Sunset Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Quincy, Illinois.
- Location
- 418 Washington Street, Quincy, Illinois 62301
- CMS Provider Number
- 145800
- Inspections on file
- 40
- Latest survey
- November 19, 2025
- Citations (last 12 mo.)
- 4 (2 serious)
Citation history
Health deficiencies cited at Sunset Home during CMS and state inspections, most recent first.
A resident with cognitive impairment was subjected to aggressive handling by a CNA, witnessed by multiple staff who reported the actions as inappropriate and distressing. The facility failed to conduct a thorough abuse investigation by not interviewing all witnesses and allowed the accused CNA to return to work before the investigation was complete, resulting in an Immediate Jeopardy finding.
A resident with dementia and limited communication abilities was forcibly moved down a hallway by a CNA, despite her resistance and care plan instructions to avoid physical contact. Multiple staff witnessed the incident, noting the CNA's anger and inappropriate language. The event caused the resident to appear scared and traumatized, and was later substantiated as abuse after further investigation.
The facility did not ensure that CNA staff received the required 12 hours of annual in-service education, including abuse and dementia training. Documentation was lacking to confirm completion of these trainings, and leadership acknowledged uncertainty and absence of proof for the required education, potentially affecting all residents.
A resident was found with a large, unexplained bruise on the left mid-back, which was observed by an LPN and reported to the DON. Despite facility policy requiring immediate reporting of injuries of unknown origin, the incident was not reported to the state agency, as confirmed by both the DON and the administrator.
A resident was found with a large, unexplained bruise on the left mid back, which was reported by an LPN to the DON. Despite facility policy requiring prompt and thorough investigation of injuries of unknown origin, no investigation was initiated or documented. Both the DON and Administrator acknowledged that an investigation should have occurred but did not.
A resident developed a stage 4 pressure ulcer due to the facility's failure to follow physician orders and implement pressure-relieving interventions. The resident, with multiple health issues and moderate cognitive impairment, was dependent on staff for mobility. Despite care plan directives, wound care was inconsistently documented, and staff reported supply shortages. The ulcer worsened, becoming infected and painful, with staff and the resident's power of attorney noting inadequate repositioning and care practices.
A resident with Type 2 Diabetes Mellitus received incorrect insulin for 45 days due to a transcription error, leading to hypoglycemic episodes requiring glucagon injections. The facility failed to administer the correct insulin as per the physician's order, and the error was discovered after the resident's blood sugar levels fluctuated significantly.
A resident with multiple health conditions experienced a medication error involving insulin, which was not communicated to the family or physician. The resident's blood sugar levels dropped significantly, but the NP was not notified at the time. The facility lacked a specific policy for notifying family and physicians of such incidents.
A resident with multiple serious health conditions was admitted to the facility, but vital signs were not recorded until four days later, and required assessments were delayed. The DON confirmed the lapse, noting that documentation often remains on paper and is not entered into the system promptly.
A resident with multiple health conditions, including diabetes, was sent home with the wrong insulin during a home visit. The error occurred when an LPN gave the resident an insulin syringe from the medication cart, which was not intended for her. The facility lacked a policy on medication storage, and the error was discovered when the resident was contacted and advised not to take the insulin.
The facility failed to maintain a sanitary environment, leading to a cockroach infestation in the kitchen and dining areas. Despite regular pest control treatments, live and dead cockroaches were observed, and staff reported seeing them on resident trays and in dining areas. The issue persisted due to food trays left overnight, contributing to the infestation, affecting all 96 residents.
The facility failed to provide adequate supervision and assistance to residents at risk for falls and those needing dining help. Observations showed a resident left unsupervised in a wheelchair and CNAs eating instead of assisting residents. There was also a lack of documentation for meal intakes and incontinence care, affecting residents with significant weight loss, frequent incontinence, and high fall risk.
The facility failed to monitor and document the chemical dishwasher's sanitizer concentration and did not label opened freezer food items with dates. Additionally, cool down temperatures for soups prepared and stored in the freezer were not recorded, contrary to facility policy. These deficiencies could potentially affect all 87 residents.
The facility failed to ensure proper respiratory care for four residents by not dating oxygen tubing and humidification bottles, and not storing oxygen tubing in a bag when not in use. Observations revealed undated and improperly stored equipment for residents receiving oxygen therapy, contrary to the facility's policy. The DON confirmed the requirement for dating and proper storage.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with open wounds and indwelling urinary catheters. Despite the policy requiring gowns and gloves during high-contact care to prevent MDRO spread, no EBP signs or PPE were observed during a facility tour. Residents and staff confirmed the absence of PPE use during catheter care. The ADON admitted to not ensuring EBP implementation, leading to a lack of infection prevention measures for at-risk residents.
The facility failed to ensure call lights were within reach for three residents, including one with severe cognitive impairment and another dependent on care. Observations revealed call lights placed out of reach, confirmed by staff, compromising residents' ability to request assistance.
