The Citadel At Saint Anne Place
Inspection history, citations, penalties and survey trends for this long-term care facility in Rockford, Illinois.
- Location
- 4405 Highcrest Road, Rockford, Illinois 61107
- CMS Provider Number
- 145563
- Inspections on file
- 36
- Latest survey
- December 16, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at The Citadel At Saint Anne Place during CMS and state inspections, most recent first.
A resident with dementia, stroke, and mobility deficits was transferred from the bathroom by a CNA without required two-person assistance or a gait belt, contrary to the care plan. The resident fell to the floor, sustaining a skin tear, and required help from three staff to return to the wheelchair. Facility policy on safe lifting and movement was not followed.
A resident with severe cognitive impairment and left-sided weakness developed a large bruise and pain in her left upper arm, which was observed by multiple CNAs and nurses. Despite these observations, there was no timely assessment, documentation, or provider notification, resulting in a delay of several days before an X-ray was ordered and a non-displaced humerus fracture was diagnosed. Facility policy required prompt action for such injuries, but this was not followed.
Multiple residents with existing or newly developed pressure ulcers did not receive timely wound assessments, weekly documentation, or prompt treatment interventions. Delays in identifying and treating wounds led to progression to advanced stages, and recommended nutritional support was not always provided. Staff interviews confirmed that required assessments and interventions were not consistently performed, resulting in untreated and worsening pressure ulcers.
Multiple residents experienced significant weight loss or lacked proper weight monitoring due to failures in obtaining accurate weights, identifying and reporting significant changes, and implementing RD recommendations. In several cases, missing or delayed weight documentation prevented the RD from assessing nutritional needs, and recommended interventions were not consistently put into place due to breakdowns in communication and order entry.
Three residents experienced falls and injuries due to inadequate supervision and failure to maintain a safe environment. One resident fell and fractured his hip and wrist after being unable to reach his urinal and not receiving timely assistance. Another slipped out of a mechanical lift during transfer while wearing inappropriate footwear, and a third fell and sustained a black eye and other injuries after being left unattended on the bed during a transfer. In each case, staff did not provide the required assistance or ensure accident hazards were minimized.
Staff failed to prevent cross-contamination during meal service by using the same gloved hands to handle multiple food items, touch clothing, and surfaces without changing gloves, and by not using utensils for lemon wedges. Additionally, a can opener with caked-on debris was used on consecutive days, despite being reportedly cleaned, increasing the risk of food contamination.
The facility failed to correctly transcribe physician orders and ensure accurate medication administration for four residents, resulting in incorrect medications, dosages, and extended courses of treatment. These errors included giving a resident the wrong medications, administering an antibiotic longer than prescribed, providing a lower dose of Budesonide than ordered, and continuing a prednisone taper past the intended stop date.
Six residents with dysphagia or stroke were served pureed peas that contained chunks and pieces of skin, requiring chewing to swallow. The food was not blended to a smooth consistency as required for pureed diets, and this was confirmed by both staff and surveyors during meal preparation.
Three residents experienced a lack of dignity in care, including disruptive nighttime dressing changes, long delays in call light response, dismissive staff interactions, and failure to assist a female resident with personal hygiene related to facial hair. These actions did not align with facility policies requiring respect and dignity for all residents.
A resident with multiple comorbidities, including CHF and pressure ulcers, developed two skin tears on the left arm. Staff failed to assess the wounds or obtain physician treatment orders, and there was no documentation of wound assessment or treatment in the medical record, contrary to facility policy.
A resident with obstructive sleep apnea and other respiratory conditions did not have physician orders in place for CPAP use upon admission, and the care plan lacked specific CPAP instructions. The CPAP equipment was not consistently cleaned or stored according to facility policy, with the mask left unbagged on the bedside table and no documentation of daily cleaning prior to new orders being added.
Multiple residents with significant medical needs reported long delays in staff response to call lights, with one resident experiencing a fall and injury after waiting for assistance and attempting to manage independently. Residents described frequent waits of up to an hour, and staff acknowledged limitations with the facility's outdated call light system and lack of monitoring.
