Sullivan Healthcare & Senior Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Sullivan, Illinois.
- Location
- 11 Hawthorne Lane, Sullivan, Illinois 61951
- CMS Provider Number
- 145370
- Inspections on file
- 31
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Sullivan Healthcare & Senior Living during CMS and state inspections, most recent first.
The facility failed to follow its call system policy requiring staff to answer call lights within five minutes, resulting in multiple cognitively intact residents reporting prolonged waits for assistance. A resident with significant physical impairments and a sacral pressure ulcer stated she often waits over an hour for help with toileting, sometimes leading to incontinence episodes. Another resident reported similar long delays for her roommate’s call light, and a third resident described frequent waits of over 30 minutes, particularly on night shift. CNAs acknowledged that residents regularly complain about long call light response times and attributed delays to insufficient CNA staffing on evening and night shifts. The Administrator confirmed that residents rely on the call system for toileting assistance and that staff are expected to respond promptly, and acknowledged that delayed responses can negatively affect resident care.
A resident with severe dementia and significant cognitive impairment was being assisted into bed by two CNAs when the resident grabbed one CNA’s head. According to a witness CNA, the involved CNA responded by striking the resident’s hand and verbally telling the resident not to grab her head, while the involved CNA’s written statement claimed she only removed the resident’s hand. The resident was later assessed for injuries and vital signs, and was observed to be unable to answer questions due to cognitive impairment. The facility’s abuse prevention policy affirms residents’ rights to be free from physical abuse and commits to protecting residents from abuse by staff and others.
The facility did not ensure RN coverage for eight consecutive hours on a specific day, with only partial coverage documented and no evidence that the remaining hours were staffed by an RN. Staffing records were inconsistent, and administrative staff could not confirm or document that the required RN services were provided, potentially affecting all residents.
The facility did not employ a clinically qualified Director of Food and Nutrition Services, with dietary operations supervised by a cook lacking required credentials or training. The dietician was only present one day per month, and surveyors observed multiple food safety and sanitation issues, including improper food scooping, a can opener with metal shavings, and unsanitary cooler floors, potentially affecting all residents.
Surveyors found that kitchen staff failed to maintain sanitary conditions, with soiled walk-in cooler floors, an unclean can opener with food residue and metal shavings, and a disposable foam cup used as a scoop in a bulk flour container, all of which could affect all residents.
The facility did not ensure the DON attended required quarterly QAA committee meetings, as evidenced by a sign-in sheet for a meeting that the DON could not have attended due to being on vacation. The DON confirmed she had not participated in any official QAA meetings since her employment began, despite facility policy requiring her attendance. This deficiency potentially affects all 70 residents.
Two residents were found using bed linens that were stained and excessively worn, with some sheets so thin that the mattress was visible. One resident, who was cognitively intact, reported receiving stained sheets and expressed dissatisfaction, while a CNA confirmed that most linens were in poor condition and that complaints had been made to management. The laundry supervisor acknowledged the issue and noted that inadequate linens may have been used during her absence.
A resident dependent on staff for hygiene did not receive timely incontinence care or scheduled showers. The resident reported long waits for staff assistance after using the call light and received only three showers in 55 days, despite being scheduled for two per week. Staff confirmed the resident's dependence and reliability in reporting these issues, and resident council minutes documented ongoing concerns about delayed responses to call lights and inadequate bathing.
A resident with severe cognitive impairment and total dependence on staff was observed multiple times in common areas with visible white mucous on her mouth and lips, indicating a lack of adequate oral care by staff despite facility expectations for daily and as-needed assistance.
A resident reported missing jackets to staff and the Ombudsman, who notified the Administrator, but the grievance was not documented or acted upon for nearly two months. Facility policy requiring prompt reporting and investigation of grievances was not followed, and the Social Service Director was not informed until the issue was raised during survey.
A resident with moderate cognitive impairment experienced a witnessed fall from a wheelchair, resulting in a skin tear, which was documented in facility records but not accurately reflected in the most recent MDS assessment. Both the DON and administrator confirmed the omission, noting that the fall event was missed during MDS coding due to staff changes.
A resident who was severely cognitively impaired and fully dependent on staff developed Stage I and II pressure ulcers on the lower legs due to the facility's failure to implement prescribed preventative measures, such as floating heels and using cushions. Despite care plan interventions and physician orders for daily skin checks, staff did not provide the required skin protection, and the wounds were not assessed or documented in a timely manner.
A resident with multiple medical conditions, including quadriplegia and diabetes, experienced deterioration of buttock wounds due to the facility's failure to assess, monitor, and notify the physician for treatment orders. The resident's care plan, which required checking and changing incontinence briefs every two hours, was not followed. Additionally, a CNA cross-contaminated the resident's wounds during care, and the facility lacked a policy for turning and positioning. The resident's mattress was also in poor condition, contributing to the issue.
A resident with multiple medical conditions did not receive timely incontinence care, leading to cross-contamination of open wounds during care. CNAs failed to adhere to the care plan, and there was a lack of communication and responsibility among staff. The DON acknowledged the importance of regular care but found no policy for preventing cross-contamination.