A resident with range of motion limitations did not have a physician-ordered hand splint applied as required. Observations showed the resident's hand in a tight contracture without the splint, and the care plan did not address the need for the splint. Facility staff confirmed the splint was not regularly applied, and there was no documentation of its use or refusals.
A resident with dementia and a history of falls was left unsupervised in the lobby, leading to a fall outside the building. Despite being high risk for falls, the resident exited the facility by following an employee through a door before the alarm sounded. The receptionist saw the resident slip out and called the nursing office, but the resident had already fallen by the time help arrived.
A facility failed to cover a resident's urinary catheter drainage bag with a privacy bag as required by their Catheter Care Procedure. The resident, who has a supra pubic urinary catheter, was observed twice with the catheter bag unsecured to the bottom of his wheelchair without a privacy bag. An LPN confirmed the deficiency, acknowledging the requirement for a privacy bag but was unsure why it was not in place.
A facility failed to follow a physician's order for daily weight monitoring for a resident receiving dialysis. Despite a policy requiring daily weights, the resident, who has End Stage Renal Disease and Heart Failure, was not weighed on multiple occasions. The resident confirmed the inconsistency, and the DON acknowledged the oversight.
The facility failed to justify the use of antipsychotic medications for two residents with dementia, as required by its policy. One resident had no documented behaviors justifying Risperidone use, and no psychotropic assessment was completed since the previous year. Another resident's care plan showed no behaviors warranting antipsychotic medication, and a pharmacy recommendation for dose reduction was denied without rationale. Staff confirmed the lack of behaviors justifying medication use, highlighting the facility's non-compliance with its policy.
A resident's Health Care Power of Attorney raised multiple concerns about the resident's care, including foot treatment and CNA access to medical records. Despite reporting these issues to the facility's administrator, the grievances were neither documented nor addressed, as confirmed by the administrator, who admitted to neglecting the concerns.
The facility failed to document wound care and provide thickened liquids as ordered for three residents. A resident did not receive consistent wound care, with missing documentation on multiple dates, and two residents requiring thickened liquids were given regular water instead. The DON and staff confirmed these deficiencies.
A facility failed to obtain timely physician orders and document weekly assessments for a resident's pressure ulcer. The ulcer was identified, but treatment orders were delayed by a week, and no further wound measurements were documented. The DON confirmed the lack of documentation and was unsure why the physician was not notified or why treatment was delayed.
Staff failed to immediately notify the Administrator of possible abuse involving a resident with multiple diagnoses, including sepsis and a left ankle fracture. The resident reported that a CNA yelled and was rough during a transfer, causing pain. The LPN did not immediately inform the Administrator, as required by the facility's policy, leading to a delay in addressing the incident.
A resident with severely impaired cognition and a history of wandering eloped from her unit through an open double door, passed through an alarmed door, and was found on a stairway landing. The resident, diagnosed with Dementia and a history of falls, was independently propelling her wheelchair prior to the incident. The care plan did not reflect her increased elopement risk. Staff members did not respond to the door alarms, citing they did not hear them, and there were discrepancies in staff accounts regarding alarm handling. The investigation revealed gaps in staff communication and awareness of the door alarm system, as well as inconsistencies in staff responses during the search for the resident.
A resident developed a severe UTI and sepsis due to the facility's failure to notify the physician of significant changes in the resident's condition. Despite documented abnormal urinary symptoms, the LPN did not inform the physician, leading to delayed treatment and hospitalization.
Failure to Investigate Abuse Allegation and Protect Resident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with Alzheimer's Disease, depression, and hypertension, who was rarely or never understood according to her MDS. On the day of the incident, the resident became verbally aggressive and was observed by multiple staff members to be resisting redirection away from a door. A certified nurse aide (CNA) intervened by forcefully hooking her arm under the resident's arm, turning her around, and walking her down the hallway despite the resident's resistance. Several staff members reported that the CNA appeared angry, used inappropriate language, and that the resident was dragged down the hallway while fighting and yelling. Witnesses, including a registered nurse (RN), a licensed practical nurse (LPN), and another CNA, expressed discomfort with the CNA's actions and described the interaction as aggressive and inappropriate. Despite these observations and statements, the facility's initial abuse investigation was incomplete. The CNA involved was suspended immediately after the incident but was allowed to return to work after the investigation was deemed unsubstantiated. The administrator confirmed that not all witnesses present during the incident were interviewed, including a CNA who directly intervened and took over care of the resident. Additionally, other staff members present on the hallway at the time were not interviewed as part of the initial investigation. The administrator admitted to not being concerned due to a lack of prior issues with the CNA, which contributed to the incomplete investigation. The facility's failure to follow its own abuse and neglect policy, which requires a thorough investigation including interviews with all relevant staff and witnesses, resulted in the CNA returning to work with the resident and other residents before the investigation was properly completed. This failure to protect the resident from further potential abuse and to conduct a comprehensive investigation led to an Immediate Jeopardy finding by surveyors.
