South Elgin Living & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in South Elgin, Illinois.
- Location
- 746 West Spring Street, South Elgin, Illinois 60177
- CMS Provider Number
- 145825
- Inspections on file
- 20
- Latest survey
- August 21, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at South Elgin Living & Rehab Center during CMS and state inspections, most recent first.
Two residents with complex medical and psychiatric histories engaged in a physical altercation over room temperature, resulting in one resident sustaining a fractured nose that required hospital treatment. Staff and facility records confirmed the incident, which was not prevented despite an abuse prevention policy.
The facility failed to manage a Strep A outbreak effectively, not adhering to health department instructions for testing and treatment, and failing to enforce a masking mandate. A resident with a positive Strep A wound infection was not under proper precautions, and staff and residents were observed unmasked. The facility's infection control policies were not effectively implemented, contributing to ongoing transmission concerns.
A facility failed to repair an exposed ceiling area with exposed pipes outside the rooms of three residents. The issue stemmed from a pipe leak fixed by an outside plumbing company, but the ceiling remained open with a loose plastic covering and debris. The Housekeeper Supervisor and Administrator confirmed the lack of maintenance staff to address the repair, despite requests to corporate management. The facility's maintenance guidelines emphasize prompt repair of such damage.
A registered nurse in an LTC facility demonstrated a lack of competency in administering medications and transcribing orders, affecting four residents. One resident reported receiving incorrect dosages, while another had to correct the nurse on missing evening medications. A third resident refused a pill that did not match her usual regimen, and a physician order was transcribed incorrectly. The nurse's personnel file lacked competency evaluations, and concerns were raised about her skills. The facility did not have a policy on nurse competencies.
The facility failed to maintain a full-time Director of Nursing (DON), affecting all 60 residents. The previous DON resigned, and the subsequent DON worked briefly. The facility relied on a Regional Director of Clinical and an Acting DON from a sister facility, neither present full-time. The Acting DON was instructed to work 20 hours focusing on infection control, but lacked structured job duties. The Regional Director had limited availability due to personal commitments. Concerns were raised about the Acting DON dividing her time between two facilities.
The facility failed to provide structured activities for residents during weekends, affecting several individuals with various diagnoses. Observations and interviews revealed that residents were left without activities, leading to boredom. Staff indicated that activities should be available seven days a week, but there was no policy in place to ensure this.
The facility failed to follow physician's orders for psychotropic medication administration and did not adhere to its psychotropic medication policy by failing to monitor residents for Extrapyramidal Symptoms (EPS) and not attempting a Gradual Dose Reduction (GDR) for a resident who no longer exhibited anxiety behaviors. These failures resulted in a resident receiving the wrong psychotropic medications and at excessive dosages, leading to side effects of increased abnormal involuntary movements.
The facility failed to properly label, date, seal, and store food items in the kitchen, affecting 53 residents who receive oral nutrition. Various food items were found to be improperly labeled or not labeled at all, violating the facility's food storage policies. The Dietary Manager and Dietician acknowledged the risks of serving expired food, which could lead to food poisoning.
The facility failed to follow its policy on behavior monitoring for residents with known behaviors and receiving psychotropic medications. Despite care plans specifying the need for behavior monitoring and documentation, the RN admitted to not documenting behaviors for any of his assigned residents. This lapse in protocol compromised the ability to manage and adjust psychiatric care effectively for the residents involved.
The facility failed to ensure that Ascorbic Acid 500 mg was available for administration to residents with physician's orders. The medication had been unavailable since May 27, 2024, affecting at least five residents. The issue was observed during medication passes and confirmed through interviews and record reviews.
The facility failed to administer medications as ordered by the physician, resulting in a 10.81% medication error rate. A registered nurse was unable to provide specific medications to three residents due to unavailability and oversight, contrary to the facility's medication administration policy.
The facility failed to adhere to proper infection prevention and control protocols, particularly in the use of PPE in rooms requiring Enhanced Barrier Precautions (EBP). Staff did not wear gowns and gloves while providing care to residents with open wounds, gastrostomy tubes, and catheters, despite the presence of signs indicating the need for EBP. The facility's failure to implement and enforce proper infection control measures put residents at risk of infection and compromised their safety.
The facility failed to use a standardized tool to determine the necessity of antibiotic therapy for five residents, leading to undocumented and potentially unnecessary antibiotic use. Staff interviews revealed a lack of awareness and adherence to McGeer's criteria, and the facility could not provide an Antibiotic/Antimicrobial Stewardship Program-Mission Statement and Guidelines.