A resident in cardiac arrest did not receive adequate ventilation during CPR due to the absence of a functional bag valve mask (BVM) in the facility's emergency crash cart. Despite staff efforts to provide manual ventilation with an Ambu bag, the lack of a BVM mask led to insufficient life-sustaining ventilation. The resident, who had a POLST indicating a wish for full treatment, subsequently expired.
The facility failed to implement post-fall interventions for two residents and did not adequately recognize, document, or investigate falls from bed for one resident. One resident with severe cognitive impairment was observed with numerous bruises and an unsafe bed height, while another resident frequently rolled out of bed onto a mattress without these incidents being documented as falls. The facility did not adhere to its fall prevention policy, failing to assess, document, and report these occurrences.
A facility failed to protect residents from abuse when a verbal altercation between two residents escalated into physical violence in the dining room. One resident verbally abused another, leading to a third resident intervening and striking the abuser. Staff intervened to separate the residents, but the incident caused distress among other residents present. The involved residents have various cognitive and mental health issues, contributing to the incident.
The facility did not ensure residents were informed of their rights, as several residents reported not having their rights communicated during Resident Council meetings. They received a booklet upon admission, but it had been some time since then. Meeting minutes from several months showed no discussion of resident rights, and the Activity Director confirmed this omission. The facility houses 71 residents.
The facility failed to deliver mail to residents on Saturdays, affecting all 71 residents. During a resident group meeting, several residents reported not receiving mail on Saturdays. The administrator claimed the post office does not deliver on Saturdays, but a local mail clerk confirmed that mail is delivered and placed in the facility's mailbox. Facility documentation states that mail must be delivered promptly.
The facility failed to employ a qualified Director of Food and Nutrition Services, affecting nearly all 71 residents who consume food prepared in the facility kitchen. The Administrator confirmed the absence of a Dietary Manager, and a Cook was observed managing dietary activities without the necessary qualifications. The Cook only held a Food Service Sanitation certificate and lacked formal training required for the role. Issues with food storage, sanitation, and equipment cleanliness were also identified. Four residents were noted to be NPO and did not receive meal trays.
The facility failed to properly implement food storage and leftover tracking processes, maintain bulk food cleanliness, and ensure kitchen equipment cleanliness, potentially leading to food contamination. Observations revealed undated food items, unsanitary kitchen conditions, and non-compliance with facility policies on food storage and cleanliness.
The facility failed to provide adequate ADL assistance and hygiene care to several residents. A resident with cognitive impairment and total dependence on staff was not given necessary oral care, with staff confirming a lack of supplies and documentation. Additionally, multiple residents reported not receiving scheduled showers, with documentation showing missed baths/showers and no record of actions taken if a resident refused care.
The facility failed to implement enhanced barrier precautions for residents with medical devices and open wounds, affecting five residents. Staff, including CNAs and the DON, were observed providing care without wearing gowns, despite the facility's policy requiring gowns and gloves during high-contact care activities. The lack of signage and PPE setup contributed to this deficiency.
A resident's family was not informed of a decrease in the dosage of Risperdal, an antipsychotic medication, leading to noticeable changes in the resident's behavior. The facility's policy requires notifying family representatives of significant medical changes, but staff did not inform the family, believing a gradual dose reduction was mandatory.
A resident with moderate cognitive impairment and mobility needs did not receive a timely resolution to a grievance filed by their family representative for a specialized wheelchair. Despite the grievance being unresolved for several months, the facility did not provide an adequate temporary solution, and the resident continued to use uncomfortable and unsuitable wheelchairs. An occupational therapy evaluation confirmed the need for a custom wheelchair, but it was conducted months after the grievance was filed.
A resident with quadriplegia and neurological issues was found with hand mitten restraints that were not removed as per the care plan, which required removal every two hours. Staff confirmed the mittens were only removed on shower days, contrary to the facility's policy. The resident's inability to remove the mittens and the condition of her fingernails indicated infrequent removal.
A facility failed to include a urinary catheter in a resident's care plan, despite the resident having a diagnosis of urine retention and an unspecified UTI. The physician's orders required a 16 French catheter with a 10-milliliter bulb, to be changed every 28 days or as needed. The care plan lacked any interventions for the catheter until the issue was identified and corrected by the MDS/Care Plan Coordinator after being informed by the Administrator.
A resident with multiple health conditions developed new Stage II pressure ulcers that were not assessed or documented in a timely manner by the facility. Despite CNAs notifying the DON about the ulcers, there was an eight-hour delay in assessment and documentation, contrary to the facility's policy.
A resident with a tracheostomy, who was documented as NPO, experienced a significant medication error when the DON administered a sublingual Hyoscyamine tablet instead of using the prescribed G-tube route. This resulted in the resident coughing violently and struggling to breathe, highlighting a failure to adhere to the correct medication administration route as per the facility's policy.