Removal Plan
- Administrator, DON, and ADON reviewed Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating.
- Staff were educated on Abuse Prevention Policy by DON and ADON.
- Staff not working dayshift were called by Administrator, DON, and ADON and were given education via phone of Abuse Prevention policy.
- Remainder of the staff not working or reached by phone will be required to receive the education prior to working their next shift by DON and/or ADON or designee and will be required to sign the education sign-in sheet.
- An Emergency QAPI (Quality Assurance Performance Improvement) discussion was held with Medical Director, Administrator, DON, ADON and Social Service Director to review the investigation findings and conclusion and review the QA audit tools for ongoing audit plan. QA Audit for thorough investigation will be conducted with each allegation investigation. These audit findings will be reported monthly on the QAPI scorecard and reported at the quarterly Quality assurance meeting.
- Administrator and DON will meet monthly to review all audit findings and discuss, if any, possible further training/education or policy review changes need to occur.
- R1's Care Plan was updated with at risk for abuse/harm and interventions by Social Service Director.
Forcible Handling of Resident with Dementia Results in Substantiated Abuse
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's Disease, depression, and hypertension, who was rarely or never understood and had a care plan indicating a need for personal space and minimal physical contact, was forcibly moved down a hallway against her will by a certified nurse aide (CNA). The resident was exhibiting combative behaviors and was near a door at the end of the hallway when a registered nurse (RN) attempted to redirect her. The CNA intervened by hooking her arm under the resident's arm and physically moving her, despite the resident's resistance and vocal objections. Multiple staff interviews confirmed that the CNA was visibly angry and used inappropriate language during the incident, stating, "we aint doing this sh*t today," before forcibly moving the resident. Other staff, including an LPN and another CNA, witnessed the event and expressed discomfort with the CNA's actions, describing the resident as being dragged while fighting and yelling. The resident was described as acting scared and traumatized following the incident, and staff noted that she followed another CNA around for the rest of the night. The facility's initial abuse investigation deemed the allegation unfounded, but after further staff interviews and review, the incident was substantiated as abuse. The facility's policy prohibits abuse, including the willful infliction of injury or unreasonable confinement, and requires interventions that respect residents' needs and behaviors. The failure to follow the resident's care plan and the use of force resulted in psychosocial harm, as evidenced by the resident's subsequent behavior and staff observations.
Removal Plan
- Administrator, Director of Nursing, and Assistant Director of Nursing reviewed Abuse Policy and intervening and reporting with quiz; Stress and Burnout Handout, Coping with Workplace Stress, Training and Tips for Spotting Stress or Burnout with all on duty staff in person. All staff not working at the time were reached by phone and were educated. Any staff who were not reachable will not be able to clock in for their next shift until DON or ADON provide the education and handouts.
- The Abuse policy and intervening and reporting with quiz, Stress and Burnout Handout, Coping with Workplace Stress, Training and Tips for Spotting Stress or Burnout specific to intervention of preventing abuse and recognizing stress and burnout in co-workers and intervening was added to the orientation packet for new staff.
- An emergency QAPI (Quality Assurance and Performance Improvement) discussion was held with the Medical Director, Administrator, DON, ADON, and Social Service Director to review the investigation findings and conclusion and review the QA audit tools for ongoing audit plan. QA Audit will be conducted of 5 residents and 5 staff per month by DON, ADON, Social Services Director and/or designees about Abuse, Stress, and Burnout and concerns regarding any cares. These audit tools will be reported monthly on the QAPI scorecard and reported at the QA meeting.
- All residents with Alzheimer's Disease/Dementia were reviewed for At Risk for Abuse/Harm and any identified, care plan was added and/or updated by Social Services Director.
- Administrator and Director of Nursing will meet monthly to review all audit findings for discussion for need, if any, for further training/education and/or policy review changes.
Failure to Provide Required In-Service Education for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant (CNA) staff received the required 12 hours of annual in-service education, including abuse and dementia training. Review of facility records and interviews revealed that while some CNAs attended abuse training sessions during Town Hall meetings, there was no documentation to confirm that all CNAs completed the mandated 12 hours of in-service education. Additionally, there was no evidence of dementia training being provided to CNAs within the past one and a half years. Interviews with the Director of Nursing (DON) and the Administrator confirmed uncertainty regarding the completion and documentation of required training for CNAs. The Administrator acknowledged the absence of proof for the 12 hours of annual in-service education and the lack of dementia training. This deficiency has the potential to affect all 88 residents residing in the facility.
Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The facility failed to report an injury of unknown origin to the state agency as required by its Abuse and Neglect Policy. A resident was observed by an LPN to have a large, circular red/purple bruise approximately six inches in diameter on the left mid-back during a transfer to a stretcher. The LPN noted that the resident had been on Eliquis, a blood thinning medication, which had been placed on hold, and that there were no recent falls other than one that occurred two to three weeks prior, which the nurse did not believe was related to the bruise. The LPN reported the bruise to the Director of Nursing (DON), stating that the bruise appeared overnight and its cause was unknown. Despite the facility's policy requiring immediate reporting of injuries of unknown origin to the state agency, the incident was not reported. Both the DON and the facility administrator confirmed that the injury was not reported to the state agency, acknowledging that it should have been. The facility's records did not contain documentation of the required report for this incident.
Failure to Investigate Bruise of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation following the discovery of a bruise of unknown origin on one of three residents reviewed for bruises. According to the facility's Abuse and Neglect Policy, any injury of unknown source should be promptly and thoroughly investigated, including reviewing the resident's medical record, interviewing relevant staff, witnesses, the resident (if appropriate), and documenting the results. In this case, a large circular red/purple bruise was observed on a resident's left mid back by an LPN during a transfer to a stretcher. The LPN reported the bruise to the Director of Nursing (DON), noting that the resident was on Eliquis, a blood thinner that had been placed on hold, and that there were no recent falls other than one that occurred two to three weeks prior. The LPN stated the bruise appeared overnight and could not be explained. Despite the policy requirements and the report made to the DON, no investigation was initiated or documented regarding the bruise of unknown origin. Both the DON and the facility Administrator confirmed that an investigation should have been started but was not. The lack of investigation meant that the facility did not follow its own policy for responding to injuries of unknown origin, as required for potential abuse or neglect cases.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident, resulting in a facility-acquired stage 4 pressure ulcer on the coccyx that became infected and caused pain. The resident, who had multiple diagnoses including spinal stenosis, hypertension, and chronic kidney disease, was admitted with a moderate cognitive impairment and was dependent on staff for mobility and toileting. The care plan indicated the need for specific interventions to prevent skin breakdown, including turning the resident every two hours and avoiding positioning on the coccyx. Despite these care plan directives, the facility did not consistently follow the physician's orders for wound care and pressure relief. The resident's treatment records showed multiple instances where wound care was not documented as completed, and staff interviews confirmed that supplies were often unavailable, leading to missed treatments. The resident's condition worsened over time, with the pressure ulcer progressing from a stage 2 to a stage 4, accompanied by infection and a foul odor. The nurse practitioner noted that the wound care was not being performed as ordered, and the resident was not being repositioned adequately, contributing to the deterioration of the wound. Interviews with staff and the resident's power of attorney revealed systemic issues in the facility's care practices, including inadequate turning and repositioning of residents and frequent shortages of necessary wound care supplies. The resident's power of attorney observed that the resident was often left lying on her back, contrary to care plan instructions, and expressed concerns about the quality of care on the floor where the resident was housed. The facility's administrator acknowledged that the treatment administration records indicated non-compliance with the prescribed care, and the nurse practitioner emphasized that better care could have minimized the severity of the wound.
Medication Error Leads to Hypoglycemic Episodes
Penalty
Summary
The facility failed to accurately transcribe a physician's order and administer the correct insulin to a resident, leading to significant medication errors. The resident, who has a history of Type 2 Diabetes Mellitus and other serious health conditions, was prescribed Insulin Aspart for sliding scale use and Lantus SoloStar for daily use. However, the order was incorrectly transcribed, resulting in the administration of Insulin Glargine-yfgn, a long-acting insulin, instead of the prescribed short-acting insulin for sliding scale use. This error persisted for 45 days, during which the resident experienced two episodes of hypoglycemia, requiring emergency glucagon injections. The resident's blood sugar levels dropped significantly, reaching as low as 37 and 44, without timely notification to the physician. The incorrect insulin administration was discovered after the resident's blood sugar levels continued to fluctuate, prompting a review by the Nurse Practitioner, who identified the transcription error. Interviews with facility staff revealed that the error originated from an incorrect transcription by an agency LPN, which was not caught due to a lack of checks in place to verify medication orders. The Director of Nursing and other staff members acknowledged the mistake and its duration, highlighting the absence of a system to ensure the accuracy of medication orders. The pharmacist also noted that the unusual order should have been questioned, emphasizing the seriousness of hypoglycemia, especially in elderly patients.
Failure to Notify Family and Physician of Medication Error and Change in Condition
Penalty
Summary
The facility failed to notify a resident's family and physician of a medication error and a significant change in condition. A resident, who is a male with multiple diagnoses including Type 2 Diabetes Mellitus, Atherosclerotic Heart Disease, and Chronic Kidney Disease, experienced a medication error involving insulin. The error occurred when an agency LPN incorrectly changed the resident's insulin medication from a short-acting insulin, Fiasp, to an incorrect insulin, Glargine-yfgn, which the resident received from November 4, 2024, to December 19, 2024. This error was not communicated to the resident's Power of Attorney, as confirmed by the facility's Administrator. Additionally, the resident's blood sugar levels were significantly low, with a reading of 24, and later increased to the 200 range. Despite this significant change in condition, the Nurse Practitioner was not notified at the time of the incident. The Nurse Practitioner only became aware of the blood sugar drop upon reviewing the medical records later. The Director of Nursing acknowledged the error in insulin administration and the lack of notification to the physician and family, and the Administrator admitted there was no specific policy in place for such notifications.
