The Haven Of Paris
Inspection history, citations, penalties and survey trends for this long-term care facility in Paris, Illinois.
- Location
- 1011 North Main Street, Paris, Illinois 61944
- CMS Provider Number
- 145469
- Inspections on file
- 49
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 36
Citation history
Health deficiencies cited at The Haven Of Paris during CMS and state inspections, most recent first.
Two residents with pressure ulcers and impaired skin integrity did not receive properly documented wound and skin assessments as ordered and as required by facility policy. One resident had multiple pressure ulcers and orders for weekly nurse assessments, daily skin checks, and daily foot checks, yet the TAR showed missing entries on several days, open areas and edema were recorded without corresponding progress notes or physician notification, and internal skin observation tools lacked wound measurements or detailed descriptions. Another resident had physician orders for wound care, daily foot exams, weekly skin checks, and coccyx prevention, with a physician wound note documenting specific wound size and exudate, but the EMR contained no nursing skin assessments despite an observed dressing change showing the wound closed. The DON reported that nurses were not documenting wounds as they should and that staff relied on uploading external wound clinic notes instead of completing individualized nursing documentation, contrary to the facility’s pressure/skin breakdown protocol.
A resident with dementia and a high risk for falls was not adequately supervised and was placed in a dark bedroom despite ongoing restlessness. Staff did not maintain frequent safety checks or ensure sufficient lighting, contrary to the care plan and facility policy. The resident was later found on the floor with serious injuries after an unwitnessed fall, which ultimately led to death.
A resident with a history of constipation and neurological impairment did not have bowel movements consistently monitored or documented, despite physician orders and complaints of abdominal pain. Nursing staff failed to assess or notify the physician after several days without a bowel movement, contrary to facility policy and expectations.
A resident with constipation and stomach pain repeatedly requested to be sent to the emergency room, but experienced a significant delay after informing a CNA and later an LPN, who stated a physician's order was needed. The transfer did not occur until several hours after the initial request, despite facility policy and the medical director's statement that such requests should be promptly honored.
A resident with dementia and behavioral issues repeatedly entered other residents' rooms, took assistive devices, and made inappropriate comments due to inadequate supervision and inconsistent implementation of safety interventions. This led to multiple falls and injuries, including lacerations and a hematoma, as well as significant distress among several residents who reported feeling unsafe and disturbed by the ongoing incidents.
Two residents were involved in an incident where one, with a history of dementia and aggressive behavior, physically grabbed and struck another while waiting to go outside. Despite known behavioral risks and prior interventions like increased supervision, the facility did not consistently implement all care plan measures, leading to repeated aggressive incidents and failure to protect residents from abuse.
A resident with Lewy Body Dementia and a history of severe cognitive impairment, wandering, and previous falls was not adequately supervised according to facility policy, which required frequent checks for high-risk individuals. Staff failed to perform and document the necessary 15-minute checks, resulting in the resident falling and sustaining a left hip fracture.
A resident with severe cognitive impairment and multiple comorbidities experienced a fall and subsequently reported ongoing severe right hip pain. Initial ED evaluation did not include hip imaging, and later X-rays were improperly positioned. Despite persistent pain and increased use of narcotic analgesics, further diagnostic imaging was not pursued until the family requested an MRI nearly two weeks later. The MRI was scheduled with significant delay and, when completed, revealed an acute hip fracture. There was also a delay in obtaining and acting on the MRI results, resulting in continued pain and delayed surgical intervention.
Two residents with dementia and high fall risk suffered serious injuries after one accessed an unsecured bathroom and fell, and another fell from a shower chair with malfunctioning wheels. The facility failed to maintain a safe environment and did not ensure equipment was in safe, operable condition, leading to a traumatic fall with head and chest injuries for one resident and a hip fracture requiring surgery for another.
A resident who suffered a fall and required an MRI for a hip fracture did not have proper documentation of their departure and return for the procedure. Additionally, there were discrepancies between the narcotic count sheet and the MAR regarding Tramadol administration, and pain assessments were not fully documented as ordered. The DON confirmed these lapses in record-keeping after reviewing the records.
The facility did not have a full-time DON or an Acting DON to oversee and coordinate nursing services, as confirmed by the Administrator. This deficiency affected oversight for all 83 residents in the facility.
A resident's medical records contained repeated documentation errors, with the Medical Director inaccurately recording bruising on multiple assessment dates when no such bruising was present. This resulted in incomplete and inaccurate records for the resident.
The facility did not consistently notify family representatives or POAs about physical abuse allegations involving multiple residents. Although records indicated notifications were made, interviews revealed that POAs were either not contacted or not fully informed about the incidents, with some only learning of the events from the residents themselves. This failure to provide timely and accurate information was contrary to the facility's abuse prevention policy.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not notify the Ombudsman of multiple abuse allegations, despite documentation stating otherwise. Investigation reports for several incidents of physical abuse between residents and one involving a nursing staff member indicated that the Ombudsman was informed, but the Ombudsman confirmed he received no such notifications, contrary to facility policy.
The facility did not properly notify the local police department or the physician about multiple incidents of alleged abuse and injuries involving several residents, despite documentation stating otherwise. Interviews and record reviews confirmed that neither the police nor the physician were aware of these events, and the administrator could not provide proof of notification as required by facility policy.
The facility did not interview families or other residents who may have had knowledge of several alleged abuse incidents, including resident-to-resident physical altercations and a report of rough handling by staff. Despite the facility's policy requiring such interviews, investigations were deemed complete without this step.
The facility did not timely review or revise care plans for several residents after multiple incidents of resident-to-resident physical abuse. Despite documentation in investigation reports that care plans were reviewed, the actual care plans lacked timely updates or new interventions addressing the abuse events, as confirmed by record review and staff interviews.
A resident did not receive treatment and care in accordance with physician orders and their stated preferences and goals, resulting in a deficiency related to compliance with care planning requirements.