Untimely Call Light Responses Lead to Delayed Assistance With Care Needs
Penalty
Summary
The deficiency involves the facility’s failure to meet its own policy requirement that resident call lights be answered as soon as possible and no later than five minutes. The facility’s Call System, Residents policy dated September 2022 states that each resident is provided a means to call staff for assistance and that calls should be answered promptly, with urgent requests addressed immediately. During interviews on 3/11/26, a cognitively intact resident with chronic kidney disease, severe protein calorie malnutrition, adult failure to thrive, rheumatoid arthritis, malaise, and a Stage II sacral pressure ulcer reported often waiting over an hour for staff to respond to her call light. This resident, who has upper and lower extremity impairments and requires maximal assistance for personal/toilet hygiene and transfers, stated she knows when she needs to use the bathroom but must wait for staff to transfer her, and that the delays sometimes result in her urinating in her incontinence brief, which makes her feel terrible. Another cognitively intact resident, diagnosed with Type II diabetes, muscle weakness, anxiety, and major depression, and requiring supervision and touching assistance for personal/toilet hygiene and transfers, stated it often takes staff over an hour to answer her roommate’s call light and that she feels badly because she knows it bothers her roommate when she has an accident. A third cognitively intact resident with COPD, lymphedema, obesity, and peripheral vascular disease, who uses a cane and requires supervision and touching assistance for personal/toilet hygiene and transfers, reported that it often takes staff over a half hour to answer call lights, especially on night shift. Two CNAs stated that residents frequently complain about long call light wait times and reported there is not enough CNA staff on evening and night shifts, resulting in residents waiting extremely long for assistance and their needs not being met timely. The Administrator confirmed that the resident who uses the call light for toileting knows when she needs to use the bathroom and that staff should respond to call lights quickly and within a reasonable time frame, and acknowledged that not answering call lights in a timely manner can negatively affect resident care.
Failure to Protect Cognitively Impaired Resident From Physical Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a CNA during care. On the evening of December 9, 2025, two CNAs were assisting resident R2 into bed when R2, who has severe dementia with anxiety and behavioral disturbances and is documented as having severe cognitive impairment on the MDS, reached out and grabbed one CNA’s head. According to a witness statement from the assisting CNA, the primary CNA responded by striking R2’s hand and telling R2 not to grab her head. The alleged perpetrator CNA’s written statement in the facility’s investigation file differs, indicating that she only removed R2’s hand from her head. The facility’s investigation report documents that R2 grabbed the CNA’s head and that the CNA immediately responded by grabbing and redirecting R2’s hand away from her head. R2’s EMR includes a health status note from the date of the incident indicating that a CNA reported an alleged incident during a transfer in R2’s room and that R2 was assessed for injuries and vital signs were obtained. Subsequent observation on January 15, 2026, showed R2 lying in bed, unable to respond to questions due to severe cognitive impairment. Interviews conducted later revealed that the CNA alleged to have struck R2’s hand was no longer employed at the facility and declined to discuss details of the incident, citing concern about self-incrimination. The Administrator/Abuse Coordinator later stated that the CNA had instinctively moved R2’s hand away from her long hair and confirmed there was no injury to R2. The facility’s Abuse, Neglect, Exploitation and Misappropriation Prevention Program Policy states that residents have the right to be free from physical abuse and that the facility is committed to protecting residents from abuse by anyone and to maintaining a culture of compassion and caring, particularly for residents with behavioral, cognitive, or emotional challenges.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for eight consecutive hours a day, seven days a week, as required. On August 2, 2025, the only RN scheduled was the Assistant Director of Nursing, who was documented to work from 2:00 am to 6:00 am, resulting in four hours of RN coverage instead of the required eight. There was no corresponding timecard to confirm that the RN actually worked those hours. Another RN was initially listed on the schedule but was later confirmed not to have worked due to illness. The Administrator, who is also an RN, believed she may have covered the remaining hours but could not provide documentation or medical record entries to confirm this. The Director of Nursing also could not confirm that the Administrator worked as a floor nurse on that date. The Director of Nursing reported ongoing difficulties in hiring RNs due to non-competitive wages, leading to reliance on agency staff and the hiring of additional CNAs to maintain direct care staffing. The facility's records indicated that only one RN shift was covered on the date in question, and there was no evidence of RN coverage for the required eight consecutive hours. At the time of the survey, the facility had 70 residents, all of whom were potentially affected by the lack of required RN coverage.
Lack of Qualified Dietary Manager and Food Safety Deficiencies
Penalty
Summary
The facility failed to employ a clinically qualified Director of Food and Nutrition Services, as required by federal and state regulations. During the survey, it was observed that a cook was actively supervising dietary operations without the necessary credentials or training. The cook confirmed not being a certified dietary manager, dietician, or having completed any of the required educational programs or certifications. The facility did not have a full-time designated manager for dietary services, and the dietician only worked on-site one day per month. The cook also reported only completing a one-day food service sanitation course, which did not include clinical nutrition instruction. Additionally, throughout the survey period, the facility failed to maintain proper food safety and sanitation practices. Surveyors observed the use of an unapproved food scoop in bulk flour, a can opener with accumulated metal shavings, and unsanitary floor surfaces in the walk-in cooler. These deficiencies had the potential to affect all 70 residents residing in the facility, as documented in the facility's application for Medicare and Medicaid.
