The Citadel At Saint Joseph Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Freeport, Illinois.
- Location
- 659 East Jefferson Street, Freeport, Illinois 61032
- CMS Provider Number
- 145935
- Inspections on file
- 38
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at The Citadel At Saint Joseph Village during CMS and state inspections, most recent first.
The facility failed to maintain accurate controlled substance records and documentation for several residents. For a resident receiving PRN hydrocodone-acetaminophen, a narcotic count revealed one missing tablet that was not signed out on the control sheet, and the LPN involved could not explain the discrepancy. Another resident with scheduled and PRN alprazolam had a tablet removed and documented as being used for a different resident, while the MAR did not show administration for the original resident. A third resident had Norco signed out twice on the control sheet without staff signatures and with no corresponding MAR entries. Additionally, four residents’ controlled substance sheets were not signed at the time of administration, even though the LPN later signed them during a narcotic count, contrary to facility policy requiring real-time documentation and accurate shift-to-shift controlled drug counts.
The facility did not honor resident preferences for bacon, a previously available breakfast item, after a change in ownership and guidance from the food service provider. Multiple residents and staff reported frequent requests and complaints about the absence of bacon and other breakfast meats, with documentation in grievance logs and resident council meetings. The dietary manager and registered dietitian confirmed the removal was based on nutritional guidance, and the facility lacked a policy addressing resident menu preferences.
Three residents experienced safety failures, including a laceration from improper catheter management during dressing, unsafe handling of a urinary catheter during ambulation, and a fall during showering due to inadequate supervision and miscommunication about transfer needs. These incidents involved residents with catheters, fall risks, and sensory impairments, resulting in injury and unsafe conditions.
Multiple residents reported that CNAs used personal cell phones during showers and in common areas, leading to feelings of neglect and lack of attention. Resident Council Meeting minutes confirmed ongoing concerns about staff phone use, and the DON acknowledged this as an issue, contrary to facility policy requiring staff to focus on residents and maintain their dignity.
A resident who needed staff assistance for bathing did not consistently receive the required number of showers, with records showing a 13-day gap between showers. The DON confirmed that staff are expected to provide showers twice weekly, but the facility lacked a formal policy on shower frequency.
A resident with visual impairment and a physician order for an ophthalmology consult did not receive a timely follow-up appointment after the original was canceled due to insurance issues. The resident reported worsening vision and had not seen an eye doctor or had vision testing in over a year. Facility records confirmed no rescheduled appointment, and the DON acknowledged the lapse, despite facility policy requiring timely coordination of such services.
A resident with a recent cardiac surgery did not receive daily cleansing of a surgical incision as ordered by the physician. The wound care nurse overlooked the order, and the DON was unaware of its existence, resulting in the order not being entered or followed. The facility's records only showed monitoring of the incision, with no evidence of the required cleansing being performed.
A resident with multiple chronic conditions did not receive medications as ordered when an LPN administered levothyroxine later than the prescribed time and gave two tablets of acetaminophen instead of one. The resident expressed the importance of timely administration due to dietary restrictions, and facility policy requires adherence to prescribed medication times until reviewed by the pharmacist.
Multiple residents did not consistently receive or have documented wound care and weekly skin checks as ordered, with missed treatments and incomplete records noted for wound care, skin protectant applications, and weekly assessments, despite facility policy and staff acknowledgment of their importance.
A discrepancy in a resident's lorazepam count was identified by two nurses, but the missing medication was not reported to administration or authorities as required. The ADON and Administrator confirmed that the incident was not communicated or documented according to facility policy.
A resident with a stage four pressure injury did not receive or have documentation for several ordered wound care treatments, as evidenced by gaps in the Treatment Administration Record and confirmed by the wound care nurse. Facility policy requires documentation of dressing changes, but this was not consistently done.
A resident's controlled substance records for lorazepam and morphine were not accurately maintained, with a 4 ml discrepancy in lorazepam count and incomplete documentation for a morphine dose. Staff were unable to determine the exact amount of medication in the bottle due to unclear graduation marks, and required procedures for reporting and resolving discrepancies were not followed.
A resident with multiple health issues, including a high fall risk, was injured when a CNA attempted to reposition them alone on a low air loss mattress, contrary to facility policy requiring two staff members. This resulted in the resident falling and sustaining fractures, necessitating hospitalization.
A facility failed to maintain the patency of a resident's CVC, leading to occlusion and replacement. The resident reported that the catheter was not flushed as required, and records showed multiple missed flushes and Heparin locks. Staff interviews revealed inconsistent practices and a lack of specific training for CVC flushing, contributing to the catheter's occlusion.