A staff member provided wound care to a resident with a Stage 4 pressure ulcer while only wearing gloves, failing to use a gown as required by the facility's Enhanced Barrier Precautions policy. The infection preventionist confirmed that both gown and gloves were necessary for wound care in residents with chronic wounds.
A resident with left-sided weakness and total dependence on staff for care fell out of bed during incontinence care when only one CNA was present, despite her need for two-person assistance due to limited mobility and size. The care guide did not specify the correct staffing level for incontinence care, and the facility's policies lacked guidance on assessing assistance needs, leading to the resident sustaining a hip fracture.
The facility failed to assess and notify the wound care physician of changes in a pressure injury for a resident, leading to the deterioration of the wound. Another resident developed a stage 2 pressure ulcer due to ineffective pressure-relieving interventions for oxygen tubing. The facility did not adhere to its policy on pressure injury assessment and treatment, resulting in these deficiencies.
The facility failed to supervise and implement fall prevention for two residents at high risk for falls. A resident was left unsupervised in the bathroom, resulting in a fall and injury, while another was placed in an incorrect wheelchair, contrary to their care plan. These actions violated the facility's fall prevention policy.
A facility failed to administer a prescribed lidocaine 5% patch to a resident with osteoarthritis, resulting in unmanaged pain. The RN was unaware of the absence of the patch, and the EMAR showed it was not given on multiple occasions. The LPN confirmed the patch is ordered through the facility's pharmacy, and its absence could lead to pain. This failure deviates from the facility's medication administration policy.
The facility failed to include stop dates for PRN anti-anxiety medications for two residents. One resident had an order for Ativan without a stop date, and another had an order for Lorazepam also lacking a stop date. The facility's policy requires a 14-day stop date for PRN psychotropic medications unless specified otherwise by a physician.
The facility exceeded the acceptable medication error rate with a 7.69% error rate during a medication pass. One resident did not receive a prescribed lidocaine patch, resulting in reported pain, while another resident received diclofenac gel applied incorrectly to both knees instead of just the right knee as ordered. The facility's policies require strict adherence to physician orders.
A facility failed to dispose of an expired insulin pen and did not label an opened insulin pen with the open date for a resident. The resident's physician orders included insulin aspart and insulin glargine, which were documented in the electronic medication administration record. An LPN confirmed that insulin pens should be dated when opened, as per facility policy, but was unsure of the duration for which opened insulin remains effective.
The facility failed to follow infection control protocols, as staff did not change gloves or perform hand hygiene after providing incontinence care to residents, risking cross-contamination. Additionally, staff did not wear gowns during high-contact care activities for residents under Enhanced Barrier Precautions, contrary to facility policies.
A resident was found storing Norco pills in his room, claiming to find them in his bed due to the facility's lack of medication accountability. The LPN administering the medications was surprised when the resident took the medication in her presence, as he usually refused supervision. Facility policies on controlled substances and medication administration were not followed.
A resident with multiple health conditions, including a prosthetic heart valve, did not receive his prescribed anticoagulant medication for eight days due to a failure to enter the medication order into the system. This lapse was identified by a nurse and reported to the on-call NP, and the resident's POA was informed.
Failure to Safely Transfer Resident Resulting in Fall
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident with a history of dementia, stroke, right lower leg wound, and transient ischemic attack without following the resident's care plan, which required two staff members for all transfers and toileting. The CNA transferred the resident alone and did not use a gait belt, instructing the resident to hold onto the bathroom grab bar. During the transfer, the resident's legs gave out, resulting in a fall to the bathroom floor. The CNA was unable to prevent the fall due to the absence of a gait belt and lack of assistance. Multiple staff members responded to the incident, finding the resident on the bathroom floor, kneeling and in pain, with her legs trapped between the toilet seat and grab bar. It required three staff members to safely assist the resident back to her wheelchair. The resident sustained a small skin tear to her left arm as a result of the fall. The facility's policy on safe lifting and movement of residents requires the use of appropriate techniques and devices to ensure safety, which was not followed in this incident.