Unsanitary Food Storage and Preparation Practices
Penalty
Summary
Surveyors observed that the facility failed to maintain sanitary conditions in the kitchen, specifically in the walk-in cooler and food preparation areas. On two separate dates, the walk-in cooler floor was found soiled with food debris, including a decomposed tomato, onion skins, and spilled beverages, with no evidence of cleaning between observations. Additionally, a table-mounted can opener and its receiver were noted to have dark, sticky food accumulations and metal shavings, and remained uncleaned over multiple days, despite staff acknowledging that cleaning should occur after each use. Furthermore, a disposable foam cup was being used as a scoop in a bulk flour container, with the entire cup in direct contact with the flour. These unsanitary practices were observed in areas where food is prepared and stored for all 70 residents in the facility.
Failure to Ensure DON Attendance at QAA Meetings
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON), a required member, attended the quarterly Quality Assessment and Assurance (QAA) committee meetings. According to the facility's QAPI Plan and supporting documents, the QAA meeting is to be conducted every three months and must include key personnel, including the DON. However, review of the QA meeting sign-in sheet for a meeting dated July 15, 2025, showed the DON's signature, but upon interview, the DON confirmed she was on vacation in Hawaii on that date and could not have attended the meeting. The DON further stated that she was given the sign-in sheet to sign as part of the QA meeting team, but the date and quarter reviewed were handwritten on the sheet after she signed it, and she had not attended any official QA meeting since her start date of May 27, 2025. The Administrator also confirmed that the DON was on vacation on the date of the alleged meeting and could not have been present. The facility's records indicate that there are currently 70 residents residing in the facility. The deficiency centers on the lack of required participation by the DON in the QAA committee meetings, as mandated by facility policy and federal regulations.
Failure to Provide Clean and Homelike Bed Linens
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for two residents, as evidenced by the use of stained and excessively worn bed linens. One resident, who was cognitively intact, was observed on multiple occasions lying directly on a fitted sheet that had several brown stains and was worn through to the point that the mattress was visible. This resident reported that staff provided her with clean sheets that were still stained and expressed a preference for linens without stains from previous users. A certified nurse aide confirmed that most resident bed linens were stained or worn to the point of being nearly transparent and stated that residents had complained about the condition of the linens. The aide also reported having informed management about the need for new linens. Another resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, was repeatedly observed lying on a fitted sheet with brown and grey stains, which was also worn through to the mattress. The laundry supervisor acknowledged that the facility had linens with tears, stains, and excessive wear, and stated that she attempts to remove inadequate linens during the laundry process. However, she noted that during her absence, some stained and worn linens may have continued to be used by residents. The facility's own pamphlet on resident rights specifies the obligation to provide services that maintain residents' physical and mental health and satisfaction.
Failure to Provide Timely Incontinence Care and Scheduled Bathing
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living, specifically bathing and timely incontinence care, for a resident who was dependent on staff for hygiene. Resident council meeting minutes over several months documented ongoing concerns from residents about staff not answering call lights promptly and issues with receiving showers. One resident, who was admitted with multiple diagnoses including muscle weakness, Parkinsonism, severe obesity, and was dependent on staff for all mobility and hygiene needs, reported waiting several hours for staff assistance after activating the call light for incontinence care. The resident also reported receiving only three showers over a 55-day period, despite being scheduled for two showers per week. Staff interviews confirmed the resident's reliability in reporting care issues and acknowledged the resident's dependence on staff for bathing and toileting hygiene. The resident expressed frustration with the delays, noting that staff often cited being busy with other residents as the reason for the lack of timely assistance. Documentation in the resident's care plan and assessments further supported the resident's need for substantial or maximal staff assistance for hygiene, which was not consistently provided as required.
Failure to Maintain Resident Dignity Through Adequate Oral Care
Penalty
Summary
A deficiency was identified when a resident, documented as severely cognitively impaired and fully dependent on staff for all activities of daily living, was repeatedly observed in the resident lounge with visible white mucous on her lips and mouth area. On multiple occasions, the resident was seen with either a thick line of white mucous hanging from her mouth or dried, thick white mucous on her lips and mouth corners, while in the presence of other residents and staff. The Director of Nursing confirmed that staff are expected to provide oral care at least daily and as needed, and acknowledged that this resident requires total assistance from staff for personal hygiene.
Failure to Timely Initiate and Investigate Resident Grievance Regarding Missing Personal Items
Penalty
Summary
The facility failed to initiate a grievance report in a timely manner after a resident reported missing personal items, specifically two jackets. The resident communicated the loss to multiple staff members and the Ombudsman, who then notified the Administrator on the same day. Despite this notification, the Administrator did not recall or document the grievance until nearly two months later, and no action was taken to resolve the issue during that period. The resident expressed ongoing distress and uncertainty about the missing items, stating that she had informed several staff members and the Ombudsman, but did not see any resolution or follow-up until the survey was in progress. Facility policy requires all staff to report grievances to the Social Service Director, who serves as the grievance official, and mandates that grievances be investigated and resolved within five working days. However, the Social Service Director was not informed of the grievance until the time of the survey, and the grievance was not brought to the daily Quality Assurance meeting as required. The delay in reporting and investigating the grievance resulted in a significant lapse in addressing the resident's concern in accordance with facility policy.