The facility failed to provide pureed Swiss steak with a smooth, uniform texture for residents on a pureed diet. The cook did not achieve the required consistency, and the Dietary Manager confirmed the gritty texture, which required chewing. The facility's policy mandates a smooth texture for pureed foods.
A facility failed to follow proper sanitation practices during the preparation of pureed diets for residents. A cook used the same spatula and food processor components without adequately washing, rinsing, and sanitizing them between uses, leading to potential cross-contamination. The Dietary Manager confirmed that the facility's policy requires washing, rinsing, and sanitizing kitchenware after each use, which was not followed.
A resident with emotional distress and multiple diagnoses was not treated with dignity by CNAs in a facility. Despite the care plan's emphasis on a warm and calm approach, the resident was told to stop moaning, and her incontinence brief was replaced without her consent, causing distress. The DON confirmed the staff's actions were inappropriate and not in line with the facility's dignity policy.
A facility failed to safely transfer a resident by not using a gait belt, as required by the resident's care plan. A CNA assisted the resident from a wheelchair to a bed without applying a gait belt, lifting the resident under the arm and guiding their hips with her hands. This was contrary to the facility's policy and the resident's care plan, which mandated the use of a gait belt for safety during transfers. Interviews with another CNA and the DON confirmed the necessity of using a gait belt for the resident's safety.
A resident experienced multiple medication administration errors, including incorrect dosing and failure to notify a physician when withholding medication. An LPN withheld Diltiazem without parameters, administered Timolol Maleate incorrectly, gave an incorrect dose of Milk of Magnesia, and omitted Vitamin D3. The facility's error rate was 10.81%, exceeding the acceptable 5% threshold.
A resident with Type 1 diabetes did not receive the correct insulin medications as prescribed by their endocrinologist due to transcription errors at the facility. The resident's After Visit Summary specified changes to their insulin regimen, but the facility's MAR showed incorrect insulin types and dosages were ordered and administered. The error was discovered during a medication audit by an LPN, highlighting the need for accurate medication management.
A resident with multiple health conditions fell and sustained a head injury during a transfer due to a CNA's failure to maintain a hold on the gait belt, contrary to facility procedures. The resident hit her head on an oxygen concentrator, requiring emergency medical treatment. Staff interviews confirmed the expectation of using gait belts during transfers to prevent such incidents.
A resident with dementia experienced escalating agitation due to inappropriate care by multiple staff members in a small space, leading to physical distress and lack of proper documentation. Despite having a care plan that required a calm approach, staff failed to follow guidelines, resulting in a deficiency in care.
A resident sustained a fractured femur during an unsafe transfer by a CNA who was unfamiliar with her needs and did not use a gait belt. The resident's knees buckled, and she was lowered to the floor, later diagnosed with a periprosthetic fracture. The RN noted limited leg movement and discomfort, but the resident was placed in a chair without immediate intervention. The resident, with a history of osteopenia, eventually expired under hospice care.
A facility failed to assess, treat, and document skin damage for a resident, leading to the discovery of foam patches swollen with urine on the resident's body. The resident, who preferred minimal changes, had saturated briefs and liners. CNAs and the wound care RN were unaware of the patches, and further assessment revealed a dried fluid blister and moisture-associated skin damage. The facility's records did not document these issues, indicating a failure to follow skin monitoring policies.
A resident's family requested the discontinuation of scheduled melatonin, to be given only as needed upon family request. Despite this, the resident continued to receive the scheduled dose, leading to increased sleepiness and decreased eating and drinking. The facility failed to inform the NP and update the medication orders accordingly.
The facility failed to treat residents with dignity, as evidenced by reports from three residents. One resident reported that a CNA threw her shoes under her bed, another resident stated that the CNA was rude and unhelpful when she requested assistance to use the bathroom, and a third resident reported that the CNA frequently used inappropriate language. These actions were in violation of the facility's dignity policy.