Staff did not promptly inform a resident, their physician, and a family member about important events such as injury, decline, or room changes, resulting in a breakdown of required communication.
A resident with severe cognitive impairment and multiple medical conditions was found with a large, dark abdominal bruise. Although the injury was promptly reported internally by a CNA to an LPN and then to the DON and administrator, the required report to the State Agency was delayed by several days, contrary to facility policy for reporting Injuries of Unknown Origin.
A resident with severe cognitive impairment and multiple medical conditions developed a large, unexplained abdominal bruise. Staff observed and reported the injury, but the DON did not conduct a thorough investigation, failing to review key records such as skin assessments, shower sheets, and insulin administration sites, and did not rule out abuse as a possible cause.
A resident with a history of falls and multiple medical conditions was left unattended during a shower, and the shower chair's wheels were not locked, causing the chair to move on a sloped, wet floor. The resident fell and sustained pain and bruising. Staff and resident interviews confirmed that the shower chair was unstable and that not all CNAs consistently locked the wheels or provided direct assistance during transfers.
A resident assessed as high risk for falls experienced a fall in the shower room, but the incident was not documented in the medical record and the care plan was not updated until months later. Required follow-up assessments and documentation were not completed by nursing staff, contrary to facility policy.
A resident with multiple chronic conditions and a history of skin ulcers developed signs of infection in a toe wound, including redness, swelling, and pain. Although an LPN reported the changes to the wound nurse, the physician was not notified as required by policy and physician orders. This led to a four-day delay in treatment, with antibiotics only started after the resident was seen at a scheduled wound clinic visit, at which time cellulitis was diagnosed.
A resident with multiple chronic conditions continued to receive daily wound treatments for pressure wounds on the buttocks, but weekly wound assessments and measurements were not documented as required by facility policy. The wound nurse was not informed that the wound had reopened, resulting in a lack of weekly assessments for several weeks.
A resident with multiple chronic conditions and a history of skin ulcers developed new signs of infection in a toe wound, which were observed by an LPN and reported to the wound nurse. The wound nurse did not notify the physician as required, resulting in a delay in treatment until the resident's next wound clinic visit, when an antibiotic was finally ordered.
The facility did not follow its bedbug prevention policy when a bedbug was found in a resident room. Although staff observed and reported the pest, the pest control company was not notified and the room was not treated, as confirmed by the pest control representative and maintenance director. This failure affected all residents in the facility.
A mushy, sloping, and unstable floor with an unattached transition piece was found in a shower area used by multiple residents, creating fall and trip hazards. The Maintenance Director acknowledged the unsafe condition, and the DON confirmed the area is regularly used for resident care.
Two residents in the dementia unit were not protected from physical abuse, as one resident with a known history of aggression was involved in multiple altercations, including taking another resident's walker and shoving another resident. Staff confirmed the need for increased supervision and acknowledged understaffing in the unit.
A resident with dementia accessed unsecured Morphine left on a medication cart in a dementia care unit, leading to an overdose. The resident, known for wandering and drinking from unattended containers, was found with the Morphine bottle up to their lips. The incident occurred after an LPN left the medication unsupervised, resulting in the resident becoming unresponsive and requiring Narcan and hospital transport.
A resident with Diabetes Mellitus Type II did not receive their prescribed insulin for eight days due to the medication being unavailable, and the facility failed to notify the physician promptly. The resident's blood glucose levels were affected during this period. Facility policies require notifying the prescriber and documenting medication errors, which were not followed.
Two residents with Diabetes Mellitus Type II were not provided with their physician-ordered diets. One resident was admitted with instructions for a Diabetic diet but received a regular diet due to a transcription error. Another resident was served a regular diet instead of a Consistent Carbohydrate diet, despite the correct order being in the EMR. These errors were acknowledged by facility staff and could have led to adverse health outcomes.
A facility failed to report a resident's change of condition to a nurse before conducting a COVID-19 test and did not ensure qualified staff performed the test. A CNA tested a resident for COVID-19 without notifying the nurse of the resident's condition change, which is against the facility's policy. The resident's temperature increased significantly, and the incident was confirmed by an LPN and the interim DON.
A facility failed to protect a resident's right to unrestricted access without clinical justification, leading to fear and threats of seclusion. Another resident, requiring supervision for smoking due to severe cognitive impairment, was not consistently assisted to smoke breaks, contrary to facility policy. These actions violated resident rights and demonstrated a lack of dignity and respect.
A resident was subjected to mental abuse by the facility's Administrator, who raised her voice and threatened the resident with a move back to the Dementia unit. The incident, witnessed by several staff members, left the resident feeling humiliated and fearful, leading to a withdrawal from activities. The facility's policy on abuse was not followed, and the Medical Director emphasized the seriousness of verbal and mental abuse.
A resident with a history of cerebral infarction and Alzheimer's was allegedly yelled at by the Administrator, causing distress. The incident was witnessed by the Social Service Director and the DON, but neither reported it to the appropriate authorities, violating the facility's abuse policy.
A resident with severe cognitive impairment and dependency on staff for toileting was left in a saturated incontinence brief for an extended period, resulting in skin redness. The CNA providing care failed to change gloves or perform hand hygiene after handling contaminated items, risking cross-contamination. The facility's hand hygiene policy was not adhered to, leading to this deficiency.
The facility failed to maintain safe equipment, affecting two residents. One resident experienced a malfunctioning mechanical lift during a transfer, and a sparking bed remote control posed a fire hazard. Another resident had a stuck siderail since August, complicating hospital transfers and posing an injury risk. These issues were not promptly addressed, leading to deficiencies.
A resident with severe cognitive impairment was left exposed during incontinence care when a CNA failed to close the bathroom or room door and did not use the privacy curtain. Another resident and a CNA observed the incident, and the CNA did not change gloves throughout the procedure. The Director of Nursing confirmed that privacy should have been provided.