Inaccurate MDS Coding of Resident Fall Event
Penalty
Summary
The facility failed to accurately encode a resident's health status on the Minimum Data Set (MDS) regarding falls. Specifically, a resident with moderate cognitive impairment, as indicated by a Brief Interview of Mental Status score of 10 out of 15, experienced a witnessed fall from a wheelchair in the dining room, resulting in a skin tear to the left elbow. This fall was documented in the resident's AIMS Wellness Event Record and the facility's fall log, but was not reflected in the resident's most recent quarterly MDS assessment, which incorrectly indicated that the resident had not experienced any falls since the last assessment. Interviews with facility staff confirmed the discrepancy. The DON, who reviewed the electronic medical record, acknowledged that the MDS did not accurately reflect the resident's status at the time of assessment, citing the documented fall. The administrator, who had recently taken over MDS responsibilities due to staff turnover, also recognized that the fall may have been missed in the MDS documentation. The resident was unable to recall details of the falls due to cognitive impairment.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to identify, assess, and provide appropriate treatment for pressure ulcers for a resident who was severely cognitively impaired and dependent on staff for all activities of daily living. The resident was assessed as high risk for pressure ulcers and had care plan interventions in place, including floating heels and using pillows or cushions to prevent skin-to-skin contact and pressure on the legs and feet. Despite these interventions and physician orders for daily skin checks and monitoring of red areas on the legs, staff did not implement the prescribed preventative measures. Observations over several days showed the resident lying in bed with bare legs directly on the fitted sheet, without heel protectors, pillows, or cushions in place. Documentation revealed that the resident developed a Stage II pressure ulcer on the right inner leg and a Stage I pressure ulcer on the left posterior leg, with no prior physician orders or assessments for these wounds before their identification. Staff interviews confirmed a lack of awareness and action regarding the need for skin protection and preventative measures, and the facility administrator acknowledged that the pressure ulcers were known but not addressed or documented as required by facility policy. The facility's policy mandated daily skin inspections and positioning according to the care plan, which was not followed in this case.
Failure to Monitor and Care for Resident's Wounds
Penalty
Summary
The facility failed to properly assess, monitor, and notify the physician to obtain treatment orders for a resident's open buttock wounds, which were documented to have deteriorated from reddened areas to open wounds. The resident, who is moderately cognitively impaired and dependent on staff for all care, including toileting and personal hygiene, was not provided with the necessary incontinence care as per the care plan. The care plan instructed staff to check and change the resident's incontinence brief every two hours, but staff failed to adhere to this schedule, leading to the resident's condition worsening. On one occasion, a CNA cross-contaminated the resident's open wounds with a soiled towel during incontinence care, which could potentially lead to infection. The CNAs involved did not consistently check on the resident or provide the necessary care, and there was a lack of communication and responsibility among the staff regarding the resident's care. The Director of Nurses acknowledged that the staff should have been asking the resident if he would like to be turned or provided with incontinence care every two hours, but this was not done. Additionally, the facility did not have a policy for turning, positioning, and preventing cross-contamination of wounds. The resident's mattress was also in poor condition, contributing to the issue. The Wound LPN noted that the resident's wounds were not assessed, monitored, or documented properly, and the necessary treatment orders were not obtained. The lack of monitoring and documentation meant that the facility could not determine the exact condition of the resident's wounds over time, leading to inadequate care and intervention.
Inadequate Incontinence Care and Cross-Contamination
Penalty
Summary
The facility failed to provide appropriate incontinence care and prevent cross-contamination for a resident with multiple medical conditions, including quadriplegia and diabetes. The resident, who is moderately cognitively impaired and depends on staff for all care, was found in his recliner chair without having received incontinence care for several hours. The care plan for the resident required staff to check and change incontinence briefs every two hours, but this was not adhered to. During an observed care session, a CNA cross-contaminated the resident's open wounds on the buttocks by using a soiled towel to provide bowel incontinence care, directly wiping over the wounds. Interviews with the CNAs revealed a lack of communication and responsibility regarding the resident's care. One CNA, who was assigned to the resident, admitted to not having been in the resident's room during her shift, while another CNA, who got the resident up in the morning, had not returned to provide further care. The Director of Nurses acknowledged the importance of regular repositioning and maintaining cleanliness to prevent infections, especially given the resident's history of open wounds. However, there was no policy found for turning/positioning and preventing cross-contamination, indicating a gap in the facility's procedures.