Failure to Timely Record Vitals and Assessments for New Admission
Penalty
Summary
The facility failed to conduct timely vital sign checks and assessments for a resident, identified as R3, upon admission. R3, a male with multiple serious health conditions including malignant neoplasms, embolism, thrombocytopenia, and chronic heart failure, was admitted to the facility. However, the first recorded vital signs were not documented until four days after admission, which is a significant delay. The Director of Nursing (DON) confirmed the absence of recorded vitals and acknowledged that the nurses often document on paper, which may not always be transferred to the electronic system. Additionally, the required assessments for R3, such as the Elopement Evaluation, Skin Check, and Fall Risk Evaluation, were not completed until several days post-admission, contrary to the facility's protocol. The Administrator could not find any policy clearly defining when vitals should be taken, and the DON stated that vitals should be recorded every shift for the first three days to establish a baseline. This lack of timely assessments and documentation represents a deficiency in the facility's adherence to its own protocols for new admissions.
Medication Error During Resident Home Visit
Penalty
Summary
The facility failed to ensure the correct medication was sent with a resident during a home visit, leading to a medication error. The resident, a female with multiple diagnoses including diabetes, was sent home with the wrong insulin. The facility's policy on administering medications requires that medications be administered safely and as prescribed, and that residents leaving the facility temporarily should be given the correct medications for their absence. However, during the resident's home visit, the wrong insulin was sent with her, and she was later contacted and advised not to take it. The incident occurred when the unit coordinator prepared the resident's medications, but left the floor before the resident departed. A previous LPN then gave the resident the insulin syringe that was in the medication cart, which was not intended for her. The Director of Nursing confirmed that no insulin was supposed to be sent with the resident, and the administrator acknowledged the lack of a policy on medication storage. The facility was unable to identify whose insulin was mistakenly given to the resident.
Cockroach Infestation in Kitchen and Dining Areas
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the kitchen and dining areas, resulting in a cockroach infestation. The facility's Sanitation policy, dated November 2022, mandates that all food service areas be kept clean and free from insects. Despite this, multiple pest control service slips and invoices from November 2024 to February 2025 document repeated treatments for cockroaches in various areas of the facility, including the kitchen, dining halls, and basement. Observations and interviews with staff confirmed the presence of live and dead cockroaches in these areas, indicating an ongoing issue. On February 10, 2025, a Certified Nursing Assistant (CNA) reported seeing cockroaches on resident trays in the fourth-floor dining room, and a live cockroach was observed beneath the sink and counter in the same area. The counter, which had a broken lid on a container of bread and stored clean silverware, was identified as a location where cockroaches were seen. A Dietary Assistant also reported seeing live cockroaches in the main dining room, particularly under the juice machine, and noted that the issue had persisted for several months despite regular pest control treatments. The Director of Housekeeping confirmed that housekeeping cleans the dining rooms three times a day, but food trays left overnight contribute to the infestation. The Dietary Manager acknowledged the presence of cockroaches and stated that a deep clean was conducted six months prior, but the problem persists. The facility's Administrator confirmed ongoing pest control visits but was unsure if the source of the infestation had been identified. The report indicates that the infestation has the potential to affect all 96 residents residing in the facility.
Inadequate Supervision and Documentation in Resident Care
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for residents at risk for falls and those requiring dining assistance. Observations revealed that a resident with a history of falls was left unsupervised and slouched in her wheelchair, unable to reposition herself. Despite the presence of several CNAs in the dining room, they were observed eating and not attending to the residents, including those who needed help with meals. This lack of supervision and assistance was evident as residents consumed minimal portions of their meals without encouragement or support from the staff. The facility's policies require CNAs to document meal and fluid intakes, as well as episodes of incontinence, to monitor residents' health and well-being. However, the report indicates that there was no documentation of meal intakes or incontinence care for the residents reviewed. This lack of documentation was confirmed by the Assistant Director of Nursing, who acknowledged that CNAs were not recording these details in the residents' medical records, either on paper or electronically. The report highlights specific deficiencies in the care provided to three residents. One resident experienced significant weight loss over a month, another was frequently incontinent and required extensive assistance with eating, and the third was at high risk for falls. Despite these needs, the facility failed to provide the necessary care and documentation, as evidenced by the lack of recorded meal intakes and incontinence episodes, and the inadequate supervision during mealtimes.