The facility failed to respect the rights of two residents to refuse electronic monitoring devices. Both residents, who were cognitively intact and their own responsible parties, expressed a desire to have the devices removed, citing feelings of imprisonment and mistreatment. Despite their requests, the devices were not initially removed, and there was no documentation of consent or assessment for their use. The devices were eventually removed after the residents' complaints were acknowledged by the facility's Regional Clinical Nurse.
A resident with dementia physically and verbally abused another resident in a smoking tent, while a housekeeper verbally abused a resident with severe cognitive impairment. Both incidents were witnessed by staff, highlighting the facility's failure to protect residents from abuse as per their policy.
A resident at high risk for skin breakdown did not receive documented daily skin assessments, contrary to facility policy. During wound care, a nurse used soiled gloves and unsanitized scissors to attempt sponge removal from a stage four wound, risking infection. The DON intervened with clean tweezers and noted significant wound deterioration, highlighting a need for staff education.
A resident fell while attempting to go to the bathroom due to a malfunctioning call light system. The resident reported that the call light was unreliable and not within reach, contributing to the fall. Observations confirmed the call light malfunction, and it was later replaced. The DON acknowledged the expectation for operational call lights at all times.
A facility failed to provide proper perineal and catheter care for a resident with an indwelling urinary catheter, leading to a deficiency. The CNA incorrectly cleaned the resident's catheter and neglected the front perineal area, despite the resident's high risk for UTIs. The resident had experienced multiple UTIs since admission, and the Wound Nurse confirmed the improper care and the need for re-education.
A facility failed to include a care plan for a resident with pressure ulcers. Initially noted as a superficial wound, a later assessment identified stage three pressure ulcers on both buttocks. Despite these findings, the resident's care plan lacked interventions for the ulcers. The DON acknowledged the omission.
A facility failed to properly manage pressure ulcers for three residents, resulting in severe health issues. One resident with a history of osteomyelitis and diabetes developed a maggot-infested ulcer due to inconsistent treatment and lack of notification to the wound nurse practitioner. Another resident's coccyx wound treatment was not consistently documented, and a third resident with multiple health issues was observed without necessary heel protectors, indicating systemic issues in wound care management.
The facility failed to prevent cross-contamination during pressure ulcer dressing changes for two residents. An LPN performed a dressing change for a resident with ESBL Resistance without proper hand drying due to a lack of supplies, while another staff member handled contaminated items without gloves. Additionally, an RN used gloved fingers instead of a clean swab to pack a wound for another resident, acknowledging the error. These actions indicate a breach in infection control protocols.
The facility failed to maintain sanitary conditions in its kitchen, risking cross-contamination and foodborne illness for 85 residents. A cook was observed without a beard cover, and the dishwasher area had wet, stacked glasses and dust. The can opener and plate warmer were rusted and dirty, violating the facility's cleaning standards.
The facility's assessment lacked essential documentation, including disease types, job structure, acuity, care competencies, cultural factors, and staff training, affecting the care of 85 residents. The Administrator confirmed the incomplete assessment.
Failure to Document Required Wound and Skin Assessments for Residents With Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to complete and document required wound and skin assessments for two residents with pressure ulcers and impaired skin integrity. One resident had a care plan identifying high risk for pressure ulcers and multiple existing pressure ulcers on the sacrum, ischial areas, heels, ankle, gluteal folds, and foot, with instructions for weekly licensed nurse assessments and daily monitoring for infection and physician notification if wounds were not healing. Treatment Administration Records for this resident showed missing documentation for ordered daily foot checks and daily skin checks on multiple dates, and when edema and open areas were documented, there were no corresponding progress notes describing edema, open areas, treatment, or physician notification. Skin Observation Tools listed multiple pressure areas and other skin issues but lacked wound measurements or descriptive details. Wound clinic notes on two separate visits contained detailed measurements and descriptions, including staging, presence of fibrin, exposed bone, and tunneling, but these details were not mirrored by facility nursing documentation. During observed wound care, multiple wounds were measured and described, but the report does not show that such assessments were routinely documented by facility staff. The second resident had an undated care plan for impaired skin integrity and risk for injury related to dementia, with physician orders for wound care to the left lateral ankle, daily foot exams, weekly skin checks, and preventive measures for coccyx skin breakdown. A physician wound visit documented a left lateral ankle wound with specific measurements, moderate exudate, and erythema, but the electronic medical record contained no nursing skin assessments. An observed dressing change showed the wound was closed and the resident denied pain or issues at the site, yet there was still no documented nursing assessment in the record. The DON stated that staff do not write individualized wound documentation and instead only upload wound clinic notes, and acknowledged that nurses were not documenting on wounds as required. These practices were inconsistent with the facility’s Pressure/Skin Breakdown-Clinical Protocol, which requires nurses to assess and document a full skin assessment including location, stage, dimensions, exudate, necrotic tissue, signs of infection, and impact of comorbid conditions on wound healing.
Failure to Provide Adequate Supervision and Lighting Resulting in Resident Fall and Injury
Penalty
Summary
The facility failed to ensure sufficient lighting in a resident's bedroom and did not provide adequate supervision for a resident with dementia who was known to be restless and at high risk for falls. The resident had a documented history of falls, severe cognitive impairment, and behavioral disturbances, including agitation and restlessness. The care plan included interventions such as walking with the resident when restless and providing adequate lighting, but these were not consistently implemented. On the night of the incident, the resident was observed to be agitated and repeatedly attempting to stand and walk independently. Staff had previously walked with the resident using a walker and gait belt, but later put the resident to bed with the bedroom lights off. The resident was left unsupervised, and staff did not continue frequent safety checks, despite the resident's high fall risk and recent history of falls. The resident was later found on the floor in the dark room, with injuries including a hematoma to the head and multiple skin tears, and was entangled in television cords. Interviews with staff revealed that the decision to put the resident to bed was made despite ongoing restlessness, and that agency staff felt their input regarding the resident's care would not be well received. The facility's own policy required individualized fall prevention interventions and ongoing monitoring, but these were not adequately followed. The resident ultimately died from complications related to the unwitnessed fall, as confirmed by the county coroner.