Inaccurate Documentation and Discrepancies in Controlled Substance Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate records and documentation for controlled medications for multiple residents. For one resident with an order for hydrocodone-acetaminophen (Norco) 5-325 mg every four hours as needed for pain, a narcotic count showed 14 pills remaining in the punch card, while the Controlled Drug Receipt/Record/Disposition Form indicated 15 pills remaining with the last documented dose given several days earlier, leaving one tablet unaccounted for. The LPN who participated in the narcotic count stated she had counted with the previous nurse, did not know why there was a discrepancy, and did not remember administering the medication. Another resident had an order for alprazolam 0.25 mg twice daily and every 12 hours as needed; the controlled drug record showed a tablet removed and documented as given for another resident, while that resident’s MAR did not show administration of alprazolam on that date. For a third resident, the Controlled Drug Receipt/Record/Disposition Form showed Norco signed out twice on the same day without any staff member’s name recorded, and the MAR showed that the resident did not receive Norco on that date. Additionally, controlled substance sheets for four other residents were signed off by the same LPN during a narcotic count, and the LPN stated she had administered the controlled substances but had not signed them out on the controlled substance sheets, even though the MARs showed the medications were scheduled for administration earlier that morning. Staff interviews confirmed that narcotics are supposed to be counted at shift change by two nurses, with one reviewing the book and the other the cart, and that medications should be documented at the time they are given. Facility policies required the individual administering medications to initial the MAR after each administration and mandated end-of-shift controlled substance counts with documentation and reporting of discrepancies to nursing leadership.
Failure to Honor Resident Menu Preferences Regarding Bacon
Penalty
Summary
The facility failed to honor resident preferences regarding menu items, specifically the provision of bacon, which had previously been available to residents before a change in facility ownership. Multiple residents and staff reported that bacon was regularly requested and had been a staple breakfast item prior to the new corporation taking over. After the change in ownership, bacon was removed from the menu, and staff were instructed by the food service provider that bacon would no longer be supplied due to its perceived lack of nutritional value. Observations confirmed that bacon was not present in the facility's food storage areas, and the alternative menu no longer listed bacon-containing items. Residents expressed dissatisfaction and frustration with the removal of bacon, noting that it was a preferred food item and a source of enjoyment during meals. Several residents reported repeatedly requesting bacon and being told it was unavailable, while staff corroborated that complaints about the lack of bacon and breakfast meats were frequent. The facility's grievance log and resident council meeting minutes documented ongoing concerns about the absence of bacon and breakfast meats, indicating that the issue was persistent and widely recognized among residents and staff. The dietary manager and registered dietitian confirmed that the decision to remove bacon was based on guidance from the food service provider, who cited nutritional concerns. Despite acknowledging that bacon could be enjoyed in moderation and posed no danger, the facility did not provide it as an option, even though it was previously available and listed on alternative menus. The administrator stated there was no facility policy addressing menu changes or resident preferences, and the current menu cycle did not include bacon or similar breakfast meats.
Failure to Prevent Accidents and Ensure Safe Catheter and Transfer Practices
Penalty
Summary
The facility failed to ensure resident safety and adequate supervision in three separate incidents involving residents with urinary catheters and fall risks. In the first case, a cognitively intact resident with a urinary catheter was injured when a CNA attempted to dress her by pulling the catheter system through her pants, causing a plastic clip attached to the catheter bag to lacerate her leg. The resident required emergency care and nine sutures to close the wound. The CNA later acknowledged that the catheter bag and tubing should have been managed differently to prevent contact with the resident's skin. In the second incident, a resident with a history of falls and confusion, also with a urinary catheter, was observed during therapy with her catheter drainage bag hanging from her wheelchair while she ambulated with a walker. As the resident walked, the catheter tubing was pulled taut, creating tension and pulling on her leg, as the drainage bag remained attached to the wheelchair behind her. The DON confirmed that the standard of care would be to use a leg bag or to hang the catheter bag from the walker to avoid tension on the tubing during ambulation. The third incident involved a resident with repeated falls, hearing and vision loss, and impaired mobility. During a shower, an agency CNA, who had been told the resident was independent, left her in a wheelchair while retrieving a shower chair. The resident attempted to stand on her own, lost her balance, and was lowered to the floor by the CNA. The CNA was unsure if the resident could hear or see her instructions. The DON stated that staff should verify a resident's transfer status and assistance needs using the care plan or information posted in the resident's room.
Staff Cell Phone Use During Care Undermines Resident Dignity
Penalty
Summary
The facility failed to ensure that residents were treated in a dignified manner, as evidenced by staff using personal cell phones while providing care and during resident interactions. Three residents reported that CNAs were on their cell phones during showers, with one resident stating the aide was on her phone and using earphones throughout the shower, making the resident feel unimportant and not attended to. Another resident described a similar experience, where the CNA answered a phone call and engaged in conversation during the shower, leading the resident to feel that her care was less important than the staff member's personal call. A third resident observed staff frequently using their phones in hallways and the dining room, expressing concern about staff availability if assistance was needed. Review of the facility's Resident Council Meeting minutes from April to June indicated ongoing resident concerns about staff cell phone use during work hours. The Director of Nursing confirmed that staff are not permitted to use personal phones while at work, especially during resident care, and acknowledged that this has been an ongoing issue. The facility's policy on promoting and maintaining resident dignity emphasizes the importance of treating residents with respect and focusing attention on them during care, which was not adhered to in these instances.