The facility failed to provide appropriate written notices to two residents that their Medicare coverage was ending. The Business Office Manager, who was new to the role, was unaware of the requirement to issue the Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) forms. Both residents confirmed they did not receive any written notice, and their medical records lacked the necessary documentation.
The facility failed to provide privacy during pressure ulcer dressing changes for two residents. One resident had his dressing changed with the door open and privacy curtain partially drawn, while another had the blinds open, allowing visibility from outside. Staff did not wear gowns during the procedures, violating standard protocol.
The facility failed to maintain good personal hygiene for a resident who was unable to perform activities of daily living. The resident was observed with a crusty mouth, dry lips, and a strong foul odor. Despite the CNA's efforts and reporting the issue, the condition persisted. The RN attributed the odor to a periodontal issue, but the DON was unaware of any such condition and attributed it to poor oral hygiene. Medical records did not show any related diagnosis.
The facility failed to follow a physician's laboratory order for a resident receiving phenobarbital for seizure disorder. Despite an order for a phenobarbital trough level lab draw, the lab was not conducted, and the resident's medication blood levels were not monitored as required. The DON confirmed that nurses are expected to follow such orders, but a review of the resident's lab results showed no phenobarbital trough level for the past six months.
The facility failed to safely transfer a resident with multiple diagnoses and to properly position another resident during feeding in bed. A CNA transferred a resident without using a gait belt and while the resident was barefoot, and another CNA fed a resident who was in a slouched position. The DON confirmed the need for proper use of gait belts and safe positioning during feeding.
A facility failed to ensure a resident received a prescribed double protein diet, resulting in a significant weight loss. The resident's care plan was not updated, and there was no consistent monitoring of weekly weights as required by facility policy.
The facility failed to ensure a supply of gastrostomy tube feeding formula, did not label and date feedings, and did not follow physician's orders for three residents. One resident's g-tube machine was running at an incorrect rate, and another's bag lacked necessary labeling. The DON was unaware of the shortage and emphasized the importance of following orders and labeling.
The facility failed to store narcotic medications under double-lock and improperly stored an inhaler. An unlocked medication refrigerator contained an opened bottle of Lorazepam, and a resident's Albuterol inhaler was found on their bedside table without a doctor's order to self-medicate.
The facility failed to properly store and monitor food items brought in by residents' families or visitors. One resident had opened food items requiring refrigeration stored on a dresser without a refrigerator, while another resident's refrigerator contained expired food items and lacked a thermometer and temperature log. Staff confirmed that these procedures were not followed.
The facility failed to provide timely physical therapy services to three residents, resulting in delays in care and functional decline. The delays were due to the absence of a therapy company, leading to gaps in therapy services for the residents.
The facility failed to have a full-time DON, affecting all 57 residents. Observations and interviews confirmed the absence of a DON since early April, with no interim DON appointed and no waiver from the Illinois Department of Public Health. Nurses reported difficulties due to the lack of clinical management support.
The facility failed to employ a licensed administrator, lacked a DON and IP, and did not provide therapy services between February 5, 2024, and March 22, 2024. Additionally, the facility did not document evidence for plans of correction or report to the QAPI committee, and failed to implement adequate PPE during a COVID outbreak.
The facility failed to have a designated Infection Preventionist (IP) at least part-time, affecting all 57 residents. The acting IP nurse, who lives three hours away, has had difficulty visiting weekly due to health issues. The infection control log for March 2024 was incomplete, contrary to the facility's stated adherence to CDC best practices.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse, resulting in one resident sustaining a fractured nose after being struck by his roommate. Both residents involved had significant medical and psychiatric histories, including paranoid schizophrenia, mild intellectual disability, bipolar disorder, diabetes, seizures, and depression. The incident occurred following a disagreement over the room's thermostat settings, escalating to physical violence when one resident punched the other on the bridge of the nose. The injured resident required hospital transfer and was diagnosed with a closed nasal fracture. Staff interviews and facility records confirmed that the altercation was witnessed shortly after it occurred, with blood observed on the injured resident and both residents providing statements about the argument and subsequent physical contact. The facility's abuse prevention policy affirms residents' rights to be free from abuse, defining physical abuse as the infliction of injury requiring medical attention. Despite this policy, the facility did not prevent the altercation, resulting in harm to a resident.