Failure to Assess, Document, and Notify Provider of Resident Injury
Penalty
Summary
The facility failed to assess, document, notify the provider, and monitor an injury of unknown origin for a resident with severe cognitive impairment and significant physical dependencies. The resident, who had a history of stroke with left-sided weakness and required total assistance for activities of daily living, was observed by staff to have a large bruise on her left upper arm. Multiple CNAs and nurses noticed the bruise, which was initially red and later turned yellow, but there was no documentation or assessment of the bruise in the medical record prior to several days after it was first observed. Staff interviews revealed that the bruise was reported to nurses, but the nurses either assumed it was old or did not take further action, and there was no immediate notification to the provider or documentation of the injury. The resident exhibited pain with movement of her left arm, which was noted by staff during care, but this pain was not promptly reported or documented. It was only after several days, when the unit manager was made aware of the bruise, that the nurse contacted the provider and an X-ray was ordered. The X-ray revealed a non-displaced fracture of the left humerus. The facility's policies required prompt assessment, documentation, and provider notification for new skin issues or injuries of unknown origin, but these procedures were not followed in this case. The investigation found that the lack of timely assessment and documentation led to a delay in diagnosing the resident's fracture. Staff interviews confirmed that the bruise and associated pain were observed and reported among staff, but not properly escalated or recorded. The provider was not notified until three days after the initial observation of the bruise and pain, resulting in a delay in obtaining appropriate medical orders and treatment for the resident's injury.
Failure to Timely Assess, Document, and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for multiple residents. Several residents were admitted with existing pressure ulcers at various stages, but the facility did not consistently perform timely initial wound assessments, weekly reassessments, or implement treatment interventions as required. For example, one resident was admitted with multiple stage 3 and 4 pressure ulcers, but the first documented wound assessments were not completed until several weeks after admission. Nursing staff confirmed that initial wound assessments, including measurements and wound bed descriptions, should be completed on the day of admission, but this was not done. Additionally, weekly wound assessments and documentation were not consistently performed, and treatments were not always initiated promptly upon identification of new or worsening wounds. Another resident developed a pressure wound that was not treated for 26 days after it was identified, resulting in deterioration to a stage 4 ulcer. The care plan for this resident included daily skin inspections and nutritional support, but there was no evidence that the recommended protein supplement was provided. Wound assessments were missing for several weeks, and treatment orders were delayed. The wound care nurse and DON acknowledged that floor nurses are responsible for initial wound assessments and that treatments should be started as soon as possible, but this did not occur. The wound physician noted that wounds should be identified at earlier stages and emphasized the importance of high-protein supplements and offloading for prevention and healing. A third resident with severe cognitive deficits and total dependence on staff developed multiple pressure ulcers, including stage 3 and 4 wounds, which were not identified until they had progressed to advanced stages. The facility's policy required skin assessments on admission and weekly thereafter, but documentation showed gaps in assessments and delayed identification of wounds. Another resident with a history of noncompliance and high risk for skin breakdown had a stage 4 sacral wound that was not assessed for nearly three months, and new wounds were not promptly identified or treated. Staff interviews revealed that wounds were not always discovered during routine care, and appropriate offloading devices were not consistently used, despite the resident's high risk and previous wound history.