Failure to Monitor and Document Bowel Movements Leads to Unaddressed Constipation
Penalty
Summary
The facility failed to ensure consistent monitoring and documentation of bowel movements for a resident with a diagnosis of constipation, hemiplegia, hemiparesis, unspecified muscle disorder, and difficulty walking. The resident had an active physician order for ferrous sulfate and was being monitored for bowel management. Review of the Bowel Movement Task Sheet over several days showed multiple entries of 'none' or 'not applicable,' with no bowel movements documented on several consecutive days. There were also no nursing progress notes indicating that a bowel assessment was completed on a day when the resident reported abdominal pain. The resident reported to a CNA that he was experiencing stomach pain and requested that the LPN be notified early in the morning, but the LPN did not enter the room until later. Interviews with the Medical Director and Regional Nurse Consultant confirmed that staff are expected to notify the physician if a resident has no bowel movement for three days and to assess residents who report symptoms of constipation. The facility's Bowel Management Program requires prompt documentation by CNAs and daily review by nursing staff, but these procedures were not followed, resulting in unaddressed constipation for the resident.
Delay in Honoring Resident's Request for Emergency Room Transfer
Penalty
Summary
A resident with a diagnosis of constipation reported experiencing stomach pain and repeatedly requested to be sent to the emergency room, beginning early in the morning. The resident informed a CNA multiple times to notify the nurse, but the LPN did not enter the resident's room until approximately two hours later. Upon being seen, the resident again requested to go to the hospital, but the nurse explained that a physician's order was required and that obtaining it could take time. The resident was not transferred to the emergency room until later that afternoon, several hours after the initial request. The facility's own statement of resident rights affirms that residents have the right to exercise their rights, including the right to prompt medical attention, and the medical director confirmed that residents requesting transfer to the emergency room should be sent and the physician notified afterward.
Failure to Prevent Resident Wandering and Inadequate Supervision Resulting in Resident Harm
Penalty
Summary
The facility failed to develop and implement effective interventions and provide adequate supervision to prevent a resident with dementia and behavioral disturbances from wandering into other residents' rooms, invading their privacy, disturbing their environment, taking assistive devices, and making inappropriate comments. Despite documentation of the resident's history of physical aggression, resistance to care, and impulsivity, the care plan interventions such as 10- or 15-minute checks were inconsistently documented or not performed as required. The resident was observed to have frequent behaviors, including entering other residents' rooms without permission, and staff interviews confirmed that supervision was lacking, especially during night shifts. Multiple residents reported distressing encounters with the wandering resident, including incidents where assistive devices such as walkers were taken, resulting in falls and injuries. One resident, who was independent with ambulation using a walker and had multiple medical diagnoses including heart disease and osteoporosis, suffered two unwitnessed falls after her walker was moved out of reach by the wandering resident. These falls resulted in a laceration to the knee requiring sutures, a laceration to the hand, and a hematoma to the scalp. The affected resident expressed fear and distress due to repeated intrusions and threats from the wandering resident, and reported that her concerns were not believed by staff or her family. Other residents also reported frequent and distressing intrusions into their rooms, including being awakened at night, having personal belongings taken, and experiencing threats or attempted physical aggression. Staff interviews corroborated that the resident with dementia was not adequately supervised, particularly during evening and night shifts, and that interventions such as doorway sensors and increased checks were either not implemented or not consistently followed. Documentation gaps and lack of effective supervision contributed to ongoing incidents affecting the safety and well-being of multiple residents.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by another resident, resulting in an incident where one resident with dementia and a history of aggressive behavior physically grabbed and struck another resident. The incident occurred while residents were waiting in line to go outside to smoke, when the resident with dementia approached from behind and grabbed the other resident's shoulder, causing the latter to yell and express fear. Witnesses confirmed the aggressive behavior, and it was noted that this was not the first time the resident had exhibited such conduct toward others, including attempts to hit and invade personal space of multiple residents. The resident who committed the abuse had a documented history of dementia, behavioral disturbances, and post-traumatic stress disorder, with care plans indicating episodes of physical aggression and resistance to care. Interventions such as increased supervision and 10-minute checks had been implemented previously due to these behaviors. Staff interviews revealed ongoing concerns about the resident's confusion, anger, and tendency to enter other residents' rooms, as well as difficulties in redirecting the resident and managing their impulsivity and poor safety awareness. Despite these known risks and behavioral patterns, the facility did not consistently implement or update all interventions in the care plan, such as the use of a doorway sensor, and staff reported challenges in maintaining adequate supervision. The failure to prevent the incident resulted in a resident experiencing physical abuse and fear, with staff and other residents acknowledging ongoing issues with the aggressive resident's behavior.
Failure to Provide Adequate Supervision for High-Risk Resident Resulting in Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident diagnosed with Lewy Body Dementia, resulting in a fall and acute left hip fracture. The resident had a documented history of severe cognitive impairment, wandering, and previous falls, and was identified as high risk for both falls and elopement. The care plan specified the need for frequent monitoring, with staff and policy indicating that high-risk residents should be checked every 15 minutes. However, on the day of the incident, documentation showed the resident was last repositioned at 8:22 AM, with the fall occurring at 3:50 PM, and there was no evidence of the required frequent checks being performed or documented. Interviews with staff confirmed that the resident frequently got up without assistance and that the expectation was for high-risk residents to be checked every 15 minutes. Despite this, staff were unable to provide documentation that these checks occurred as required. The resident was found by a CNA after losing balance and falling, and subsequent medical evaluation confirmed a left hip fracture. The facility's failure to implement and document the required supervision and monitoring directly led to the resident's fall and injury.