Failure to Provide Lifesaving Equipment During CPR
Penalty
Summary
The facility failed to provide lifesaving equipment for emergency airway management for a resident in cardiac and respiratory arrest. This deficiency was identified during a survey and affected one of 18 residents reviewed for advanced directives, with the potential to affect all 72 residents residing in the facility. The resident, who had a Physician Order for Life Sustaining Treatment (POLST) indicating a wish for full treatment, including CPR, was found without a pulse or respirations. Despite the initiation of CPR by facility staff, they were unable to locate a functional bag valve mask (BVM) to provide effective ventilation. The resident's medical history included unspecified asthma, hypertensive heart disease without heart failure, and age-related osteoporosis with a current pathological fracture. The resident had recently returned from the hospital after a right hip surgical repair. During the emergency, staff attempted to provide manual ventilation using an Ambu bag without a BVM mask, which did not create an adequate seal over the resident's mouth and nose. This inadequate ventilation was confirmed by the lead paramedic on the scene, who stated that the lack of a BVM mask led to insufficient life-sustaining ventilation during CPR. Interviews with facility staff revealed that the emergency crash cart did not contain a functional BVM mask at the time of the incident. The Director of Nursing and other staff members confirmed that the mask initially found was broken, and a replacement was not obtained before emergency medical technicians arrived. The facility's policy required that emergency equipment, including a BVM, be portable and readily available at all times, but this was not adhered to, resulting in the deficiency.
Removal Plan
- Provided in-service training and video for Cardio Pulmonary Resuscitation and Basic Life Support. V2, Director of Nursing (DON) was in-person and V27, Registered Nurse (RN), BLS Certified, [NAME] Health Care was present via tele-monitor.
- Inspected all onsite Ambu bags. V1, Administrator/RN and V2, DON.
- Facility will maintain 2 Ambu bags on the crash cart. Confirmed with V1, Administrator/RN.
- Began a crash cart audit checklist to be completed nightly.
- In serviced licensed nurses on restocking crash cart after use.
- In serviced licensed nurses on the crash cart checklist, replacement of faulty supplies, and notification to nursing management. V2, DON.
- CPR certifications training for licensed nurses. Confirmed.
- Began daily audits to ensure the crash cart checklist is conducted nightly.
- Began random audits of the crash cart inventory supplies.
- The Quality Assurance Quality Improvement Team meeting is scheduled to further address the event. V1, Administrator confirmed.
Failure to Implement Post-Fall Interventions and Document Falls
Penalty
Summary
The facility failed to implement post-fall interventions for two residents, R2 and R3, and did not adequately recognize, document, or investigate falls from bed for R3. R2, who has severe cognitive impairment and multiple diagnoses including dementia and osteoporosis, was observed with numerous bruises on her arms and hands. Her bed was elevated to an unsafe height, which was confirmed by the facility's administrator. Despite a documented fall from her bed on 12/04/24, the intervention of a low bed was not included in her care plan. R3, also with severe cognitive impairment and quadriplegia, experienced multiple falls, including a documented incident on 12/09/24 where he tumbled out of his wheelchair. Despite having a mattress placed on the floor next to his bed, staff did not document these occurrences as falls, nor did they conduct fall reports or notify the family. The facility's Director of Nursing acknowledged that R3 consistently rolled out of bed onto the mattress, but these incidents were not considered falls, and thus, no investigations or reports were made. The facility's fall prevention policy requires immediate assessment and documentation of falls, as well as discussion in Quality Assurance meetings. However, the facility did not adhere to these procedures for R3, as his frequent changes in plane were not documented or reported as falls. This lack of documentation and investigation represents a failure to follow established protocols for fall prevention and resident safety.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from verbal and physical abuse, as evidenced by an altercation involving four residents. The incident occurred in the dining room, where one resident verbally abused another by using derogatory and offensive language. This verbal abuse escalated when another resident intervened, leading to a physical altercation where the intervening resident struck the verbally abusive resident multiple times. The staff eventually separated the residents, but the incident had already caused distress among other residents present. The residents involved in the incident have various medical diagnoses that may have contributed to their behavior. One resident, who initiated the verbal abuse, has dementia with psychotic disturbances and is moderately cognitively impaired. Another resident, who responded physically, has a history of anxiety, psychotic disorder with delusions, and other mental health issues, and is also moderately cognitively impaired. The third resident, who was the initial target of the verbal abuse, has dementia with agitation and moderate intellectual disabilities, and requires assistance with daily activities. Staff members, including a Licensed Practical Nurse and Certified Nurse Aides, witnessed parts of the altercation and intervened to separate the residents. However, the initial verbal abuse and subsequent physical altercation occurred in front of other alert and oriented residents, causing fear and distress. The facility's failure to prevent this incident highlights a deficiency in protecting residents from abuse, as outlined in their abuse prevention policy.
