexia, congestive heart failure, gout, hypertension, dementia, and Parkinson's Disease, was observed with reddened areas, scratch marks, and multiple small scabbed areas on her right forearm. A dressing was also noted on the forearm, which the resident could not recall when or by whom it was applied. There was no documentation in the resident's medical records, including physician orders, care plan, or treatment administration record, regarding the skin issue or treatment for the right forearm. The Wound Nurse reported that during her last assessment of the resident, no skin issues or dressings were present on the upper arms. The Director of Nursing stated that there should be a treatment order in place if a dressing is applied, and treatments should be documented accordingly. The facility's Wound Treatment Management policy requires evidence-based treatments in accordance with physician orders and documentation of treatments. However, the lack of documentation and physician orders for the resident's wound care indicates a failure to adhere to this policy.
Resident Excluded from Care Plan Meeting Due to Hearing Concerns
Penalty
Summary
The facility failed to include a resident, identified as R7, in her care plan meetings, violating her right to participate in her person-centered plan of care. R7, who was admitted with diagnoses including diabetes, a right leg above-the-knee amputation, and wounds, was cognitively intact and able to express her needs despite a hearing impairment. However, the facility conducted a care plan meeting without her presence, instead involving her daughter, despite R7's explicit request to be included and her ability to hear when spoken to directly and clearly. The facility's social services staff, V14, expressed concerns about HIPAA compliance due to R7's hearing difficulties, which led to the decision to exclude her from the meeting. The facility's policy on resident rights mandates that residents be informed and participate in their treatment and care planning. Despite this, R7 was not invited to her care plan meeting, and her financial affairs and prosthetic needs were discussed with her daughter without her consent. The social services staff acknowledged R7's desire to be included in meetings and admitted to not utilizing available communication aids, such as a communication board, to facilitate R7's participation. The facility's administrator confirmed that all residents should be included in their care plan meetings, highlighting a clear breach of the facility's policy and resident rights.
Failure to Provide Pressure Relieving Mattresses for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to implement necessary interventions to prevent and heal pressure ulcers for two residents. One resident was admitted with a Stage 4 pressure ulcer on the sacrum and a Stage 3 ulcer on the left ischial tuberosity, while another resident had a Stage 3 pressure ulcer on the sacrum. Both residents had orders for pressure relieving mattresses, which were not provided. The wound care nurse confirmed that these residents should have received low air loss mattresses due to the severity of their pressure ulcers, and she had informed maintenance of this requirement. The facility's policy emphasizes the commitment to provide treatment and services to heal pressure ulcers and prevent new ones, yet this was not adhered to in these cases.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision for a resident, identified as R8, who was at risk for falls due to severe cognitive impairment and a history of wandering. R8, who had diagnoses including dementia, Alzheimer's Disease, recurrent psychosis, and anorexia, required staff supervision for transfers and toileting and was able to walk without an assistive device but with supervision. On the date of the incident, R8 was found to have sustained an unwitnessed fall in the hallway, resulting in swelling and redness on her forehead. Despite being sent to the hospital for evaluation, no injuries were noted from the fall. At the time of the fall, the facility's nursing schedule indicated that only one staff member, V10 RN, was present on the unit, as the other assigned staff members, V11 CNA and V12 CNA, were not on the unit. V10 RN acknowledged seeing R8 walking in the hallway but was occupied with medication administration and unable to supervise R8. The lack of adequate staff presence and supervision contributed to the resident's fall, as V10 RN stated that if a CNA had been present, they could have potentially prevented the fall.
Failure in Pain Management for Resident with Stomach Cancer
Penalty
Summary
The facility failed to ensure proper pain management for a resident with severe stomach pain due to stomach cancer, resulting in the resident experiencing severe pain. The resident, who requires Norco for pain relief, reported frequent issues with obtaining the medication, citing reasons such as the facility running out of Norco, delays in medication delivery, and lack of timely prescription renewals. On one occasion, the resident spent an entire day seeking assistance from nurses to obtain Norco, which was not available, leading to severe pain and distress. The Director of Nursing stated that medication refills should be ordered when there are about three days of medication left, and that pain medications like Norco are available in the emergency medication system. However, a Licensed Practical Nurse (LPN) admitted to not having access to the backup medication supply and not being oriented on how to access it. Another LPN confirmed that the resident had to seek out specific nurses who could access the backup supply to receive her medication. The resident's medical records confirmed a gap in receiving Norco, with the last dose administered on one day and the next dose not given until the following evening. The facility's records, including Resident Council Minutes, indicated ongoing issues with medication availability and delays in receiving pain medication. The resident's care plan highlighted the need for analgesics as ordered, yet the facility's failure to manage the medication supply and ensure timely administration of Norco led to the resident's unmanaged pain. The facility's pain management policy emphasized the importance of recognizing and managing pain, but the execution of this policy was inadequate in this case.