Delayed Diagnostic Imaging and Result Follow-Up After Fall
Penalty
Summary
The facility failed to promptly schedule and obtain results for a physician-ordered MRI of a resident's right hip following a witnessed fall during an assisted shower. The resident, who had severe cognitive impairment and multiple comorbidities including dementia, hemiplegia, and was on blood thinners, experienced a fall and was initially sent to the emergency department (ED) for evaluation. The ED performed CT scans of the head and spine, but no imaging of the right hip was conducted at that time. Upon return to the facility, the resident began to complain of right hip and shoulder pain, refused to get out of bed due to pain, and required increased administration of narcotic pain medication. Subsequent evaluation at the ED included X-rays of the right hip and shoulder, which were reported as showing no acute fracture or dislocation, but the hip X-ray was noted to be improperly positioned, potentially limiting diagnostic accuracy. Despite ongoing severe pain and a recommendation to consider a non-contrasted CT scan if symptoms persisted, there was no documentation that further imaging was pursued until the resident's family requested an MRI nearly two weeks later. The MRI was ordered and scheduled eleven days after the order, and when finally performed, revealed an acute, impacted subcapital hip fracture with lateral displacement and extensive soft tissue edema. There was an additional delay in obtaining and acting upon the MRI results, with the facility not receiving the finalized report until approximately 36 hours after the MRI was completed. The resident was then transferred to the hospital for surgical intervention. Throughout this period, the resident experienced continued severe pain and immobility, as evidenced by increased use of narcotic pain medication and family observations of the resident's inability to move her leg. The delay in both scheduling the MRI and obtaining the results directly contributed to the delay in diagnosis and surgical repair of the hip fracture.
Failure to Prevent Accidents Due to Unsafe Environment and Equipment
Penalty
Summary
The facility failed to provide a safe environment and adequate supervision to prevent accidents for two residents with dementia and high fall risk. In the first instance, a resident with moderately impaired cognition, a history of wandering, and high risk for falls and elopement was left unsupervised when a normally secured bathroom door was left ajar and unlatched. The resident accessed the bathroom independently, resulting in an unwitnessed fall that caused a large hematoma, rib fracture with a partially collapsed lung, and two brain bleeds, requiring emergency hospitalization and trauma surgery. Staff interviews revealed that the bathroom door had a malfunctioning keypad lock and was routinely left open due to difficulty in operation, and maintenance requests for repair were either not submitted or not acted upon in a timely manner. In the second instance, another resident with severe cognitive impairment, hemiplegia, and multiple comorbidities experienced a fall during an assisted shower. The fall occurred when the wheel of a small, white shower chair became stuck on a floor drain, causing the chair to tip and the resident to fall, resulting in a hip fracture that required surgical repair. Staff and maintenance interviews confirmed that the shower chair was old, had worn and malfunctioning wheels, and was known among staff to be unsafe. Despite this, the chair remained in use, and only partial repairs were made after the incident. The resident continued to experience severe pain for weeks following the fall, and diagnostic imaging confirming the fracture was delayed. Both incidents demonstrate a failure to identify and address environmental hazards and to ensure that equipment used for resident care was maintained in safe, operable condition. The facility's own policies required the environment to be free from hazards and for appropriate supervision to be provided, but these were not followed, resulting in significant injuries to both residents.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident who experienced a fall and subsequently required medical attention. The resident underwent an MRI at a local hospital, which revealed an acute, impacted subcapital hip fracture with lateral displacement and extensive soft tissue edema. However, there was no documentation in the resident's medical record indicating the departure from or return to the facility for the MRI. Additionally, there was a gap in documentation between a nurse practitioner's note and a later transfer note, with no record of the MRI event or related care during that period. Further review of the resident's records revealed discrepancies in the administration and documentation of Tramadol, a narcotic analgesic. The narcotic count sheet indicated that several doses were removed from the supply on specific dates, but these administrations were not recorded on the Medication Administration Record (MAR). Pain assessments, as ordered to be completed every shift using a 1-10 scale, were also not properly documented, with nurses signing off on completion but failing to record the actual pain scores. The Director of Nursing confirmed these documentation failures after reviewing the records and speaking with the involved nurses.
Lack of Full-Time Director of Nursing
Penalty
Summary
The facility failed to provide a full-time Director of Nursing (DON) to oversee and coordinate nursing services. During the survey conducted from 8/19/25 through 8/22/25, it was observed that there was no DON present in the building. The Administrator/Abuse Prevention Coordinator confirmed that the previous DON's last day was 8/15/25 and that no Registered Nurse had been hired for the DON position, nor was there an Acting DON in place to provide oversight of nursing services. At the time of the survey, the facility's resident roster documented 83 residents residing in the facility.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one of nine residents reviewed for abuse or injury of unknown origin. Multiple physician notes for this resident, signed by the Medical Director, documented the presence of bruises on the left cheek and left lower rib cage across several assessment dates. Upon review, the Medical Director acknowledged that these entries were inaccurate, as the resident had experienced bruising only following a fall in a previous month and did not have bruising on the dates documented. The Medical Director confirmed these were documentation errors, resulting in inaccurate medical records for the resident.