Failure to Provide Required Showers for Dependent Resident
Penalty
Summary
A resident who required staff assistance and supervision for showering or bathing, as indicated in their care plan, did not consistently receive the required showers. Interview and record review revealed that the resident reported sometimes receiving only one shower per week or none at all, despite being supposed to receive at least two showers weekly. Shower records from 5/1/25 to 7/21/25 showed a gap of 13 days between showers, with the resident receiving a shower on 6/27/25 and not again until 7/11/25. The DON confirmed that staff are expected to offer or provide showers or baths twice a week, but also stated that the facility did not have a policy specifying the frequency of showers or baths.
Failure to Arrange Ophthalmology Appointment for Visually Impaired Resident
Penalty
Summary
A resident with a history of visual impairment, who required eyeglasses, had a physician order for an ophthalmology consult and treatment as indicated. The resident reported that his vision had worsened recently, even while wearing his glasses, and stated that he had not been seen by an ophthalmologist or had his vision tested in over a year. The resident recalled having an appointment scheduled with an eye doctor, but it was canceled, and he was unaware of the reason for the cancellation. Record review showed that the ophthalmology appointment was canceled because the provider did not accept the resident's insurance, and no subsequent appointment was scheduled from the time of cancellation through the review period. The DON confirmed awareness of the canceled appointment and acknowledged that a new appointment had not been arranged. Facility policy required social services to coordinate and arrange for physician-ordered services in a timely manner, but this was not followed in the resident's case.
Failure to Follow Physician's Wound Care Orders for Surgical Incision
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician's orders for a resident who was admitted with multiple complex medical conditions, including recent cardiac surgery. The resident's hospital discharge instructions specifically ordered daily cleansing of a surgical incision with soap and water, monitoring for signs of infection, and avoiding lotions or ointments on the site. However, upon review of the resident's electronic Treatment Administration Record (eTAR) and medical record, there was no evidence that an order to wash the incision daily was entered or carried out during the resident's stay. The only documented intervention was monitoring the incision site, with no record of actual cleansing as directed by the physician's order. Interviews with facility staff revealed that the wound care nurse overlooked the order to wash the incision daily and did not ensure the order was entered or followed. The Director of Nursing was unaware of the wound care order and stated that such orders are typically managed by the wound care nurse, who coordinates with the facility's wound care physician or nurse practitioner. The facility's policy requires that treatment orders specify the treatment, frequency, and duration, and that a current list of orders be maintained in each resident's clinical record. This process was not followed, resulting in the omission of the required wound care for the resident.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to administer medications as ordered by the physician for one resident. The resident, who had multiple diagnoses including fibromyalgia, heart disease, hypothyroidism, and major depressive disorder, had a physician's order for levothyroxine to be given at 7:00 AM and acetaminophen 500 mg, one tablet by mouth four times daily. During a morning medication pass, an LPN administered the levothyroxine later than the prescribed time and gave two tablets of acetaminophen instead of the ordered one tablet. The resident later stated that she needs to take her levothyroxine at 7:00 AM because she has to wait to eat. The facility's policy requires staff to follow prescribed medication times until reviewed by the facility pharmacist and discussed with the resident or responsible party.
Failure to Provide and Document Ordered Wound Care and Weekly Skin Checks
Penalty
Summary
The facility failed to provide wound and skin treatments as ordered and did not consistently perform or document weekly skin checks for multiple residents. Four out of five residents reviewed for improper nursing care were affected. For example, one resident with skin infections, morbid obesity, and congestive heart failure reported receiving leg wound care only one to two times per week, despite orders for more frequent treatments. Treatment Administration Records (TARs) for this resident showed missed documentation of both wound care and weekly skin checks on several ordered dates. Another resident with non-pressure wounds to the right upper buttock and left lower leg stated that wound care was only provided once a week during physician rounds, even though daily and three-times-weekly treatments were ordered. Documentation for this resident also showed missed skin checks and wound treatments on multiple dates. Additional residents had orders for protective skin preparations to be applied to their heels twice daily, but the TARs indicated numerous missed or undocumented applications and weekly skin checks. Staff interviews confirmed that the purpose of weekly skin checks is to identify skin concerns early and that wound care is essential for healing and infection prevention. The facility's own policy required weekly general skin checks with documentation in the medical record, but records showed this was not consistently done. The findings demonstrate a pattern of missed or undocumented wound care and skin checks, contrary to physician orders and facility policy.