Failure to Accurately Monitor Weights and Implement Dietitian Recommendations
Penalty
Summary
The facility failed to ensure accurate and timely weight monitoring, identification, and reporting of significant weight loss, as well as failed to implement dietitian recommendations for multiple residents. For one resident with multiple diagnoses including anemia, hypertension, and pressure ulcers, significant weight loss occurred over a short period without notification to the Registered Dietitian (RD). The RD was not informed of the weight change, and there were concerns about the accuracy of the weights recorded. The resident's care plan required regular weight monitoring and prompt reporting of significant changes, but these protocols were not followed. Another resident with severe cognitive deficits and a history of malnutrition and pressure wounds was not weighed upon readmission from the hospital, contrary to facility policy requiring daily weights for the first three days post-admission. The RD was unable to assess for significant weight loss due to missing weights, and scheduled weekly weights were not documented in the electronic record. The lack of timely and accurate weight documentation prevented the RD from making necessary nutritional assessments and interventions. Additional residents experienced similar deficiencies. One resident with Alzheimer's and a history of pressure ulcers and hip fracture had a documented 14.3% weight loss over two months, with a missing monthly weight that was not entered into the electronic health record as required. Another resident with a history of fluctuating weights and multiple diagnoses did not receive a recommended nutritional supplement because the RD's recommendation was not converted into a physician order, resulting in the intervention not being implemented. Facility policies required regular weight monitoring, reweighs for significant changes, and prompt communication of RD recommendations, but these were not consistently followed.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for residents at risk for falls and accidents. One resident with diagnoses including adult failure to thrive, diabetes, chronic kidney disease, and low back pain, who required maximum assistance for standing and toileting, was left unable to reach his urinal. Despite having his call light on and waiting for staff assistance, he attempted to retrieve the urinal himself after waiting for half an hour, resulting in a fall that caused a fractured hip and wrist. The resident reported that staff perceived him as independent due to his age and cognitive status, despite his documented need for assistance. Another resident, dependent on staff for toileting and requiring a sit-to-stand mechanical lift for transfers, slipped out of the lift and fell while being transferred from bed to the bathroom. At the time of the incident, the resident was wearing house shoes instead of the required non-slip footwear, which contributed to the fall. Two staff members were present during the transfer, and the resident reported feeling her feet slip and requested the lift be raised, but the fall occurred regardless. A third resident, who required substantial assistance for dressing and transfers and was to be transferred with a gait belt and two staff, sustained a black eye after falling during a transfer. The resident was left sitting on the edge of the bed while the CNA retrieved clothes from the closet, during which time the resident reached for a shirt and fell forward, hitting his head on the lift. The incident resulted in a cut and swelling to the left eyebrow, as well as scrapes to the left knee and ankle. In each case, the facility did not provide the necessary supervision or ensure the environment was free from accident hazards, directly leading to resident injuries.
Failure to Prevent Cross-Contamination in Food Handling and Equipment
Penalty
Summary
The facility failed to handle food in a manner that prevents cross-contamination and did not maintain food preparation equipment to prevent contamination. During lunch service, a cook used gloved hands to handle multiple food items, including lemon wedges, peas, french fries, and fish, without changing gloves between tasks. The cook also touched her clothing, door handles, and food carts with the same gloves and did not change them during the entire lunch service. No utensils were provided for handling lemon wedges, and the cook used her gloved hand to place them on plates for all residents. Additionally, the facility's can opener was observed to have caked-on debris on the sharp cutting tip on two consecutive days. The dietary supervisor confirmed that the can opener had been used and cleaned, but acknowledged that the tip remained dirty and posed a risk of cross-contamination. The supervisor also stated that food should not be touched with potentially contaminated gloved hands and that utensils should be used for items like lemon wedges. The facility's policy requires all food service equipment and utensils to be sanitized according to guidelines and mandates safe food handling practices.
Medication Transcription and Administration Errors
Penalty
Summary
The facility failed to provide proper pharmaceutical services by not correctly transcribing physician orders and not ensuring the correct medications and dosages were administered to residents. One resident with multiple diagnoses, including cerebral infarction and dementia, was given incorrect medications such as cetirizine, gabapentin, quetiapine, and memantine, which was discovered by another RN as the nurse was leaving the room. Another resident with liver cell carcinoma and other chronic conditions received an antibiotic for 12 days instead of the prescribed 5 days because the medication stop date was not entered by the nurse. A third resident with a history of chronic bowel disease and repeated falls was prescribed Budesonide 9mg daily, but only received 3mg due to a pharmacy dispensing error that was not caught by staff. Additionally, a resident with urinary tract infection and other chronic illnesses was given a prednisone taper beyond the intended stop date because the order was not entered correctly, resulting in the medication being continued until the error was discovered. These incidents were identified through interviews and record reviews, and all occurred within a three-month period.