Failure to Administer Prescribed Nasal Spray Due to Pharmacy Communication Lapse
Penalty
Summary
The facility failed to ensure that a resident's prescribed nasal spray, Flonase Allergy Relief, was obtained from the pharmacy and administered as ordered. The Physician Order Summary indicated an active order for the nasal spray to be administered once daily at 9:00 AM, starting on January 18, 2025. However, the Medication Administration Summary revealed that the medication was not administered on January 18, 19, and 21, 2025, due to it being unavailable, and it was incorrectly marked as given on January 20, 2025, despite not being present at the facility. On January 22, 2025, an LPN was unable to administer the Flonase to the resident because it was still unavailable. The LPN acknowledged that they should have followed up with the pharmacy sooner to determine why the medication was not sent. The pharmacy later informed the LPN that the medication was not sent because they had not received an over-the-counter form from the facility. The Director of Nursing stated that it is unacceptable to wait four days to follow up on unavailable medications. The facility's policy requires medications to be ordered or reordered in a timely manner, with any discrepancies reported within 24 hours.
Failure to Obtain Physician Orders Upon Admission
Penalty
Summary
The facility failed to obtain physician orders upon the admission of a resident, identified as R1, who was admitted on 12/3/2024. R1's Admission Record dated 12/16/2024 indicates that the resident was originally admitted on the same date. During an interview on 12/16/2024, a Licensed Practical Nurse (LPN), identified as V10, admitted to not calling a provider to obtain necessary orders for wound care upon R1's admission, despite the presence of wounds. The Director of Nursing (DON), identified as V2, confirmed that the protocol requires the nurse to call the provider to get appropriate orders for the resident's care needs upon admission. A review of R1's Order Summary Report dated 12/16/2024 showed no active orders for wound care were entered during R1's admission on 12/3/2024. The facility's policy, revised on 9/1/2024, states that residents are admitted under the orders of the attending physician.
Failure to Provide Wound Care Assessment and Treatment
Penalty
Summary
The facility failed to assess and provide appropriate wound care for a resident who was admitted with wounds. Upon admission, the resident had wounds on the chest, back, and abdomen, but the Licensed Practical Nurse (LPN) did not change the resident's dressing. The Director of Nursing (DON) stated that an initial assessment should be conducted upon admission, and if wounds are present, the facility's wound protocol should be followed. However, the Wound Nurse LPN confirmed that staff did not contact her for recommendations regarding the resident's wound care, nor did they contact the physician for wound care orders. The resident's Treatment Administration Record (TAR) for December did not document any wound care, and the admission assessment lacked a complete description of the wounds. The facility's Wound Treatment Management policy requires the licensed nurse to notify the physician to obtain treatment orders in the absence of existing orders, but this was not done. The facility's failure to provide a completed admission assessment and to follow wound care protocols resulted in a deficiency in the care provided to the resident.
Failure to Supervise High-Risk Resident Leads to Fall and Injury
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for a resident who was at high risk for falls, resulting in the resident falling and sustaining serious injuries. The resident, who had severe cognitive impairment and a history of falls, was found on the floor after an unwitnessed fall. The resident's care plan required supervision and assistance when ambulating, particularly to and from her room before and after meals. However, on the day of the incident, the resident was seen walking towards her room with a rolling walker without the necessary supervision and assistance, leading to her fall. The resident was later found lying flat on her back with a bump on the back of her head and was subsequently admitted to the ICU with a subarachnoid hemorrhage and a subdural hematoma. The facility's reports indicated that the fall was attributed to the resident suddenly losing her balance while ambulating. The resident's care plan had been updated previously to include specific interventions to prevent falls, but these were not followed, resulting in the resident's fall and subsequent injuries.
Failure to Conduct Quarterly Care Plan Conferences
Penalty
Summary
The facility failed to conduct quarterly care plan conferences for three out of five residents reviewed, leading to a deficiency in care planning. Resident 1 reported never having attended a care plan conference since admission, and there was no documentation in the electronic medical record (EMR) of any conferences or refusals until the Social Service Director (SSD) added information on the day of the survey. Resident 1 was cognitively intact, indicating the ability to participate in care planning. Resident 2's son, who holds power of attorney, stated that they had not had a care plan conference until he requested one due to dissatisfaction with care. The EMR showed a significant delay in documenting a care plan conference, and another conference was missed in August/September. Resident 4 also reported not having a care plan conference for a while, with the last documented conference over a year ago. The SSD added documentation for conferences supposedly held earlier in the year, but these were not recorded until the day of the survey, indicating a delay of several months. Resident 4 was also cognitively intact, suggesting the ability to participate in care planning. The facility's policy supports resident participation in care planning, but the lack of timely documentation and scheduling of conferences indicates a failure to adhere to this policy.