Failure to Report Missing Controlled Substance
Penalty
Summary
The facility failed to identify and report the diversion of a resident's controlled substance, specifically lorazepam. According to the medication administration record and controlled drug count sheet, a discrepancy of 4.0 ml of lorazepam was noted during a routine count, with two nurses signing off on the correction. Despite this discrepancy, there was no documentation or evidence that the missing medication was reported to facility administration or to the appropriate authorities. Interviews with nursing staff revealed that one nurse believed the other would report the issue, but neither confirmed that a report was made. The Assistant Director of Nursing confirmed that the missing lorazepam had not been reported, and the new Administrator, who also serves as the abuse coordinator, stated she was not made aware of the incident. The facility's policy requires prompt reporting of any suspected abuse, neglect, or misappropriation of resident property, including controlled substance discrepancies, to local, state, and federal agencies. The failure to report the missing lorazepam as required by policy and regulation resulted in a deficiency related to the timely reporting of suspected theft or diversion of a resident's medication.
Failure to Document and Provide Ordered Pressure Ulcer Care
Penalty
Summary
The facility failed to provide and document ordered wound care treatments for a resident with a stage four pressure injury located above the buttocks. Review of the resident's Treatment Administration Records (TAR) for April and May showed that several evening wound care treatments were not documented as completed, specifically on 4/29, 4/30, and 5/10. The wound care nurse confirmed that if wound care is not documented, it is considered not done, and any refusals or absences should be noted in the TAR. The facility's policy requires that the date and time of dressing changes be recorded in the resident's medical record or treatment sheet. At the time of observation, the wound appeared as previously described, with a red wound bed and no active drainage.
Failure to Maintain Accurate Controlled Substance Records and Procedures
Penalty
Summary
The facility failed to maintain accurate records and procedures for controlled substances, specifically lorazepam and morphine, for one resident. The medication administration record showed that lorazepam was to be administered as needed, and the controlled drug count sheet indicated a discrepancy of 4 ml, with the count being corrected from 28.0 ml to 24.0 ml by two nurses. One nurse stated she noticed the discrepancy during the shift count and signed off on the correction, believing the other nurse would report it, but was unaware of what happened to the missing medication. The Assistant Director of Nursing confirmed that the nurse should not have signed off on the count and should have notified a nurse manager, and was not aware of the discrepancy until it was brought to her attention during the survey. Additionally, the physical bottle of lorazepam had unclear graduation marks, making it difficult for staff to accurately measure the remaining medication. For the same resident, the morphine count sheet showed a dose was documented as given without a date, time, amount left, or nurse signature. The nurse on duty stated she had not dispensed any morphine and that discrepancies should be reported to administration. The Assistant Director of Nursing was not aware of the incomplete documentation and stated it should have been identified and addressed at shift change. The facility's policy required controlled substances to be counted at each shift change, with discrepancies reported to the Director of Nursing or designee, and for the outgoing nurse to remain until the issue was resolved.
Failure to Safely Reposition Resident Leads to Injury
Penalty
Summary
The facility failed to safely reposition a resident in bed, leading to the resident experiencing multiple fractures and requiring hospitalization. The resident, who was admitted with diagnoses including fibromyalgia, morbid obesity, spinal stenosis, cervical spine fusion, major depressive disorder, repeated falls, and pain, required substantial assistance for bed mobility. Despite this, a CNA attempted to reposition the resident alone on a low air loss mattress, contrary to the facility's policy requiring two staff members for such tasks. This resulted in the resident falling off the bed and sustaining significant injuries, including a humerus shaft fracture, a laceration on the leg, and a pubic ramus fracture. Interviews revealed that the CNA was unaware of the policy requiring two staff members for repositioning residents on low air loss mattresses. The Assistant Director of Nursing confirmed that the incident could have been prevented if the policy had been followed. The resident expressed that the CNA was in a hurry and that the accident was unnecessary, indicating that the CNA's actions were not in line with the required care plan. The incident highlights a lapse in adherence to safety protocols, which directly contributed to the resident's injuries.