Failure to Notify POAs of Abuse Allegations
Penalty
Summary
The facility failed to properly notify family representatives or Powers of Attorney (POA) regarding allegations of physical abuse involving five residents. In several documented incidents, the facility's records indicated that POAs were notified as per policy, but interviews with the POAs and family members revealed that they were either not informed at all or were not given accurate or complete information about the nature of the incidents. For example, in one case, a POA was told that two residents were arguing, with no mention of physical contact, despite documentation of a physical altercation. In other cases, POAs stated they were unaware of any calls from the facility regarding abuse allegations, and only learned of the incidents from the residents themselves. Additionally, in an incident where a resident was handled roughly by staff resulting in a bruise, the POA was only informed about the presence of a bruise with no explanation of the alleged rough handling or abuse. The facility's abuse prevention policy requires immediate and accurate notification to POAs, physicians, and authorities, but the documentation and interviews indicate a pattern of incomplete or absent communication. The administrator acknowledged that nurses are responsible for accurate documentation and timely notification, but the evidence shows this was not consistently done.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Notify Ombudsman of Abuse Allegations
Penalty
Summary
The facility failed to operationalize its abuse prevention policy by not notifying the Ombudsman of multiple abuse allegations, despite documentation indicating that such notifications had occurred. Specifically, investigation reports for several incidents of resident-to-resident physical abuse and an incident involving a nursing staff member causing a bruise to a resident's arm all stated that the Ombudsman was notified, as required by the facility's policy. These reports were documented by the Administrator/Abuse Prevention Coordinator. However, during an interview, the Ombudsman confirmed that he had not been notified of any of the abuse allegations listed in the reports. The Ombudsman reviewed his records, including notes, emails, and phone calls, and found no evidence of notification from the facility. He also stated that he was present in the facility during the relevant period and was not informed in person about any of the incidents. The facility's abuse policy requires immediate reporting of all abuse allegations to the Administrator and timely notification to authorities, including the Ombudsman, but this procedure was not followed.
Failure to Report Abuse Allegations to Police and Physician
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or injuries of unknown origin to the local police department and the physician as required by its own abuse prevention policy. Specifically, five residents were involved in incidents of resident-to-resident physical abuse, staff-to-resident physical abuse, and injuries of unknown origin. Although facility documentation indicated that the police and physician were notified for each incident, interviews with the local police department and the facility's medical director revealed that neither party had any record or knowledge of these reports. The administrator responsible for abuse prevention admitted to not having proof of contacting the police and relied on nursing staff documentation for physician and family notifications, which could not be substantiated. The incidents included one resident smacking another's face, another swatting a resident's back, a resident grabbing another's wrist, and a staff member allegedly handling a resident roughly, resulting in a bruise. Despite the facility's policy requiring immediate reporting to authorities, the lack of verifiable communication with the police and physician was confirmed through interviews and record reviews. The administrator acknowledged the absence of documentation to support that proper notifications were made, and the medical director confirmed that neither he nor the on-call physicians were informed of the abuse allegations.
Failure to Interview Key Witnesses During Abuse Investigations
Penalty
Summary
The facility failed to conduct thorough investigations into multiple alleged abuse incidents by not interviewing families who frequently visit the facility or other residents who may have had knowledge of the alleged events. Specifically, in several cases involving resident-to-resident physical abuse and an incident where a resident reported being handled roughly by unidentified nursing staff, the facility determined the allegations to be unfounded without seeking input from potential witnesses such as family members or other residents. The administrator confirmed that these investigations were considered complete despite not including these interviews. The facility's own abuse policy requires that investigations include interviews with residents, staff, visitors, and vendors, but this was not followed in the reviewed cases.
Failure to Timely Review and Revise Care Plans After Resident-to-Resident Abuse
Penalty
Summary
The facility failed to timely review and revise care plans for four of nine residents following incidents of resident-to-resident physical abuse. Multiple abuse investigation reports documented physical altercations between residents, such as one resident smacking another's face, swatting another's back, and grabbing a wrist. Although the investigation reports indicated that the involved residents' care plans were reviewed or revised, the actual care plans did not reflect timely updates or new interventions related to the abuse incidents. For example, care plans for residents with histories of dementia, psychiatric diagnoses, and aggressive behaviors were not updated to address the specific abuse events as required. Record review and staff interviews confirmed that the care plans for the involved residents had not been updated as they should have been after each abuse allegation. The facility's own abuse policy requires prompt investigation and necessary changes to prevent future occurrences, but documentation showed that care plans remained unchanged or were not revised in a timely manner following the incidents. The lack of timely care plan review and revision was acknowledged by facility leadership during the survey.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required by regulations.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping relevant parties informed about significant events impacting the resident's care or condition.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to timely report an Injury of Unknown Origin for one resident who was severely cognitively impaired and required significant assistance with daily activities. The resident, who had multiple medical diagnoses including dementia, diabetes, and heart failure, was found to have a large, dark purple bruise on the left lower abdomen. The bruise was first observed by a CNA during the early morning hours and was immediately reported to an LPN, who then informed the Director of Nursing (DON). The DON was notified of the injury the same morning, and the administrator was also informed. Despite the immediate internal reporting, the facility did not submit the required initial report to the State Agency until four days after the injury was discovered. The facility's policy requires that such incidents, especially those classified as Injuries of Unknown Origin, be reported to the State Agency immediately after assessment. Interviews with staff and review of records confirmed that the injury met the criteria for immediate reporting, but this was not done in accordance with policy.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation into an injury of unknown origin for a resident with multiple medical diagnoses, including severe cognitive impairment, diabetes, and heart failure. The resident was found to have a large, dark purple bruise on the left lower abdomen, which was not present during a prior skin assessment and was first observed by a CNA, who reported it to an LPN. The bruise was subsequently reported to the DON and the physician, but the resident was unable to explain the cause of the injury, and no fall or other incident was noted. Documentation showed that insulin had been administered in the same area, but this information, along with shower sheets and daily skin assessments, was not reviewed as part of the investigation. Interviews with staff confirmed that the investigation did not adequately consider all relevant information or rule out abuse as a possible cause of the injury. The DON acknowledged that the investigation was incomplete, and the administrator confirmed that important records were not reviewed to determine the etiology of the bruise. The facility's abuse policy defines injuries of unknown source and outlines the need for thorough investigation, which was not followed in this case.