Inadequate Infection Control During Strep A Outbreak
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols during an outbreak of Group A Streptococcus (Strep A) disease. The facility did not follow the State Department of Public Health and the Local County Health Department's instructions for facility-wide testing and treatment initiation for a resident with positive test results. Additionally, the facility did not comply with the mandated facility-wide masking requirement. The facility's management was unaware of the outbreak's start date, the number of cases, and the residents involved, despite being informed of the outbreak in May 2024. The facility's infection preventionist and other staff members were not adequately informed or trained on the necessary precautions and procedures. A resident with a positive Strep A wound infection was not placed under the correct contact precautions, and the resident frequently left the facility without completing the prescribed antibiotic treatment. The facility also failed to conduct proper testing and reassessment of staff and residents, as instructed by health authorities, leading to ongoing transmission concerns. Observations revealed that staff and residents were not consistently wearing masks, despite the masking mandate. The facility's infection control policies were not effectively implemented, and there was a lack of compliance with infection control practices. The facility's prior management did not conduct accurate employee assessments or perform necessary testing, contributing to the continued outbreak and the need for mandated masking.
Unrepaired Ceiling Hazard in Resident Hallway
Penalty
Summary
The facility failed to safely repair an exposed ceiling area located outside the rooms of three residents. During environmental rounds, an open ceiling area with exposed pipes was observed above the entrance of the housekeeping room, which is situated in the resident hall directly across from the rooms of three residents. The ceiling area had a loose plastic covering with drywall debris, inadequately secured with scattered pieces of blue painter's tape. The issue originated from a pipe leak that occurred approximately three weeks prior, and despite the leak being fixed by an outside plumbing company, the ceiling remained unrepaired. The Housekeeper Supervisor confirmed the lack of available maintenance staff to address the ceiling repair, and the Administrator acknowledged being informed of the leak about a month ago. Despite requests to corporate management for repair assistance, the ceiling remained in its compromised state. The facility's maintenance documentation emphasized the importance of repairing wall or ceiling damage promptly to maintain smoke barriers, highlighting the facility's failure to adhere to its own maintenance guidelines.
Medication Administration and Competency Deficiencies
Penalty
Summary
The facility failed to ensure that a registered nurse, identified as V3, was competent in administering medications and transcribing orders, affecting four residents. Resident R3 reported that V3 did not provide the correct dosage of her medications, including lamotrigine, aripiprazole, and gabapentin, during a morning medication pass. R3 had to inform V3 of the missing medications, which were then corrected. Similarly, Resident R4 experienced issues with V3 during evening medication passes, where V3 initially provided fewer pills than prescribed. R4 had to point out the discrepancy, and V3 corrected it after being shown the list of medications by R4. Resident R8 also encountered a medication error when V3 attempted to give her a pill that did not match her usual medication regimen. R8, who was aware of her medication, refused the pill and informed V3 of the mistake, which was subsequently rectified. Additionally, Resident R7's physician order for Haldol was transcribed incorrectly by V3, leading to a potential medication error. The physician expressed dissatisfaction with the transcription error, and V3 acknowledged the mistake. The facility's documentation revealed that V3's personnel file lacked any Nurse Competency Checklists, and V3 herself confirmed she had not undergone any competency evaluations. The previous Director of Nursing expressed concerns about V3's competency and thoroughness in providing care. The current Director of Nursing stated that all nurses should complete an orientation and competency form, but V3 did not appear to have completed this process. The facility did not have a policy on nurse competencies, and the Resident Council Minutes indicated that V3 needed improvement.
Deficiency in Full-Time Director of Nursing Coverage
Penalty
Summary
The facility failed to have a Director of Nursing (DON) on a full-time basis, which has the potential to affect all 60 residents residing in the facility. The deficiency was identified through observations, interviews, and record reviews. On multiple occasions, staff members confirmed the absence of a full-time DON. The facility's administrator and other staff members indicated that the previous DON resigned, and the subsequent DON only worked for a short period. Since then, the facility has relied on a Regional Director of Clinical and an Acting DON from a sister facility to cover the role, but neither was present full-time. The Acting DON, who is also the full-time DON at a sister facility, was instructed to work 20 hours at the facility in question, focusing on infection control. However, there was no structured clinical meeting to outline her job duties. The Regional Director of Clinical, who was also assisting, had personal commitments and other responsibilities, limiting her availability. The Health Department Communicable Disease Supervisor expressed concerns about the Acting DON dividing her time between two facilities, emphasizing the need for focused attention on infection control and outbreaks at the facility.