Failure to Maintain Patency of Central Venous Catheter
Penalty
Summary
The facility failed to provide physician-ordered interventions to maintain the patency of a Central Venous Catheter (CVC) for a resident, resulting in the occlusion and subsequent need for replacement of the catheter. The resident, who is cognitively intact, reported that the catheter was not being flushed as required, leading to repeated clogging. Observations revealed that the catheter had dark red blood in the tubing, and the resident confirmed that the line had not been flushed on the day of observation. Interviews with nursing staff indicated a lack of consistent practice in flushing the CVC, with some staff members not performing the procedure and others documenting flushes that were not actually conducted. The Medication Administration Records for November and December showed multiple instances where the prescribed Normal Saline flushes and Heparin locks were not administered as ordered. A narrative from a medical doctor confirmed that the catheter was filled with clots, indicating improper flushing and locking practices. The Director of Nurses acknowledged the absence of specific training for CVC flushing, relying instead on a computer program for instruction. This lack of training and adherence to protocol contributed to the catheter's occlusion and the need for its replacement.
Failure to Ensure Proper Texture of Pureed Diets
Penalty
Summary
The facility failed to ensure that pureed Swiss steak was prepared to a smooth, uniform texture as required for residents on a pureed diet. During an observation, the cook, identified as V11, was seen pureeing Swiss steak for lunch but did not achieve the desired consistency similar to mashed potatoes. The pureed Swiss steak appeared slightly chunky, and V11 did not perform a taste test to verify the texture. A test tray provided by the facility revealed that the pureed Swiss steak was gritty with small granules, necessitating chewing before swallowing. The Dietary Manager, V6, confirmed the gritty texture and noted that staff should taste test the product every time before completing the puree. The facility's policy on Modified Texture Foods states that foods requiring modification to a puree texture should have a smooth texture.
Improper Sanitation Practices in Pureed Diet Preparation
Penalty
Summary
The facility failed to ensure proper sanitation practices were followed in the preparation of pureed diets for four residents. During an observation, a cook was seen using a spatula and food processor components without adequately washing, rinsing, and sanitizing them between uses. The cook used the same spatula to transfer different food items, such as Swiss steak, mashed potatoes, and broccoli, without proper cleaning, which could lead to cross-contamination. The Dietary Manager confirmed that the cook should have used either new containers with lids and blades for each food item or should have washed, rinsed, and sanitized each component before reuse. The facility's policy on cleaning food and nonfood contact surfaces requires that kitchenware and food-contact surfaces be washed, rinsed, and sanitized after each use to prevent cross-contamination. This policy was not adhered to during the preparation of pureed diets for the residents.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to treat a resident, identified as R9, in a dignified manner, as observed during a survey. R9, who was admitted with diagnoses including Parkinson's disease, chronic obstructive pulmonary disease, and generalized anxiety disorder, was noted to have emotional and spiritual distress due to hopelessness and lack of family support. The care plan for R9 emphasized the need for staff to approach her warmly, positively, and calmly, offering reassurance before initiating care. However, on December 9, 2024, R9 was observed moaning and asking to go to bed, with her moans audible across the hall. When two CNAs, V8 and V9, entered her room, V8 told R9 to stop moaning, stating, "Nobody wants to hear that," while V9 loudly informed R9 that they were going to replace her incontinence brief, causing R9 to wince. The Director of Nursing (DON), identified as V2, confirmed that R9 was not hard of hearing and could hear without someone speaking close to her ear. V2 acknowledged that the responses from V8 and V9 were inappropriate and not in line with the facility's policy on dignity, which requires staff to speak respectfully to residents at all times. The facility's Quality of Life-Dignity policy, revised in December 2021, mandates that each resident be cared for in a manner that promotes dignity, respect, and individuality, and that staff should address residents by their name of choice rather than by room number, diagnosis, or care needs.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to safely transfer a resident by not using a gait belt during a transfer, as required by the resident's care plan. The care plan specified that a gait belt should be used for all transfers with the assistance of one person. On December 9, 2024, a Certified Nursing Assistant (CNA) assisted the resident from a wheelchair to a bed without applying a gait belt, instead lifting the resident under the arm and guiding their hips with her hands. This action was contrary to the facility's policy and the resident's care plan, which both mandated the use of a gait belt for safety during transfers. Interviews with another CNA and the Director of Nursing confirmed that the use of a gait belt is necessary for the resident's safety during transfers.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 10.81%, which is above the acceptable threshold of 5%. This deficiency was observed in one of the three residents during a medication pass. Specifically, a Licensed Practical Nurse (LPN) did not administer Diltiazem to a resident with hypertension, despite the absence of hold parameters in the order. The LPN decided to withhold the medication due to the resident's pulse being less than 70, but failed to notify the physician about this decision. Additionally, the LPN administered Timolol Maleate eye drops incorrectly by applying them to both eyes instead of just the left eye as ordered. The LPN also administered Milk of Magnesia on a day it was not due and gave a double dose. Furthermore, the LPN did not administer Vitamin D3 as ordered. The Director of Nursing confirmed that all medications should be given as ordered and that any deviations should be communicated to the physician for approval.