Deficiencies in Food Safety Practices and Documentation
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of the chemical dishwasher's sanitizer concentration, as well as the labeling and dating of opened freezer food items. The Dietary Manager, identified as V7, conducted a test on the dishwasher's chemical level and stated that sanitation checks should be completed twice daily. However, the facility's Dish Machine-PPM Sanitizer Record log for September and October 2024 showed multiple instances where these checks were not completed, indicating a lapse in adherence to the facility's policy. Additionally, opened bags of frozen food items such as french fries, onion rings, pork fritters, and chicken strips were found in the walk-in freezer without labels indicating the date opened or a use-by date, contrary to the facility's policy. Furthermore, the facility did not record cool down temperatures for soups prepared ahead and stored in the freezer, which is a requirement according to the facility's Food Preparation and Service policy. The Dietary Manager, V7, confirmed that various soups made in October were stored in the freezer without documentation of their cool down temperatures. The cook, V9, admitted to not considering the need for cool down logs for these soups. This oversight in documentation and monitoring of food safety practices has the potential to affect all 87 residents residing in the facility.
Failure to Properly Date and Store Oxygen Equipment
Penalty
Summary
The facility failed to ensure proper respiratory care for four residents by not adhering to the established protocol for oxygen tubing and humidification bottles. Specifically, the oxygen tubing and humidification bottles for residents were not dated, and the oxygen tubing was not stored in a bag when not in use. This was observed in four residents who were part of a sample of 36 reviewed for respiratory care. The facility's policy requires that oxygen tubing and masks be changed every seven days and as needed, and that they be dated and stored properly. For instance, one resident's nasal cannula oxygen tubing was found on the floor, undated, and unbagged, with the humidification bottle also undated. Another resident was observed with oxygen flowing at three liters per nasal cannula, with both the tubing and humidification bottle undated. Similar issues were noted with two other residents, where the oxygen tubing was not labeled with the date and was not stored in a bag when not in use. The Director of Nursing confirmed that all oxygen tubing and humidifier bottles should be dated and stored in plastic bags when not in use.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with open wounds and indwelling urinary catheters, affecting 10 out of 10 residents reviewed for EBP in a sample of 36. The facility's EBP policy requires the use of gowns and gloves during high-contact resident care activities to prevent the spread of multi-drug resistant organisms (MDROs). However, during a facility tour, it was observed that no EBP signs were posted on any resident's door, and no personal protective equipment (PPE) was available inside or outside the rooms of residents who required EBP. Interviews with residents and staff confirmed that staff did not wear gowns or other PPE when providing catheter care. Specific residents, such as those with indwelling urinary catheters, were not placed on EBP despite being identified as needing such precautions. The Assistant Director of Nursing (ADON) and Infection Preventionist admitted to not ensuring the implementation of EBP for residents who required it. The ADON acknowledged the lack of monitoring to ensure EBP signs were posted, PPE was available, and staff were following the EBP protocols. This oversight led to a failure in implementing necessary infection prevention measures for residents at increased risk.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were placed within reach for three residents, leading to a deficiency in accommodating their needs. Resident 37, who is severely cognitively impaired and at high risk for falls, was observed lying in bed with the call light placed on top of her side table, out of reach. This was confirmed by a CNA who acknowledged that the call light was not accessible to the resident. Resident 30, who has severe cognitive impairment and requires assistance for daily activities, was found sitting in a wheelchair without a call light in reach. The call light was clipped to a recliner, and the resident expressed unawareness of its location. Additionally, Resident 64, who is dependent on care, was observed in a high back wheelchair with the call light hanging over a bedside table, out of reach. The resident reported that the call light is often inaccessible, and a CNA confirmed that it should be attached to the resident or the wheelchair. The Director of Nursing stated that call lights should always be within reach.
Failure to Implement Physician-Ordered Hand Splint for Resident
Penalty
Summary
The facility failed to ensure that a physician-ordered hand splint was in place daily for a resident with limitations in range of motion. The resident, identified as R73, had a physician's order to wear a left upper extremity splint during daytime hours, which was not consistently followed. Observations revealed that the resident's left hand was in a tight fist contracture without the splint, and the resident's care plan did not address the limitations in range of motion or the use of the splint. Interviews with the resident's Power of Attorney and facility staff confirmed that the splint was not regularly applied, and there was no documentation of the splint's use or any refusals by the resident. The facility's Rehabilitation/Restorative Programs policy requires that residents be evaluated for individual status and potential rehabilitation/restorative programs upon admission or onset of a decline in activities of daily living. However, the resident's care plan was not updated to reflect the need for the splint, and the Director of Nursing was unaware of the order. Additionally, the restorative care logs and behavior management program did not document the administration or refusals of the splint, indicating a lack of communication and documentation regarding the resident's care needs.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to adequately supervise a resident with dementia and a history of falls, leading to an incident where the resident fell outside the building. The resident, who has multiple diagnoses including dementia, anxiety, Parkinson's disease, and a history of falls, was left unsupervised in the facility lobby. The resident's care plan indicated a high risk for falls due to impaired cognition, poor safety awareness, and other factors. Despite these risks, the resident was left unattended in the lobby while staff gathered other residents for an outdoor activity. On the day of the incident, the resident managed to exit the building by following an employee through a door before the alarm could sound. The receptionist observed the resident slipping out and notified the nursing office, but by the time the Director of Nursing arrived, the resident had already fallen off the curb outside. The activity aide confirmed that the resident was left in the lobby without supervision, which was not unusual for the resident's behavior, as she was known to be strong-willed and act independently.