Failure to Provide Properly Pureed Food for Residents with Swallowing Difficulties
Penalty
Summary
The facility failed to provide pureed peas in a smooth consistency for six residents who required pureed diets due to diagnoses such as difficulty swallowing and stroke. During meal preparation, the cook completed the pureeing process for peas, but visible chunks and pieces of skin remained, requiring chewing to swallow. Both the surveyor and the dietary supervisor confirmed the peas were not smooth, and the dietary supervisor acknowledged that peas are difficult to puree but should be blended until smooth. The pureed peas were only reprocessed after the deficiency was identified by staff. All six affected residents had documented medical conditions necessitating pureed diets, including difficulty swallowing and stroke. The facility's own protocol required altered consistency diets to manage aspiration risks, but the initial preparation of the peas did not meet these requirements, as the food was not adequately pureed before being served.
Failure to Maintain Resident Dignity and Timely Care
Penalty
Summary
The facility failed to ensure that residents dependent on staff for care were treated in a dignified manner, as evidenced by multiple incidents involving three residents. One resident, who was cognitively intact and required assistance with transfers and toileting, reported that her dressing changes were routinely performed in the middle of the night, disrupting her sleep. She expressed that only her pain medication was needed at those hours, and that dressing changes should be done before bedtime. Despite raising these concerns in a care conference, the issue persisted, and she also experienced significant delays in call light response, sometimes waiting up to 50 minutes for assistance with toileting, resulting in incontinence and distress. Another resident, who required assistance with activities of daily living, reported that her call light was not answered in a timely manner, often taking an hour or more. On one occasion, staff walked past her room while her call light was on and told her they could not help, leaving her feeling ignored and devalued. The DON acknowledged that this response was inappropriate and that staff should have communicated with the resident about when assistance would be provided. A third resident, who was dependent on staff for personal hygiene, was observed to have visible patches of facial hair, which her daughter stated would have been distressing to her. The resident had an electric razor in her room, but staff had not assisted her with shaving, possibly due to her refusal of showers. The DON agreed that this was a dignity issue and that staff should have addressed her facial hair between showers if needed. Facility policies reviewed emphasized the importance of treating residents with dignity and respect at all times.
Failure to Assess and Obtain Treatment Orders for Resident's Skin Tears
Penalty
Summary
A deficiency occurred when the facility failed to assess and obtain treatment orders for a resident who developed two skin tears on the left arm. The resident, who had diagnoses including congestive heart failure, severe protein-calorie malnutrition, and pressure ulcers, was observed with two dressings on the left arm. The resident reported waiting for dressing changes and was unsure of the exact circumstances of the injury. Review of the resident's medical record showed no physician orders for treatment of the skin tears and no documented assessment of the wounds. Interviews with nursing staff revealed that standard protocol involves cleaning, assessing, and dressing the wound, followed by notifying the physician and obtaining treatment orders, which are then entered into the resident's treatment record. However, in this case, the registered nurse was unaware of the condition of the wounds under the dressings and confirmed there were no orders or assessments documented. The Director of Nursing also confirmed that such wounds should be tracked and treated according to facility policy, which was not done in this instance.
Failure to Ensure Orders and Proper Care for CPAP Equipment
Penalty
Summary
The facility failed to ensure that a resident with a history of pulmonary embolism, obstructive sleep apnea, and other respiratory conditions had appropriate physician orders in place for the use of a CPAP machine upon admission. Review of the resident's records showed that there were no CPAP orders documented from the time of admission until several weeks later, despite the resident's need for this respiratory support. Additionally, the care plan did not include specific CPAP settings or instructions for CPAP care, and there was no evidence that the CPAP was being properly cared for during this period. Observations revealed that the CPAP equipment was not consistently stored in a sanitary manner, with the mask left unbagged on the bedside table. The resident reported that staff typically left the CPAP on the table and only recently began placing it in a bag. The facility's policy required daily cleaning and proper storage of CPAP equipment, but there was no documentation or evidence that these procedures were followed prior to the addition of new treatment orders. The DON confirmed that orders should be entered upon admission and that staff are expected to follow facility policy for cleaning and storage.