Lack of Weekend Activities for Residents
Penalty
Summary
The facility failed to provide structured activities for residents during weekends, affecting 7 out of 8 residents reviewed for activities. Observations on a Saturday revealed that residents were either in the day room or in their rooms without any activities. Several residents expressed their dissatisfaction with the lack of activities on weekends, stating that they had nothing to do and found it boring. The residents involved had various diagnoses, including anoxic brain damage, depression, paranoid schizophrenia, bipolar disorder, and major depressive disorder, with BIMS scores indicating varying levels of cognitive function. Interviews with staff members, including a CNA and the Administrator, revealed that there was an expectation for activities to be provided seven days a week. However, it was noted that if activity aides were not working on weekends, activities such as games and puzzles should have been left for residents to engage with. The facility was unable to provide a policy on activities for residents, indicating a lack of structured planning and oversight in ensuring that residents' needs for engagement and stimulation were met consistently throughout the week.
Failure to Follow Psychotropic Medication Policies and Monitoring Protocols
Penalty
Summary
The facility failed to follow physician's orders for psychotropic medication administration for a resident (R36). The facility did not adhere to its psychotropic medication policy by failing to monitor residents (R1, R14, R36) for Extrapyramidal Symptoms (EPS) due to antipsychotic medication use and did not attempt or request a Gradual Dose Reduction (GDR) of a Benzodiazepine medication for a resident (R14) who no longer exhibited anxiety behaviors. These failures resulted in R36 receiving the wrong psychotropic medications and at excessive dosages, leading to side effects of increased abnormal involuntary movements. R36's medical record showed she was receiving psychiatric care for major depression, anxiety, and insomnia. Despite being cognitively impaired and not showing mood symptoms, R36 was observed displaying abnormal movements such as rocking, lip-smacking, and repetitive tongue movements. The facility's care plan for R36 included monitoring for antipsychotic side effects and performing AIMS assessments every six months. However, the facility failed to follow these protocols, resulting in R36 receiving incorrect dosages of Aripiprazole and Quetiapine, which were not aligned with the psychiatric nurse practitioner's orders. R1 and R14 also experienced deficiencies in their care. R1, who was receiving psychiatric care for schizoaffective disorder, bipolar disorder, depression, and psychosis, was observed displaying abnormal oral movements. Despite this, the facility did not adequately monitor or report these side effects. Similarly, R14, who was receiving psychiatric care for anxiety and adjustment disorder with depressed mood, was observed to be excessively sleepy and confused. The facility did not attempt a GDR for R14's Benzodiazepine medication, despite recommendations from the pharmacy consultation report. These failures highlight significant lapses in the facility's adherence to psychotropic medication policies and monitoring protocols.
Improper Food Labeling and Storage in Facility Kitchen
Penalty
Summary
The facility failed to properly label, date, seal, and store food items in the kitchen, affecting 53 residents who receive oral nutrition and foods prepared in the facility kitchen. During a tour of the facility kitchen, several food items were found to be improperly labeled or not labeled at all, including various types of pasta, bread, tomato soup, cranberry juice, orange juice, steak, sausage patties, breaded fish patties, minestrone soup, and bread dough. These items were either missing dates of receipt, expiration dates, or both, which is a violation of the facility's policies for food storage and handling. The Dietary Manager acknowledged that expired items should be discarded to prevent accidental consumption, which could potentially make residents sick. The Dietician also confirmed that serving expired food could lead to food poisoning. The facility's policies for food storage, both dry and refrigerated/frozen, require all items to be dated upon receipt and containers to be labeled with the name of the item and the date it was opened or prepared. The failure to adhere to these policies was observed and documented during the survey, indicating a significant lapse in food safety practices within the facility.