Significant Medication Error Due to Incorrect Insulin Transcription
Penalty
Summary
The facility failed to ensure that a resident received the correct insulin medications as prescribed by their endocrinologist, resulting in a significant medication error. The resident, who has Type 1 diabetes mellitus with polyneuropathy, reported that the facility did not accurately transcribe her insulin orders following an endocrinology appointment. The After Visit Summary from the endocrinologist specified changes to the resident's insulin regimen, including adjustments to the doses of Basaglar (long-acting insulin) and Novolog (short-acting insulin). However, the facility's September Medication Administration Record (MAR) showed that incorrect insulin types and dosages were ordered and administered to the resident until the error was identified and corrected at the end of the month. The Director of Nursing acknowledged that the nurses should have followed the medication orders on the After Visit Summary when transcribing new orders. It was noted that Novolog and Novolin N are different types of insulin and are not interchangeable, highlighting the importance of accurate transcription and understanding of medication types. The Licensed Practical Nurse responsible for medication audits discovered the error during her end-of-month review, which led to the correction of the resident's insulin orders. This incident underscores the critical need for precise medication management and adherence to prescribed treatment plans in the facility.
Resident Fall Due to Improper Transfer Procedure
Penalty
Summary
The facility failed to safely transfer a resident, resulting in a fall and head injury. The incident involved a resident who was being assisted by a CNA to transfer from a bed to a wheelchair. The resident, who had a history of chronic kidney disease, morbid obesity, anxiety, insomnia, persistent atrial fibrillation, congestive heart failure, chronic obstructive pulmonary disease, generalized weakness, and gait abnormalities, required partial to moderate assistance for transfers. Despite the care plan indicating the use of a gait belt and walker, the CNA did not maintain a hold on the gait belt during the transfer, leading to the resident losing balance and falling. The resident fell forward and hit her head on an oxygen concentrator, resulting in a laceration that required emergency medical attention, including 6 staples and 2 sutures. The CNA admitted to not having a hold on the gait belt at the time of the fall, which is against the facility's procedures that require staff to maintain contact with the gait belt to assist residents safely. The incident report inaccurately documented that a gait belt was used during the transfer, although the CNA's account and the resident's statement indicated otherwise. Interviews with facility staff, including a nurse, occupational therapist, nurse practitioner, and the Director of Nursing, confirmed the expectation that gait belts should be used and held during transfers to prevent falls and reduce injury risk. The facility's procedures emphasize the importance of using gait belts to ensure resident safety during transfers, highlighting a failure in adherence to these protocols in this incident.
Deficiency in Dementia Care Leads to Resident Agitation
Penalty
Summary
The facility failed to provide appropriate care to a resident with dementia, leading to escalating agitation. The resident, who had severe cognitive impairment and required assistance with activities of daily living, was involved in an incident where four staff members attempted to assist him in the bathroom. The resident's family expressed concerns about the number of staff involved and the manner in which care was provided, noting that the resident became overwhelmed and agitated due to the loud and multiple instructions given by the staff. The resident was found with bruises and a bump on his head the following day, which the family believed were related to the incident. On another occasion, video footage showed two CNAs providing incontinence care to the resident, who was visibly agitated and in pain. The CNAs continued to provide care despite the resident's resistance and complaints of pain, without giving him time to calm down. The resident's care plan indicated that he required a calm approach and time to process instructions, but these guidelines were not followed during the care provided. The facility's staff did not document the incidents in the resident's progress notes, and there was no dementia care policy in place. The resident's psychiatric provider noted that he had been experiencing agitation and aggression since moving to the facility, with attempts at redirection often escalating his agitation. The facility's Director of Nursing and Administrator acknowledged that the presence of multiple staff members during care was overwhelming for the resident and that additional dementia care training was needed. Despite the facility's efforts to provide dementia care in-services, the incidents highlighted a deficiency in the care provided to the resident with dementia.