Failure to Provide Adequate Supervision and Safe Equipment During Shower Resulting in Resident Fall
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including a history of falls, diabetes with polyneuropathy, and a left artificial hip joint, was not provided adequate assistance and safe equipment during a shower, resulting in a fall. The resident was assessed as high risk for falls and required partial to moderate assistance with bathing, meaning staff should provide less than half the effort but still assist with lifting, holding, or supporting as needed. During the incident, the resident was left unattended while the CNA retrieved a towel, and the shower chair's wheels were not locked, causing the chair to move on the sloped, wet floor. The resident reported that the shower chair wobbled due to the uneven floor and that the brakes were not engaged, which allowed the chair to move abruptly when the resident attempted to stand. The CNA was not within arm's reach at the time, and the resident fell forward, landing on the same hip previously fractured before admission. The resident experienced pain and bruising following the fall, and later required an X-ray to rule out a new fracture. The resident also described previous falls, including one at home and others in the facility, but specifically noted that this shower fall was due to equipment instability and lack of staff assistance at the critical moment. Observations and interviews with other staff and residents confirmed that the shower chair was unstable even when locked, and that not all CNAs consistently locked the wheels or provided direct assistance during transfers. The shower room's design, with a sloped floor and a lightweight, wheeled shower chair, contributed to the hazard. Staff acknowledged the potential for falls under these conditions and indicated that locking the chair and providing hands-on assistance were not always standard practice.
Failure to Maintain Complete and Accurate Medical Record After Resident Fall
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident following a fall in the shower room. The resident, who had no cognitive impairment and was assessed as high risk for falls, experienced a fall during a transfer in the shower room. The fall was documented in the facility's fall incident log and a fall investigation report, but there was no corresponding documentation in the resident's medical record. The care plan was not updated with an intervention for the fall until more than two months later, during the survey. The resident confirmed the fall and described circumstances that differed from the staff account, including the staff member's distance at the time of the incident and the condition of the shower area. Interviews with facility staff, including the DON and Regional Director of Operations, confirmed the absence of required documentation in the resident's chart, such as the initial incident report and follow-up nursing assessments. The facility's own policy requires immediate investigation, documentation, and follow-up charting for 72 hours after an incident, as well as timely updates to the care plan. These procedures were not followed, resulting in incomplete and inaccurate medical records for the resident after the fall.
Failure to Notify Physician of Wound Changes Resulting in Delayed Treatment
Penalty
Summary
Facility staff failed to notify a resident's physician of significant changes in a vascular wound, specifically increased redness, swelling, and pain in the resident's right second toe. The resident had a history of atherosclerotic heart disease, diabetes mellitus type II, dementia, and local skin infections, and had physician orders for daily foot checks with instructions to notify the physician of any changes. On the day the wound changes were observed, the LPN notified the facility wound nurse, but the physician was not contacted as required by policy and physician orders. The wound nurse acknowledged being informed of the changes but did not notify the physician, mistakenly planning to do so later and forgetting that the wound was under the care of a vascular wound physician. As a result, no treatment for potential infection was initiated until the resident's next scheduled wound clinic appointment four days later, at which point the wound was diagnosed as cellulitis and antibiotics were ordered. The delay in physician notification and treatment resulted in a delay in addressing the wound infection.
Failure to Complete Weekly Pressure Wound Assessments
Penalty
Summary
The facility failed to complete weekly pressure wound assessments and measurements for one resident who was being treated for pressure wounds on the buttocks. According to the facility's Pressure Ulcer policy, weekly documentation and assessment of pressure ulcers are required until the wound is healed, including details such as wound characteristics, treatment, and progress. The resident, who had diagnoses including atherosclerotic heart disease, diabetes mellitus type II, dementia, and local skin infections, continued to receive daily wound treatments after the wounds were initially deemed healed. However, there was no documentation of weekly wound assessments for the pressure wounds after they were considered healed, despite ongoing treatment. The wound nurse confirmed she was not informed that the wound had reopened and, as a result, had not performed weekly assessments for the past four weeks.
Failure to Notify Physician of Wound Infection Signs
Penalty
Summary
The facility failed to notify a resident's physician of signs of a wound infection, as required by policy. A resident with diagnoses including atherosclerotic heart disease, diabetes mellitus type II, dementia, and local skin infections had an order for daily foot checks and physician notification of any changes. On one occasion, an LPN observed that the resident's right second toe was swollen, red, and painful to touch, and reported these changes to the facility wound nurse. However, the wound nurse did not notify the resident's physician or wound care physician about the change. The wound nurse acknowledged being informed of the wound changes but did not contact the physician, intending to do so later but ultimately forgetting. As a result, no treatment for a potential infection was initiated until the resident's next scheduled wound clinic appointment, at which time an antibiotic was ordered for cellulitis. The lack of timely physician notification delayed the initiation of appropriate treatment for the resident's wound infection.
Failure to Follow Bedbug Prevention Policy
Penalty
Summary
The facility failed to follow its bedbug prevention and management policy, which requires that if evidence of bedbugs is found, a specimen should be collected and the pest control company notified. Documentation showed that 82 residents resided in the facility at the time. A Terminex inspection report confirmed treatment for bedbugs in one room, but staff interviews revealed that a bedbug had recently been seen in another room and was reported to the Assistant Director of Nursing. A CNA was aware of bedbugs being found in two residents' room but did not believe the room had been treated. The Maintenance Director stated that if only one bedbug is found, the facility does not spend the money to spray the room. The Terminex representative confirmed that he only treats rooms when notified by the facility and emphasized the importance of being called even if only one bedbug is found, as this could lead to an outbreak. There was no evidence that the pest control company was notified or that treatment occurred in the room where the bedbug was recently seen.