Failure to Follow Behavior Monitoring Policy for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to follow its policy on behavior monitoring for residents with known behaviors and receiving psychotropic medications. This deficiency was observed in five residents (R1, R8, R14, R36, and R39) who had multiple diagnoses including schizoaffective disorder, bipolar disorder, depression, psychosis, autism, developmental delay, anxiety, and dementia. Despite the care plans specifying the need for behavior monitoring and documentation, the Registered Nurse (V3) admitted to not documenting behaviors for any of his assigned residents. This lack of documentation was confirmed through observations and interviews, where residents exhibited behaviors such as inappropriate sexual gestures, hallucinations, yelling, and refusing care, but these were not recorded as required by the facility's policy. The Director of Nursing (V2) and the Psychiatric Nurse Practitioner (V14) both emphasized the importance of behavior tracking for managing psychiatric services and medication effectiveness. However, the facility's social worker only sometimes provided behavior-tracking documentation sheets, and the nurses did not consistently use them. The facility's policy on the reduction of psychotropic medications, which includes the implementation of a Behavioral Tracking sheet, was not adhered to, leading to a failure in monitoring and documenting resident behaviors as mandated. This lapse in protocol compromised the ability to manage and adjust psychiatric care effectively for the residents involved.
Medication Unavailability for Residents
Penalty
Summary
The facility failed to ensure that medications were available for administration to residents with physician's orders. On multiple occasions, a registered nurse (RN) was unable to administer Ascorbic Acid 500 mg to residents due to the medication being unavailable. This issue was observed during medication passes and confirmed through interviews and record reviews. Specifically, the RN reported that Ascorbic Acid was not available in the medication cart, medication room, or the small closet where house stocks are kept. The medication had been unavailable since May 27, 2024, affecting at least five residents who had orders for Ascorbic Acid 500 mg, 1 tablet due at 8:00 AM. The Medication Administration Records (MAR) for these residents showed that the medication was marked as
Medication Administration Errors
Penalty
Summary
The facility failed to administer medications as ordered by the physician, resulting in a medication error rate of 10.81%. This deficiency was observed in three residents. On one occasion, a registered nurse (RN) was unable to administer Ascorbic Acid 500 mg to a resident because it was not available in the medication cart, medication room, or house stock. The RN confirmed that the medication had been unavailable since May 27, 2024. The resident's Physician Order Sheet (POS) indicated that Ascorbic Acid 500 mg was due at 8:00 AM, but it was not administered as required. In another instance, the same RN administered medications to a second resident but failed to provide Calcium 600 mg/Vitamin D3 400 mg and Ascorbic Acid 500 mg as ordered at 8:00 AM. Additionally, the RN did not administer Docusate Na 100 mg to a third resident as ordered at 8:00 AM. The facility's policy on medication administration, which includes verifying medications with the physician's orders and promptly recording the time and dose given, was not followed in these cases.
Failure to Adhere to Infection Control Protocols
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, particularly in the use of Personal Protective Equipment (PPE) in rooms requiring Enhanced Barrier Precautions (EBP). During the survey, it was observed that staff did not wear gowns and gloves while providing care to residents with open wounds, gastrostomy tubes, and catheters. For instance, a nurse and a wound doctor entered a resident's room and performed wound care without wearing gowns, despite the presence of signs indicating the need for EBP. The Director of Nursing (DON) acknowledged that staff should wear gowns and gloves for residents with wounds, gastrostomy tubes, and catheters, and noted that the staff had been recently in-serviced on this requirement. However, the staff failed to comply with these precautions during the survey observations. Additionally, the facility's policy on EBP was not consistently followed, as evidenced by the lack of appropriate signage and staff awareness of the precautions required for certain residents. The Assistant Director of Nursing (ADON) and the DON both confirmed that the staff should have known and adhered to the EBP protocols, but this was not the case during the survey. The facility's failure to implement and enforce proper infection control measures put residents at risk of infection and compromised their safety.
Failure to Utilize Standardized Tool for Antibiotic Therapy
Penalty
Summary
The facility failed to utilize a standardized tool to determine the necessity of antibiotic therapy prescribed to residents. This deficiency was identified in five residents who were prescribed various antibiotics without proper documentation or adherence to McGeer's criteria. For instance, one resident was prescribed Bactrim DS without a documented reason in the Physician Order Sheet or medication administration log. Another resident was prescribed Bacitracin and Keflex, but the infection control binder and medical records lacked the McGeer's criteria form, and the onset date for Bacitracin did not match the physician's order sheet. Similar issues were found with other residents who were prescribed Erythromycin, Doxycycline, Cefadroxil, and Augmentin, with missing or inconsistent documentation in the infection control and antimicrobial logs, and the absence of McGeer's criteria forms in their medical records. Interviews with facility staff revealed a lack of awareness and adherence to McGeer's criteria. The Director of Nursing/Infection Preventionist, who had been at the facility for only a few weeks, acknowledged that the facility should follow McGeer's criteria to ensure appropriate antibiotic use but was unsure why it was not done. The physician admitted to not following McGeer's criteria and refused to discuss it further. A registered nurse stated that they follow physician orders when signs of infection are observed but had never heard of McGeer's criteria. The facility's policy on Infection Control Surveillance and Monitoring required daily updates to the infection control log to analyze data and identify trends, but the facility could not provide an Antibiotic/Antimicrobial Stewardship Program-Mission Statement and Guidelines.