Failure to Communicate Resident Rights
Penalty
Summary
The facility failed to ensure that residents were informed of and understood their rights while living in the nursing home. During a resident group meeting, several residents stated that they did not have their resident rights communicated to them during Resident Council meetings. They mentioned receiving a booklet upon admission, but it had been a while since then. A review of the Resident Council meeting minutes from April to September 2024 showed no documentation that resident rights were discussed. The Activity Director confirmed that resident rights were not covered in the meetings. The facility's documentation indicates that 71 residents reside in the facility.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to deliver mail to residents on Saturdays, which has the potential to affect all 71 residents residing in the facility. During a resident group meeting, several residents reported that they do not receive mail on Saturdays. The facility administrator stated that the residents do not receive mail on Saturdays because the post office does not deliver mail to the facility on that day. However, a local post office mail clerk confirmed that mail is indeed delivered to the nursing home on Saturdays and placed in their mailbox. The facility's documentation on residents' rights indicates that mail must be delivered promptly.
Facility Lacks Qualified Director of Food and Nutrition Services
Penalty
Summary
The facility failed to employ a qualified Director of Food and Nutrition Services, which has the potential to affect nearly all 71 residents who consume food prepared in the facility kitchen. On a specific date, the Administrator confirmed the absence of a Dietary Manager. A Cook was observed managing and directing dietary personnel and food preparation activities without possessing the necessary qualifications, such as a Certified Dietary Manager (CDM) certificate. The Cook only held a Food Service Sanitation (FSS) certificate, which is not managerial in nature, and lacked formal training or education required for the role of Director of Food Service. Additionally, issues related to food storage, food sanitation, and equipment cleanliness were identified in the facility kitchen. Four residents were noted to be NPO and did not receive meal trays.
Deficiencies in Food Storage and Kitchen Cleanliness
Penalty
Summary
The facility failed to implement proper food storage and leftover tracking processes, maintain cleanliness of bulk food, and ensure kitchen equipment cleanliness, which could potentially lead to food contamination. During an observation, it was noted that food items in the dry storage area were not dated to indicate when they were received, hindering the 'first in first out' rotation process. A cook acknowledged that dating items depended on who put them away. Additionally, a bag of mixed salad in the walk-in refrigerator was not dated or labeled, and the cook admitted that leftovers were supposed to be dated, but this was not consistently done. Further observations revealed unsanitary conditions in the kitchen, including a microwave interior splattered with an unidentified dark red substance and a plastic cup left inside a bulk sugar bin. A cook mentioned that such items were frequently left in the bins, requiring daily removal. A Styrofoam bowl was also found in a bulk flour bin, used by a cook to scoop flour. The range hood had copious amounts of lint and dust hanging from the fire suppression outlets, grease track, and fire suppression supply pipes, which the administrator acknowledged had been previously noted by life safety inspectors. The facility's policies on food storage and cleanliness were not adhered to, as evidenced by these findings.
Failure to Provide Adequate ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) assistance to six out of seven residents reviewed. One resident, who is non-verbal and totally dependent on staff for personal hygiene and oral care, was observed with a crusted white matter on her lips and dry, cracked mucous membranes. Despite her cognitive impairment, which prevents her from modifying her behavior, staff did not provide the necessary oral care. The resident's nurse and CNA confirmed the lack of oral care supplies and documentation of care refusal, indicating a failure to meet the resident's care needs. Additionally, several residents reported not receiving showers as scheduled, with some going up to three weeks without a shower. Documentation confirmed that multiple residents did not receive the required number of baths or showers, and there was no record of what actions were taken if a resident refused a bath or shower. The facility's policy requires notifying the charge nurse if a resident refuses a bath or shower, but this was not documented, leading to inadequate hygiene care for the residents.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions for residents with specific medical conditions, including tracheostomy airway access, gastrostomy feeding tubes, pressure ulcers, urinary catheters, and intravenous access ports. This deficiency was observed in five residents during the survey. For instance, one resident with an indwelling urinary catheter and pressure ulcers did not have Enhanced Barrier Precaution signage or personal protective equipment available in their room. Certified Nursing Assistants and the Director of Nursing were observed providing care without wearing gowns, despite handling high-contact care activities that could transfer multidrug-resistant organisms. The facility's Enhanced Barrier Precautions policy requires the use of gowns and gloves during high-contact care activities for residents with indwelling medical devices and open wounds. However, during the survey, there were no signs posted to guide staff in following these precautions, and staff did not consistently wear the required personal protective equipment. The facility administrator acknowledged that implementing these precautions would affect nearly all residents, indicating a systemic issue in adhering to the policy.
Failure to Notify Family of Medication Change
Penalty
Summary
The facility failed to notify a family representative of a decrease in the dosage of an antipsychotic medication for a resident with moderate cognitive impairment. The resident, who has been on Risperdal for years, experienced a reduction in the frequency of the medication from three times a day to two times a day without the family representative's knowledge. This change was documented in the resident's Medication Administration Record (MAR) for September 2024. The family representative noticed a significant change in the resident's behavior, including staring into space and being unable to talk, during visits. Upon inquiry, the family representative learned about the medication change from the facility administrator. The facility's policy requires notifying appropriate individuals, including family representatives, of significant changes in a resident's medical treatment. However, the facility staff did not inform the family representative about the medication adjustment, believing they were required to attempt a gradual dose reduction regardless of family input. The facility's administrator and director of nursing acknowledged the oversight, stating they were unaware of the need for family approval for the medication change. This lack of communication led to the family representative's dissatisfaction and concern for the resident's well-being.