Failure to Cover Urinary Catheter Drainage Bag
Penalty
Summary
The facility failed to ensure that an indwelling urinary catheter drainage bag was covered for a resident with a supra pubic urinary catheter. The facility's Catheter Care Procedure requires that the catheter drainage bag be inside a cloth dignity bag and that the catheter tubing and dignity bag do not touch the floor. However, observations revealed that the resident's catheter bag was secured to the bottom of his wheelchair without a privacy bag covering it. This was confirmed on two separate occasions, once when the resident was in his room and once when he was sitting across from the nursing station. An Agency Licensed Practical Nurse verified the absence of the privacy bag and acknowledged that the resident should have had one, but was unsure why it was missing.
Failure to Follow Daily Weight Monitoring for Dialysis Resident
Penalty
Summary
The facility failed to adhere to a physician's order for daily weight monitoring for a resident receiving dialysis, identified as R45. The facility's policy mandates daily weighing of residents undergoing hemodialysis, with any significant weight increase to be reported. R45, who has diagnoses including End Stage Renal Disease and Heart Failure, was admitted with a physician's order to be weighed daily and to notify the physician if there was a weight increase of more than five pounds over three days. However, R45's weight records show multiple instances where daily weights were not recorded, specifically on 15 different dates. The resident confirmed that daily weighing was not consistently performed, and the Director of Nursing acknowledged the failure to follow the order for daily weights.
Inappropriate Use of Antipsychotic Medications
Penalty
Summary
The facility failed to document behaviors and diagnoses to justify the use of antipsychotic medications, perform psychotropic assessments quarterly, and perform gradual dose reductions of scheduled antipsychotic medications for two residents diagnosed with dementia. The facility's policy requires that psychotropic medications be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. However, for one resident, there was no evidence of a psychotropic drug assessment since September of the previous year, and no attempt at a gradual dose reduction was made within the last year. The resident was observed to have no behaviors justifying the use of Risperidone, with the only noted behavior being wandering. Another resident was prescribed Risperidone for dementia with behaviors related to Lewy Body Dementia, but the care plan documented no behaviors warranting the use of antipsychotic medication. The resident's behavior management program tracking sheets showed no behaviors from June through September, with only two instances of repetitive verbalizations in October. Despite a pharmacy recommendation for a gradual dose reduction, it was denied by the nurse practitioner without documented clinical rationale. Interviews with facility staff, including CNAs and the Director of Nursing, confirmed that the residents did not exhibit behaviors that justified the continued use of antipsychotic medications. The Director of Nursing acknowledged the lack of psychotropic drug assessments and the absence of a clinical rationale for not attempting a gradual dose reduction. The facility's failure to adhere to its policy and regulatory requirements resulted in the inappropriate use of antipsychotic medications for these residents.
Failure to Document and Address Resident Grievances
Penalty
Summary
The facility failed to document and address a grievance for one resident, identified as R3, out of three reviewed for resolution of grievances in a sample of seven. The facility's Grievance/Concern Policy outlines that department directors are responsible for following up on concerns and ensuring appropriate resolution, with Social Services maintaining a log of grievances. However, the facility's grievance log showed no entries for several months, indicating a lack of documentation and follow-up on grievances. R3's Health Care Power of Attorney, identified as V5, reported having multiple concerns regarding R3's care, including issues with foot treatment, liquid intake, and CNA access to electronic medical records. V5 communicated these concerns to the facility's administrator, V1, on two occasions, but V1 admitted to not documenting or addressing these grievances. V1 acknowledged the oversight, stating that she "dropped the ball" on addressing V5's concerns.
Failure to Document Wound Care and Provide Thickened Liquids
Penalty
Summary
The facility failed to complete wound assessment documentation and perform wound care for a resident, identified as R4, and did not provide thickened water between meals for two other residents, R3 and R7. R4, who is cognitively intact with a BIMS score of 15 out of 15, had physician orders for Silvadene cream and a specific wound care regimen for a skin abrasion on the right knee. However, the Treatment Administration Record lacked documentation of these treatments on multiple dates, and there was no description or measurement of the wound in R4's medical record. R4 expressed that treatments were inconsistent and dependent on staff availability, and the Director of Nursing confirmed the absence of necessary documentation. Additionally, the facility did not adhere to physician orders for thickened liquids for residents R3 and R7, who required nectar-thick liquids due to swallowing difficulties. R3's Health Care Power of Attorney reported finding regular water at R3's bedside on multiple occasions, and a CNA confirmed having to replace regular water with thickened water after being alerted by R3's family. Similarly, R7 was found with a pitcher of unthickened water, which was confirmed by a registered nurse as inappropriate given R7's need for thickened liquids.