Failure to Provide Written Notices of Medicare Coverage Termination
Penalty
Summary
The facility failed to provide appropriate written notices to residents that their Medicare coverage was coming to an end. This deficiency was identified during an interview and record review, where it was found that two residents were not given the required Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) forms. The Business Office Manager, who was new to the position, admitted to not being aware of the requirement to provide these forms and only informed the residents verbally about their remaining Medicare days. The facility was unable to provide a policy regarding the issuance of these notices. One resident, who was cognitively intact with a BIMS score of 15, confirmed that she was not given any written notice about her Medicare coverage. Her medical record also lacked the required NOMNC and SNF-ABN forms. Another resident, who was moderately impaired in cognition with a BIMS score of 9, also confirmed that he did not receive any written notice. His medical record similarly lacked the necessary forms. The facility's failure to provide these written notices constitutes a deficiency in ensuring residents are informed about their Medicare coverage and potential liability for services not covered.
Failure to Provide Privacy During Wound Care
Penalty
Summary
The facility failed to provide privacy during pressure ulcer dressing changes for two residents. Resident R47, who has a stage 3 pressure ulcer on his right heel, had his dressing changed by an RN and a wound doctor without proper privacy measures. The door was left open, and the privacy curtain was only partially drawn, while the resident's roommate was present in the room. Additionally, the staff did not wear gowns during the procedure, which is against standard protocol for infection control and resident dignity. Similarly, Resident R50, who has a stage 4 pressure ulcer on his left heel, experienced a dressing change with the blinds open, allowing visibility from outside the facility. The RN and wound doctor did not wear gowns during the procedure, and the wound doctor applied pain medication and debrided the wound without ensuring the resident's privacy. The Director of Nursing acknowledged that privacy measures, such as closing doors and blinds, should be followed during such procedures. The facility's policy on AM care also emphasizes the importance of providing privacy by pulling window curtains and privacy curtains.
Failure to Maintain Resident's Oral Hygiene
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for one resident (R11) who was unable to perform activities of daily living. On multiple occasions, R11 was observed with a crusty mouth, dry lips, and a very strong foul odor emanating from his mouth. Despite the CNA's (V10) efforts to provide mouth care and reporting the issue to the nurses, R11's condition persisted. The RN (V5) attributed the odor to a periodontal issue, but the DON (V2) was unaware of any such condition and attributed the foul odor to poor oral hygiene. A review of R11's medical records did not show any diagnosis related to his mouth, teeth, or gums.
Failure to Follow Physician's Laboratory Order for Anticonvulsant Medication
Penalty
Summary
The facility failed to follow a physician's laboratory order for the management of anticonvulsant medication for a resident with multiple diagnoses, including general convulsant epilepsy, intractable seizure disorder, encephalomalacia, and encephalitis. The resident was receiving phenobarbital, and an order was placed for a phenobarbital trough level laboratory draw. However, upon review, it was found that the lab draw had not been conducted. The Registered Nurse confirmed that the resident's medication blood levels should be monitored as ordered but was unable to find the lab result. The Director of Nursing stated that nurses are expected to follow physician lab orders. A review of the resident's lab results for the past six months showed no phenobarbital trough level. A pharmacy consultation report also indicated that the resident's medical record did not have a phenobarbital trough level within the previous six months, and a recommendation to monitor the trough concentration was accepted by the physician but not followed through. The resident's care plan included interventions such as labs as ordered and monitoring for adverse reactions and medication toxicity, but these were not adhered to.