Failure to Timely Resolve Grievance for Specialized Wheelchair
Penalty
Summary
The facility failed to resolve a grievance regarding the provision of a specialized wheelchair for a resident with moderate cognitive impairment and mobility needs. The resident's family representative initially filed a grievance on February 14, 2024, requesting a new wheelchair due to the resident's weight gain and the inadequacy of the current wheelchair. Despite the grievance being marked as unresolved on May 15, 2024, the facility did not take timely action to address the issue. The administrator explained that the facility's corporation would not fund a new wheelchair due to financial constraints, and the resident was left using various uncomfortable and unsuitable wheelchairs available in the facility. The resident's occupational therapy evaluation, conducted on August 28, 2024, confirmed the need for a custom wheelchair to accommodate the resident's specific physical conditions, including range of motion limitations and scoliosis. However, this evaluation occurred six and a half months after the initial grievance was filed. The facility's grievance policy mandates that investigations be completed within 15 days, but this timeline was not adhered to, resulting in the resident continuing to use inadequate wheelchairs. The family representative expressed dissatisfaction with the facility's handling of the grievance, noting the resident's discomfort and the poor condition of the temporary wheelchairs provided.
Failure to Follow Restraint Release Protocol for Resident
Penalty
Summary
The facility failed to adhere to the care plan for a resident, identified as R17, who was observed with secured hand mitten restraints that were not removed according to the prescribed schedule. R17, who has a medical history of quadriplegia, traumatic brain injury, and neurological devastation, was supposed to have her mittens released every two hours as per her care plan. However, observations and staff interviews revealed that the mittens were only removed on shower days, contrary to the care plan's directives. This was confirmed by a CNA who stated that the mittens were not removed every two hours due to concerns about the resident pulling out her G-tube. Further investigation showed that the facility's policy on physical restraints required that restraints be released at a minimum of every two hours for necessary care and repositioning. Despite this policy, the resident's mittens were not removed regularly, as evidenced by the resident's long and soiled fingernails, indicating infrequent removal. The resident was unable to remove the mittens herself, as demonstrated by her unsuccessful attempts to do so when asked. The facility's failure to follow the care plan and policy resulted in the resident being restrained for extended periods without the required breaks.
Failure to Include Urinary Catheter in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized care plan for a resident with an indwelling urinary catheter. This deficiency was identified during a review of the care plans for 20 residents, affecting one resident who had a diagnosis of urine retention and an unspecified urinary tract infection. The physician's orders specified that the resident should have a 16 French urinary catheter with a 10-milliliter bulb, to be changed every 28 days or as necessary. However, the resident's care plan, dated September 12, 2024, did not include any category plan or interventions for the urinary catheter. On September 12, 2024, the Minimum Data Set/Care Plan Coordinator acknowledged that the care plan did not cover the resident's catheter and was informed by the Administrator to correct this oversight. The facility's policy on comprehensive care planning requires that care plans be reviewed and revised as necessary to reflect the residents' current needs, but this was not initially done for the resident in question.
Delayed Assessment and Documentation of Pressure Ulcers
Penalty
Summary
The facility failed to assess and document new, facility-acquired Stage II pressure ulcers in a timely manner for a resident with multiple diagnoses, including Diabetes Mellitus II with Diabetic Polyneuropathy, Spinal Stenosis, Cervicalgia, Obesity, and Unspecified Quadriplegia. On a specific day, Certified Nursing Assistants (CNAs) discovered open pressure areas on the resident's buttocks during a transfer and peri-care. Despite notifying the Director of Nursing (DON) about the condition, the assessment and documentation of the pressure ulcers were delayed by approximately eight hours. The facility's policy requires immediate assessment and documentation of pressure ulcers upon notification, but this was not followed. The DON acknowledged the delay, attributing it to being occupied with other duties such as medication administration. The resident's medical record lacked documentation of a current pressure ulcer treatment until after the observation and interviews, indicating a lapse in the facility's adherence to its own policy for pressure ulcer care.
Failure to Maintain NPO Status Leads to Medication Error
Penalty
Summary
The facility failed to adhere to the NPO (nothing by mouth) status of a resident with a tracheostomy, leading to a significant medication error. The resident, identified as R15, had a physician order sheet indicating that medications should be administered via a G-tube due to their NPO status, which was documented in their care plan. Despite this, during a medication pass, the Director of Nursing (DON) administered a sublingual Hyoscyamine tablet by placing it under the resident's tongue, contrary to the prescribed route of administration. This action resulted in the resident experiencing distress, as they began coughing violently, appeared red, and struggled to breathe, eventually expelling the tablet from their mouth. The facility's medication administration policy emphasizes the importance of following the correct route for medication administration, which was not adhered to in this instance. The incident highlights a failure in maintaining accurate and consistent adherence to the resident's care plan and physician orders, specifically regarding their NPO status and the correct route for medication administration.
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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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