Failure to Obtain Timely Treatment Orders for Pressure Ulcer
Penalty
Summary
The facility failed to obtain timely physician orders for the treatment of a pressure ulcer and did not document weekly assessments for a resident's pressure ulcer. The facility's Skin Care/Ulcers policy requires documentation of all skin ulcers and physician-ordered treatments. However, a resident's pressure ulcer on the left heel was identified on 7/23/24, but there was no documentation of physician notification or treatment orders at that time. The resident's Treatment Administration Record indicated that treatment orders were not initiated until 7/30/24, a week after the ulcer was first noted. Additionally, the facility did not document any further wound measurements or assessments after the initial discovery of the ulcer. The Director of Nursing confirmed the lack of documentation and was unsure why the physician was not notified or why treatment was delayed. Furthermore, there were no nurse's notes explaining why the treatment was not completed on 7/30/24 and 7/31/24, as indicated by the Treatment Administration Record. This lack of documentation and delay in treatment represents a failure to adhere to the facility's policy and provide appropriate care for the resident's pressure ulcer.
Failure to Immediately Report Suspected Abuse
Penalty
Summary
Staff failed to immediately notify the Administrator of possible abuse involving a resident who was admitted for short-term rehab with diagnoses including sepsis, left ankle fracture, hypertension, and type 2 diabetes mellitus. The incident occurred when a Certified Nursing Assistant (CNA) allegedly yelled at the resident and was rough during a transfer, causing pain to the resident's left foot. The resident reported the incident to a Licensed Practical Nurse (LPN), who did not immediately inform the Administrator as required by the facility's Abuse and Neglect Policy. Instead, the LPN intended to report the incident but was interrupted by a phone call from the resident's Nurse Practitioner, who had already been informed by the resident. The LPN then reported the incident to the Unit Coordinator, who subsequently sent the CNA home after taking a statement. The facility's policy mandates that any suspected abuse, allegations of abuse, or incidents of abuse must be reported to the Administrator immediately. Despite attending an in-service on abuse reporting, the LPN did not follow this protocol. The Administrator was eventually informed of the incident by the Nurse Practitioner and took action to remove the CNA from the facility. The delay in reporting the incident to the Administrator constitutes a failure to adhere to the facility's abuse reporting procedures, as outlined in their policy dated July 2023.
Supervision and Response Deficiency in Resident Elopement Incident
Penalty
Summary
The report details a significant deficiency in a nursing home's supervision and response to a resident with severely impaired cognition and a history of wandering. The resident, identified as R1, eloped from her unit through an open double door that is normally closed, passed through an alarmed door leading to a stairway, and was found on a landing after descending 8 steps. R1, an elderly individual with diagnoses including Dementia, History of Falls with Fractures, and other medical conditions, was observed independently propelling her wheelchair and interacting with peers and staff prior to the elopement. Despite being known as a wanderer and requiring substantial assistance with transfers, R1's care plan had not been updated to reflect her increased risk for elopement. The facility's failure to provide adequate supervision to prevent R1's elopement was compounded by staff members' lack of response to door alarms at the time of the incident. Staff members reported not hearing the alarm sound when R1 exited through the alarmed door, and there were discrepancies in staff accounts regarding the handling of door alarms. The investigation following R1's elopement revealed gaps in staff communication and awareness of the facility's door alarm system. Additionally, the report highlighted inconsistencies in staff responses and actions during the search for R1, indicating a breakdown in communication and coordination among team members.
Failure to Notify Physician of Significant Change in Condition
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for a resident (R4), resulting in a severe urinary tract infection (UTI), sepsis, and a five-day hospitalization. R4 was admitted to the facility with multiple diagnoses, including a history of UTIs and urinary retention. On two occasions, the Licensed Practical Nurse (LPN) documented abnormal urinary symptoms, including foul odor and mucus discharge, but did not notify the physician or nurse practitioner of these changes. This lack of communication led to a delay in treatment for R4's UTI, which subsequently worsened into sepsis and metabolic encephalopathy. R4's family member (V27) noticed a decline in R4's condition and attempted to communicate concerns to the staff, who dismissed them. On the day R4 was sent to the hospital, V27 observed that R4 was unresponsive and had a limp head, prompting V27 to insist on hospital transfer. The Director of Nursing (DON) confirmed that there was no documented evidence of physician notification regarding R4's abnormal urine symptoms, which should have been reported according to the facility's policy. The Nurse Practitioner (NP) stated that there was no record of being notified about R4's symptoms, and had they been informed, they would have ordered a urinalysis and started antibiotic treatment. The failure to notify the physician of R4's significant change in condition led to a severe UTI and sepsis, resulting in R4's hospitalization. The facility's policy mandates timely notification of the physician for significant changes in a resident's condition, which was not adhered to in this case.
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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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