Failure to Safely Transfer and Position Residents
Penalty
Summary
The facility failed to safely transfer a resident (R10) and safely position a resident (R14) when assisting with feeding in bed. R10, who has multiple diagnoses including epilepsy, hemiparesis, and degenerative joint disease, required substantial to maximal staff assistance with transfers. On the observed date, a CNA transferred R10 from the bed to a shower chair without using a gait belt and while R10 was barefoot, contrary to the resident's care plan and facility policy. The Director of Nursing confirmed that staff should use a gait belt and ensure proper footwear during transfers for safety. R14, who has diagnoses including cerebral infarction and muscle weakness, required partial to moderate staff assistance with bed mobility. During the observation, a CNA was feeding R14 in bed while R14 was in a slouched position, with his buttock lower than the bend of the bed. The Director of Nursing confirmed that residents being fed in bed should be in a safe position and not slouched. The facility did not have a policy for feeding or positioning in bed, although R14's care plan included interventions for bed mobility to maintain safety and increase independence.
Failure to Provide Prescribed Double Protein Diet
Penalty
Summary
The facility failed to monitor and ensure that a resident with orders for a double protein diet received the diet as ordered by the physician. This failure resulted in a -10.16% weight loss from November 2023 to May 2024. On 05/29/2024, the resident was observed in the dining room appearing emaciated and weak. The meal tray served to the resident did not include the double protein as prescribed. The resident's medical records showed significant weight loss over several months, and the dietary manager and cook acknowledged the oversight in meal preparation. The resident's care plan was not updated to reflect the significant weight loss and the need for double protein meals, and there was no evidence of weekly meetings or consistent monitoring of weekly weights as recommended. The facility's policies on weight committee meetings and resident weight monitoring were not followed, contributing to the resident's continued weight loss. The dietary manager and registered dietician confirmed the necessity of the double protein diet to prevent further weight loss, but the facility failed to implement and monitor this intervention effectively.
Failure to Ensure Proper Gastrostomy Tube Feeding Procedures
Penalty
Summary
The facility failed to ensure they had a supply of gastrostomy tube feeding formula for residents per order, failed to label and date gastrostomy tube feedings, and failed to follow physician's orders for feedings. This deficiency was observed in three residents. One resident with quadriplegia and dysphagia was found connected to a g-tube machine running at 70 ML/HR, but the bag was not labeled or dated. Another resident with cerebral infarction and gastrostomy status was connected to a g-tube machine running at 55 ML/HR, contrary to the physician's order of 60 ML/HR, and the bag was also not labeled or dated. The nurse admitted to using substitute feedings due to a shortage of the prescribed formula and acknowledged the need to label and date the bags. The Director of Nursing was unaware of the shortage and emphasized the importance of following doctor's orders and labeling the bags. A third resident was observed with a gastrostomy feed running at 80 ML/HR, but the bag lacked a label indicating the date, time, and quantity of the feed. The nurse confirmed that the bag should have been labeled with this information. The facility's policy requires that all tube feeding bags be labeled and replaced every 24 hours, and that physician orders be followed precisely. The Director of Nursing reiterated the necessity of labeling the bags with the resident's name, type of feed, rate, date, start time, and nurse's initials.
Improper Storage of Narcotic Medications and Inhaler
Penalty
Summary
The facility failed to store narcotic medications under double-lock and improperly stored an inhaler. During an inspection of the medication room, it was observed that the medication refrigerator was not locked, and an opened bottle of Lorazepam Concentrate 2mg/ml belonging to a resident was found inside. The RN confirmed that the refrigerator is never locked, and the ADON acknowledged that all narcotics should be double locked to prevent theft and diversion. The facility's policy on the procurement and storage of medication did not address the storage of Lorazepam. Additionally, an Albuterol inhaler was observed on a resident's bedside table, which the resident stated was used as needed for breathing difficulties. The DON confirmed that a doctor's order is required to keep medications at the bedside and that the resident did not have such an order. A review of the resident's Physician Order Sheet confirmed the absence of an order to self-medicate.
Failure to Properly Store and Monitor Resident Food Items
Penalty
Summary
The facility failed to properly store and monitor food items brought in by residents' families or visitors. In one instance, a resident (R51) had several opened food items that required refrigeration, such as ranch dip, Miracle Whip, and mustard, stored on top of his dresser without a refrigerator in the room. These items were observed on two separate occasions, indicating that they were not being properly stored. Additionally, a loaf of bread with an expired best-by date was also found in the room. The resident was not available for an interview during the surveyor's visits. In another instance, a resident (R28) had a refrigerator in his room containing various food items, including mayonnaise, peppers, butter, and potato salad with expired sell-by dates. The refrigerator lacked a thermometer, and there was no temperature log maintained. The resident confirmed that staff never checked his refrigerator. The facility's policies require that all resident refrigerators have thermometers and temperature logs, and that housekeeping staff or a designee monitor and document refrigerator temperatures daily. However, these procedures were not followed, as confirmed by the Administrator and the Assistant Director of Nursing.