Delayed Call Light Response for Multiple Residents
Penalty
Summary
The facility failed to respond to residents' call lights in a timely manner, as evidenced by multiple resident accounts and staff interview. One resident, admitted with adult failure to thrive, Type 2 Diabetes Mellitus, chronic kidney disease, and low back pain, required maximum assistance for standing and toileting. This resident reported activating the call light for help reaching a urinal, but after waiting for half an hour without response, attempted to manage independently, resulting in a fall and self-reported hip injury. The resident stated that staff perceived him as independent due to his cognitive status, despite his physical needs. Another resident with Bell's Palsy, atrial fibrillation, and left-side paralysis, who was cognitively intact, reported that call lights often took a long time to be answered, including an instance where she waited an hour to be changed. A third resident with muscle weakness, COPD, and diabetes, also cognitively intact, described frequent delays in call light response, sometimes waiting up to an hour, and recounted being ignored by staff who walked past while her call light was on. The Director of Nursing acknowledged the facility's outdated call light system and lack of monitoring capability, and no facility policy regarding call lights was provided.
Failure to Use Required PPE During Wound Care Under Enhanced Barrier Precautions
Penalty
Summary
A staff member failed to follow the facility's Enhanced Barrier Precautions policy while providing wound care to a resident with a Stage 4 pressure ulcer. The resident, who had been admitted with this diagnosis, was on Enhanced Barrier Precautions as indicated by signage on her door, which required the use of both a gown and gloves during wound care. During an observed wound care procedure, the staff member wore only gloves and did not don a gown as required. The facility's infection preventionist confirmed that both gown and gloves should have been used for residents with chronic wounds under Enhanced Barrier Precautions, in accordance with the facility's policy last approved in May 2024.
Failure to Provide Adequate Supervision During Incontinence Care Resulting in Resident Fall
Penalty
Summary
A deficiency occurred when a resident, who was totally dependent on staff for care due to left-sided weakness from a stroke and was described as a larger individual, fell out of bed during incontinence care. The resident required significant assistance for bed mobility and incontinence care, as she was unable to support herself or roll independently. Despite this, only one CNA was present during the provision of incontinence care, and the resident rolled out of bed, landing on her knees and later being diagnosed with a left femoral neck fracture. Interviews with staff revealed that the determination of whether one or two CNAs were needed for incontinence care was based on the resident's size and bed mobility, but this information was not clearly communicated or documented in the care guide. The CNA providing care at the time of the incident was not informed that two staff members were required for this resident, and the care guide only indicated the need for one staff member for bed mobility, not specifically for incontinence care. Multiple staff members, including the LPN, unit manager, and other CNAs, stated that two staff should have been present due to the resident's condition and inability to support herself. The facility's policies on urinary incontinence did not address the assessment of the level of staff assistance required for incontinence care. As a result, there was a lack of clear guidance and communication regarding the appropriate staffing needed to safely provide care for residents with significant mobility limitations, directly contributing to the resident's fall and subsequent injury.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to properly assess and notify the wound care physician of changes in a pressure injury for a resident, R100, and did not implement pressure-relieving interventions to prevent the development of a new pressure injury. R100, who had a history of type I diabetes mellitus and a hip fracture, was found to have a stage 1 pressure ulcer on his right heel, which later deteriorated to an unstageable pressure injury. Despite recommendations from a vascular surgery appointment to follow up with a wound care doctor, no appointments were set up, and the wound care nurse was not informed of the wound's deterioration. Another resident, R95, developed a stage 2 pressure ulcer behind his right ear due to the continuous use of oxygen tubing. The facility's interventions, such as using ear protectors, were ineffective as they frequently fell off or slid around, and staff did not perform daily checks behind the ears of residents on oxygen. The lack of effective pressure-relieving interventions and inadequate monitoring contributed to the development of the pressure injury. The facility's policy on pressure injury assessment and treatment, revised in July 2024, emphasizes the need for pressure-relieving devices to be observed for effectiveness and interventions to be changed or implemented to prevent pressure injuries. However, the facility failed to adhere to these guidelines, resulting in the deterioration of R100's pressure injury and the development of a new pressure injury for R95.