Resident Injury Due to Unsafe Transfer
Penalty
Summary
The facility failed to ensure a safe transfer for a resident, resulting in a fractured femur. During a transfer from bed to chair, the resident's knees buckled, and the CNA lowered her to the floor. The CNA did not use a gait belt and was unfamiliar with the resident's transfer needs, assuming she required only one-person assistance. The resident was lowered to the floor and later assessed by an RN, who noted the resident's ability to move her legs, albeit weakly, and reported some pain in the right leg. Despite these observations, the resident was placed in a chair without further immediate intervention. The resident was later diagnosed with a periprosthetic fracture of the distal femur at a local hospital. The radiologist noted that the fracture pattern suggested a twisting motion and some energy involved, which typically results from a fall rather than causing one. The resident had a history of osteopenia, which may have contributed to the injury. The RN on the following shift noted the resident's discomfort and limited knee movement, indicating a potential injury. The resident's condition deteriorated, and she eventually expired under hospice care in the facility.
Failure to Assess and Document Skin Damage
Penalty
Summary
The facility failed to properly assess, treat, and document skin damage for a resident, identified as R1, who was part of a sample reviewed for skin alterations. On July 31, 2024, during a perineal care session, certified nursing assistants (CNAs) V4 and V5 discovered foam patches on R1's coccyx, left anterior thigh, and outer left knee, which were swollen with urine. R1 was unaware of the patches and expressed a preference to be changed only once per shift, which contributed to her brief and liner being saturated with urine. The CNAs did not remove the patches, as they were unsure of what was underneath and did not want to expose R1's skin. The registered nurse (RN) responsible for wound care, V6, was also unaware of the patches and noted that R1 had returned from the hospital recently, with her skin previously in good condition. Upon further assessment, V6 found no open areas under the patch on R1's buttocks but identified a dried fluid blister under the patch on her left knee and moisture-associated skin damage (MASD) on her right inner thigh. The facility's records, including R1's electronic medical record and admission skin assessment sheet, did not document any open areas on R1's inner thigh or left knee at the time of her readmission from the hospital. The facility's policy on skin identification and monitoring requires licensed nursing staff to evaluate skin integrity upon admission and when significant changes occur, but this was not adequately followed, leading to the deficiency.
Failure to Follow Resident's Medication Choice
Penalty
Summary
The facility failed to ensure a resident's medication choice was followed, specifically for melatonin administration. The resident's family had requested that the scheduled melatonin dose be discontinued and only given as needed upon family request. Despite this, the resident continued to receive the scheduled dose. The Director of Nursing (DON) was unaware of who printed or reviewed the medication orders with the family, and the Nurse Practitioner (NP) was not informed of the family's request. The resident's Medication Administration Record (MAR) showed that the resident received melatonin on multiple occasions, contrary to the family's instructions. The resident's Power of Attorney (POA) confirmed that they had communicated the request to discontinue the scheduled melatonin to the nurse on duty, who assured them that the doctor would be informed and the orders would be changed. However, this change was not implemented, and the resident continued to receive the medication, leading to increased sleepiness and decreased eating and drinking. The facility's Resident Rights Policy states that residents are entitled to exercise their personal and legal rights, which was not upheld in this case.
Failure to Treat Residents with Dignity
Penalty
Summary
The facility failed to treat residents in a dignified manner during care, as evidenced by the experiences of three residents (R1, R2, and R3). R1, who has vascular dementia, anxiety, depression, type 2 diabetes mellitus, and difficulty walking, reported that CNA V9 threw her shoes under her bed where she could not reach them. This incident was corroborated by another CNA, V6, who found the shoes under the bed and reported the incident to the administrator, V1. R2, who has anxiety disorder, depression, chronic pain, and weakness, and is assessed as a moderate fall risk, reported that V9 was rude and unhelpful when she requested assistance to use the bathroom. R2 stated that V9 initially refused to help her and only assisted after she insisted on her need for help due to her fall risk. R3, who has arthritis, cellulitis of the lower extremities, and muscle weakness, reported that V9 frequently used inappropriate language, including swearing, while at work, which she found undignified and unprofessional. The facility's dignity policy and procedure, revised in April 2024, emphasizes that each resident should be cared for in a manner that promotes dignity, respect, and individuality. The policy specifically states that associates should not handle or move a resident's personal belongings without permission. The care plans for R1 and R2 highlight their need for additional attention, reassurance, and assistance with activities of daily living due to their medical conditions. Despite these guidelines, the actions of CNA V9, as reported by the residents and corroborated by staff, indicate a failure to adhere to the facility's dignity policy, resulting in undignified treatment of the residents involved.
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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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