Failure to Provide Timely Physical Therapy Services
Penalty
Summary
The facility failed to obtain orders and provide physical therapy services to residents, resulting in a delay in care and functional decline. Resident R103, who had multiple diagnoses including hypertensive heart disease and dementia, was admitted to the facility and initially could walk independently. However, in February, R103 suddenly stopped walking and was sent to the hospital. Upon readmission, the facility did not obtain an order for physical therapy, and R103 did not start receiving therapy until nearly a month later, leading to a prolonged recovery period. The delay was attributed to the facility not having a therapy company to provide services at that time. Resident R102, with diagnoses including chronic obstructive pulmonary disease and anxiety, was also affected by the lack of therapy services. R102 had been receiving physical therapy but went a month without it when the previous therapy company stopped services. The facility did not send R102 to an outside company for therapy, resulting in a gap in care until the new therapy company started. This interruption in therapy services was not documented as being due to R102 meeting her highest practicable level of function. Similarly, Resident R101, who had chronic kidney disease and dementia, experienced a disruption in physical therapy services. R101 required maximal assistance for mobility and had a physician order for physical therapy five times a week. However, there was no documentation of therapy services being provided between February and March, and the physician confirmed that therapy should not have been stopped. The facility's failure to provide continuous therapy services was due to the absence of a therapy company, leading to a delay in care for R101 as well.
Facility Lacks Full-Time Director of Nursing
Penalty
Summary
The facility failed to have a full-time Director of Nursing (DON) on duty, affecting all 57 residents. The Facility Data Sheet dated April 17, 2024, showed no DON or Assistant Director of Nursing (ADON) listed. Observations on April 17, 18, 22, and 23, 2024, confirmed the absence of a DON. Interviews with the Interim Business Office Manager and the Administrator revealed that the facility has been without a DON since April 3, 2024, and no interim DON has been appointed. Additionally, the facility does not have a waiver from the Illinois Department of Public Health to waive the staffing requirement for a full-time DON. Nurses at the facility expressed difficulties due to the lack of a DON. One RN mentioned that the absence of a DON has resulted in less support during situations when a resident experiences a change in condition. Another RN stated that without a DON, there is no clinical management person to consult when a resident has an Activities of Daily Living (ADL) decline. The Facility Assessment Tool dated March 7, 2024, indicated that the staffing plan included one DON and one ADON, but these positions were not filled at the time of the survey.
Failure to Employ Licensed Administrator and Provide Therapy Services
Penalty
Summary
The facility failed to employ a licensed administrator to ensure the facility could meet resident needs. The administrator, V1, held a temporary nursing home administrator license for a different facility and did not have the necessary documentation to work at the current facility. Additionally, the facility lacked a Director of Nursing (DON) and an Infection Preventionist (IP), with the Regional Director of Clinical Operations, V9, attempting to fill the IP role despite living three hours away and having health issues that limited her availability. The facility also failed to provide therapy services to residents between February 5, 2024, and March 22, 2024, when transitioning between rehab companies, leaving residents without necessary rehab services during this period. The facility administration failed to document evidence for plans of correction and evidence of reporting to the Quality Assurance Performance Improvement (QAPI) committee. Specifically, there was no evidence that medication counts were reviewed daily for three months as mandated by the facility's plan of correction related to missing narcotic medication. The facility's plan required the Director of Nursing or designee and QA to review medication counts daily for one month and for the next three months through the QA process, but this was not documented. The facility's failure to implement adequate personal protection equipment (PPE) during a COVID outbreak was also noted, further highlighting deficiencies in infection control practices.
Lack of Designated Infection Preventionist
Penalty
Summary
The facility failed to have a designated Infection Preventionist (IP) at least part-time, affecting all 57 residents. The Regional Director of Clinical Operations, who is currently acting as the IP nurse, lives three hours away and has had difficulty visiting the facility weekly due to health issues. During her visits, she reviews and updates the infection control logs, but the log for March 2024 was found to be incomplete. The Facility Assessment Tool dated March 7, 2024, indicated that the facility follows CDC best practices and has an Infection Nurse overseeing the program, which was not the case at the time of the survey.
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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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