Inadequate Supervision and Fall Prevention for High-Risk Residents
Penalty
Summary
The facility failed to ensure adequate supervision and fall prevention interventions for two residents at high risk for falls. Resident R114, who was admitted after a fall resulting in a humerus fracture, was left unsupervised in the bathroom despite being on the falling star program, which indicates a high risk for falls. This lack of supervision led to R114 falling from the toilet, resulting in a skin tear and a head injury, necessitating a transfer to the emergency room. The CNA responsible for R114 admitted to leaving her alone due to a busy morning and not being familiar with her needs, which was against the facility's fall prevention policy. Resident R4, with a history of falls and high anxiety, was observed in a high reclining wheelchair despite the care plan specifying a low reclining wheelchair to prevent falls. This discrepancy was noted after R4 had previously fallen from a higher wheelchair, and the intervention was to use a lower one. The Restorative Nurse confirmed that R4 should only be in the low reclining wheelchair, but it was unclear why she was placed in a different one. The facility's fall policy requires daily reviews of falls to identify additional interventions, but this was not effectively implemented for R4.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to provide a medication as ordered for a resident, identified as R33, who was admitted with diagnoses including osteoarthritis, repeated falls, and anxiety disorder. The physician's orders for August 2024 included a prescription for a lidocaine 5% patch to be applied to R33's lower back in the morning and removed at bedtime. However, observations on August 6, 2024, revealed that the Registered Nurse (RN) did not have the lidocaine patch for R33 and was unaware of the reason for its absence. The resident reported experiencing pain rated at 4-5/10 due to arthritis. The Electronic Medication Administration Record (EMAR) indicated that the lidocaine patch was not administered on August 1, 2, and 6, 2024. A Licensed Practical Nurse (LPN) confirmed that the patch is ordered through the facility's pharmacy and acknowledged that its absence could result in the resident experiencing pain. The facility's policy on administering medications, revised in December 2021, mandates that medications be administered safely, timely, and as prescribed. The failure to provide the lidocaine patch as ordered represents a deviation from this policy, resulting in the resident potentially experiencing unmanaged pain.
Failure to Include Stop Dates for PRN Anti-Anxiety Medications
Penalty
Summary
The facility failed to ensure that as-needed anti-anxiety medications had a stop date for two residents reviewed for psychotropic medications. Resident R4 had a physician order for Ativan 0.5 mg to be taken twice daily as needed, with a start date but no stop date. The Assistant Director of Nursing acknowledged that PRN anti-anxiety medication should have a stop date 14 days after it was ordered. Similarly, Resident R95 had an active order for Lorazepam 2 MG/ML to be taken every 2 hours as needed for anxiety/agitation, also lacking a stop date. The facility's policy on psychotropic medications, last revised in November 2022, states that PRN psychotropic medications should have a stop date of 14 days unless otherwise specified by a physician.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 7.69%, which exceeds the acceptable threshold of 5%. This deficiency was observed during a medication pass involving two residents. The first resident, identified as R33, was admitted with diagnoses including osteoarthritis, repeated falls, and anxiety disorder. The physician's order for R33 included the application of a lidocaine 5% patch to the lower back in the morning and removal at bedtime. However, on the morning of August 6, 2024, the RN administering medications did not have the lidocaine patch for R33 and was unaware of the reason for its absence. Consequently, R33 reported experiencing pain rated at 4-5 out of 10. The second resident, identified as R110, was admitted with diagnoses including osteoarthritis, chronic kidney disease, edema, weakness, and a history of falling. The physician's order for R110 specified the application of diclofenac sodium 1% gel to the right knee twice daily. During the medication pass, the RN applied the gel to both the right and left knees, contrary to the physician's order. The LPN later confirmed that physician orders should be followed precisely and that any changes requested by residents should be communicated to the nurse practitioner for a new order. The facility's policies on administering medications and handling medication errors emphasize adherence to physician orders and define medication errors as deviations from these orders.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to properly manage medication storage and labeling for a resident, identified as R99, leading to a deficiency. Specifically, an expired insulin pen was not disposed of, and an opened insulin pen was not labeled with the date it was opened. The physician orders for R99 included insulin aspart sliding scale and insulin glargine pen at bedtime, which were documented in the electronic medication administration record. During an observation, it was noted that the insulin aspart pen was opened and dated, but the insulin glargine pen was opened without a date. A Licensed Practical Nurse (LPN) acknowledged that insulin pens should be dated upon opening to ensure effectiveness and admitted uncertainty about the duration for which opened insulin remains effective. The facility's policy mandates recording the open date on multi-dose containers, and another policy specifies that opened insulin pens are good for 28 days at room temperature.