Failure to Implement Contact Isolation Precautions for Scabies Outbreak
Penalty
Summary
The facility failed to implement contact isolation precautions for a resident with a suspected contagious skin rash, leading to a potential risk of cross-contamination among residents. A resident diagnosed with scabies was not isolated from other residents, and the facility did not disinfect and sanitize a communal shower room after the resident used it. Additionally, the resident's personal belongings were not handled in a manner to prevent cross-contamination, as evidenced by a certified nursing assistant transferring a potentially contaminated bag to another resident. The facility's housekeeping staff did not wear the required personal protective equipment when cleaning the room of a resident on contact isolation for a rash. Observations showed that a housekeeper was cleaning a resident's room without wearing a protective gown, despite the resident being on contact isolation due to suspected scabies. The facility's contact isolation policy requires the use of gowns and gloves for all interactions that may involve contact with the patient or the patient's environment. The facility's Assistant Director of Nursing/Infection Preventionist acknowledged that the resident should have been placed on isolation as soon as the rashes were noticed, regardless of the resident's refusal of treatment. The Director of Housekeeping confirmed that staff must notify housekeeping immediately when a shower room needs cleaning after use by a resident with scabies. However, the facility did not have a specific policy or protocol on scabies prevention or treatment at the time of the survey, as they were undergoing a change in ownership and creating new policies.
Resident Injury Due to Lack of Supervision
Penalty
Summary
The facility failed to protect a resident from physical abuse, resulting in an incident where one resident struck another in the face. This incident involved a female resident with a history of dementia and other medical conditions, who was struck by a male resident with dementia and aggressive behaviors. The altercation occurred when the male resident, who was known to be combative and required supervision, approached the female resident and physically attacked her without provocation. The female resident sustained a closed fracture of the left zygomatic arch and was sent to the hospital for treatment. The incident was reported by various staff members, including CNAs and a nurse supervisor, who noted that the male resident had a history of aggressive behavior and required constant supervision due to his fall risk and unpredictable nature. On the day of the incident, the male resident was left unsupervised momentarily, which allowed him to attack the female resident. The facility's policies on abuse prevention were not effectively implemented, as evidenced by the lack of supervision and the subsequent injury to the resident.
Failure to Report Allegation of Sexual Abuse
Penalty
Summary
The facility staff failed to immediately report an allegation of sexual abuse involving a resident. The resident, identified as R1, reported to a Certified Nursing Assistant (CNA) that she believed she was raped by four men and was drugged. The CNA, who worked with R1 on two occasions, recalled the resident telling her the story more than once but could not remember the specific date or to whom she reported the allegation. This lack of immediate reporting to the appropriate authorities, as required by the facility's policy, constitutes a deficiency. The Director of Nursing (DON) confirmed that all allegations of abuse should be reported to the Administrator, who is the designated Abuse Coordinator, or to the DON if the Administrator is unavailable. The facility's policy mandates that suspicions of abuse must be reported immediately, defined as within two hours for serious bodily injury or within 24 hours for other allegations. The failure to adhere to this policy resulted in a delay in reporting the allegation to the state agency and initiating an investigation.
Failure to Ensure Resident Safety and Supervision
Penalty
Summary
The facility failed to ensure the safety of a resident (R1) when staff did not recognize that R1 did not return to the facility after being out on a community/day pass. R1, who was admitted for rehabilitation due to a pelvic and hip fracture, left the facility with a friend without staff being aware. The receptionist saw R1 leave but did not inform the nursing staff, and there was no physician order for R1 to leave the building on a pass that day. R1 was reported missing to the local police department later that evening after staff realized she had not returned. The facility's Out on Pass Log showed that R1 left the building at 10:46 AM and returned the next day at 2:11 PM. Nursing staff attempted to locate R1 at 4:04 PM and again at 8:35 PM but were unable to find her. It was only then that they checked the pass log and discovered R1 had left the building earlier that morning. The police were called, and R1 was found safe the next day outside a library in a neighboring town. Interviews with facility staff revealed that the receptionist did not report R1's departure to the nursing staff, assuming it was permissible since R1 had left before. The Nursing Supervisor and DON confirmed that a physician order is required for a resident to leave on a pass and that the receptionist should communicate with nursing staff each time a resident leaves. The Nurse Practitioner emphasized that even though R1 is cognitively intact, she is not physically independent and should not be gone overnight without proper authorization.
Failure to Administer Medications According to Professional Standards
Penalty
Summary
The facility failed to ensure medications were administered according to professional standards for two residents. One resident reported that a night nurse left his midnight medications on his table while he was asleep in his chair. When he woke up after 1:00 AM, he had to ask the nurse for his medications, which were left on his table. The nurse confirmed that she left the medications on the table because she did not want to wake the resident. The resident's progress note indicated that the nurse left the medications on the table where the resident could easily see them when he woke up. Another resident was found with an empty medication cup on her bedside table. She stated that she likes to go outside in the morning, so the nurses leave her medications on the bedside table for her to take when she returns. The nurse confirmed that he left the medications on the table at the resident's request, including a controlled substance and blood pressure medications. The Medication Administration Record showed that the medications were signed off as given, even though the nurse did not observe the resident taking them. The facility's policy requires that medications be administered in a safe and timely manner and that the nurse should return to administer missed medications, which was not followed in these instances.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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