Infection Control Deficiency: PPE and Hand Hygiene Failures
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, specifically in the use of personal protective equipment (PPE) and hand hygiene practices. On multiple occasions, staff members did not change gloves or perform hand hygiene after providing incontinence care to residents, which could lead to cross-contamination. For instance, a Certified Nursing Assistant (CNA) did not change gloves or perform hand hygiene after wiping a resident's buttocks and then handling clean items. Similarly, during incontinence care for another resident, two CNAs did not wear gowns as required by Enhanced Barrier Precautions (EBP) and failed to change gloves or perform hand hygiene after cleaning the resident. The facility's policies on hand hygiene and Enhanced Barrier Precautions were not followed. The hand hygiene policy requires hand hygiene before moving from a soiled to a clean body site on the same resident, and the EBP policy mandates the use of gowns and gloves during high-contact care activities for residents at risk of transmitting multidrug-resistant organisms (MDROs). Despite these policies, staff did not wear gowns or change gloves during high-contact care activities for residents with wounds or indwelling medical devices, increasing the risk of infection transmission.
Failure to Supervise Medication Administration
Penalty
Summary
The facility failed to adequately supervise a resident during medication administration, leading to the resident storing medications in his room. The resident, who was part of a sample reviewed for safety and supervision, was observed by a surveyor to have several pills, identified as Norco, stored in a cup on his over-bed table. The resident claimed that he finds medications in his bed and expressed concerns about the facility's lack of accountability for controlled medications. During an interaction with the surveyor, the resident demonstrated his routine of taking pictures of his medications before ingestion, which he claimed was for verification purposes with a hospital. The Licensed Practical Nurse (LPN) responsible for administering the resident's medications confirmed that the resident typically refuses to take medications in her presence, insisting on privacy. On the day of the survey, the LPN was surprised when the resident took the medication in front of her, as this was not his usual behavior. The facility's policies on controlled substances and medication administration were not adhered to, as controlled substances were found unsecured in the resident's room, and there was no documented assessment allowing the resident to self-administer medications safely.
Failure to Administer Anticoagulant Medication
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors. Resident R2, who has a medical history including Parkinson's Disease, Type 2 Diabetes, hypertension, chronic kidney disease, paroxysmal atrial fibrillation, and a prosthetic heart valve, did not receive his prescribed anticoagulant medication, Coumadin, for eight days. This lapse occurred from 3/10/24 to 3/19/24. The error was identified when a nurse noticed the absence of a Coumadin order in the electronic health record and reported it to the on-call Nurse Practitioner. The resident's Power of Attorney was informed, and an INR test was ordered to monitor the resident's blood clotting levels. Interviews with staff revealed that the Coumadin order was not entered into the system after the resident's lab results were reviewed, leading to the missed doses. The facility's policy requires that anticoagulant therapy be prescribed and monitored according to recognized guidelines, including appropriate lab testing and the use of a monitoring tool to track anticoagulant dosage and response. The failure to enter the new Coumadin order into the system resulted in the resident not receiving the necessary medication to ensure the proper functioning of his artificial heart valve.
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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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