Unsafe and Unhomelike Shower Room Environment Due to Damaged Flooring
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for 28 residents, as evidenced by the poor condition of the south shower hall ante-room floor. The floor was observed to be sloping, mushy, and unstable, creating a risk of falling or sliding, and the transition piece between the old and new flooring was not attached, presenting a trip hazard. Staff, including a Certified Nursing Assistant, were observed using the shower room for resident care despite these hazards. The Maintenance Director acknowledged the unsafe and unhomelike condition of the floor and stated he was unaware of the extent of the problem prior to the observation. The Director of Nursing confirmed that the affected shower is used by multiple residents. The facility's job description for the Maintenance Director specifies responsibility for maintaining a safe and comfortable environment.
Failure to Prevent Resident-to-Resident Physical Abuse in Dementia Unit
Penalty
Summary
The facility failed to protect two residents from physical abuse, as evidenced by documented altercations between residents in the dementia unit. One resident was involved in two separate incidents: in the first, the resident took another resident's walker, requiring staff intervention; in the second, the same resident purposefully shoved another resident after a dispute involving a walker. Staff interviews confirmed that the resident has a history of aggression toward others and requires close supervision. Facility staff, including the Administrator and Assistant Director of Nursing, acknowledged that the dementia unit was understaffed at the time of the incidents and lacked a dementia unit coordinator.
Unsecured Morphine Leads to Resident Overdose
Penalty
Summary
The facility failed to store a Schedule II Controlled medication, Morphine Sulfate, in a locked location, leaving it on top of a medication cart in plain view and unsupervised on a dementia care unit. This oversight allowed a resident, who had a history of wandering and drinking from unattended containers, to access the medication. The resident was found with the bottle of Morphine up to their lips, and upon retrieval, the bottle was empty. This incident led to the resident becoming unresponsive with a decreased respiration rate, necessitating the administration of Narcan and emergency transport to the hospital. The resident involved had a medical history that included dementia with psychotic disturbance, major depressive disorder, and other conduct disorders. The resident was known to wander the facility and had previously ingested non-food substances, such as fingernail polish remover, which required emergency intervention. On the day of the incident, the resident was observed wandering near the nurses' station where the medication cart was located, and later found with the Morphine bottle. The incident occurred when a Licensed Practical Nurse inadvertently left the Morphine bottle on the medication cart after administering a dose to another resident. The nurse placed the bottle in a biohazard bag on top of the cart and left the unit. The resident accessed the bottle during this time, leading to the overdose. The facility's investigation confirmed that the Morphine was not spilled, as no evidence of the liquid was found on the resident or in the surrounding area, indicating that the resident ingested the entire contents of the bottle.
Removal Plan
- R1 was evaluated and sent to the Local emergency room for evaluation. When EMS personnel arrived, they attempted to administer Narcan to R1 prior to transferring R1 to the local emergency room.
- V4, Licensed Practical Nurse, was suspended pending a comprehensive investigation of the incident.
- Upon Return to the facility, R1 was placed on 15-minute checks and increased assessment and monitoring with hourly vital signs/Level of Consciousness for eight hours and then every shift times two days.
- Upon Return to facility, R1 had a change in condition. V6, Registered Nurse, administered Narcan to R1, called 911, and sent R1 back to the Local emergency room for Evaluation.
- R1 returned from the hospital. Upon return to the facility, R1 was placed on 15-minute checks and increased assessment and monitoring with every 4 hour vital signs for 2 days.
- All licensed nursing staff were educated on Storage of Controlled Substances, Medication Administration, Accidents and Incidents, and Change of Condition Policies prior to their next scheduled shift either in person or via phone by V31 (former Director of Nursing), V2 (former Nurse and current Director of Nursing), (former Registered Nurse and current Director of Nursing), and V36 (Licensed Practical Nurse).
- V2 (former Registered Nurse and current Director of Nursing) contacted V37 (R1's Power of Attorney) for notification.
- V2 (former Registered Nurse and current Director of Nursing) contacted V12 (R1's Physician) for notification, V31 (former Director of Nursing), and the facility pharmacy provider for assistance with Medication Audits.
- V30 (Maintenance Director) completed a sweep of the Dementia Unit to ensure that all items that are liquid and hazardous products were locked up or put away out of reach.
- The Facility Corporate team (V32 Chief Nursing Officer, V33 Regional Clinical Consultant, V34 Chief Executive Officer, V35 Regional Director of Operations) reviewed and revised policies and procedures related to Medication Administration, Medication Storage, Accidents and Incidents, and Change of Condition.
- The Director of Nursing or designee will complete audits three times weekly for a period of 8 weeks in the following categories: Medication Administration Policy, Storage of controlled substances, Accidents and Incidents, and Change of Condition. Results of the above reviews will be discussed at a weekly quality assurance meeting for a period of 4 weeks and will provide additional education as needed and implement interventions for improvement until resolution.
Failure to Administer Insulin and Notify Physician
Penalty
Summary
The facility failed to administer a resident's physician-ordered insulin for eight days and did not notify the resident's physician of the medication error. The resident, who was moderately cognitively impaired, had a medical history including Diabetes Mellitus Type II, Dementia, and other conditions. The physician had ordered Levemir insulin to be administered every bedtime, but it was not given from January 21 to January 28 due to the medication not being available. During this period, the resident's blood glucose levels ranged from 166 to 562. The facility's Director of Nurses stated that the Levemir insulin was not administered because it was no longer manufactured, and the facility pharmacy had notified them on January 27. However, the physician was not informed until January 28, which delayed the change to Lantus insulin. The facility's policies require nursing staff to contact the prescriber when medication is unavailable and to document and report medication errors. The physician expressed that the facility should have notified him sooner to adjust the resident's diabetic management.
Failure to Follow Physician-Ordered Diets for Diabetic Residents
Penalty
Summary
The facility failed to adhere to physician-ordered diets for two residents, R4 and R9, both of whom have Diabetes Mellitus Type II. R4 was admitted with a hospital discharge instruction to receive a Diabetic diet, but due to a transcription error, the dietary department was instructed to serve a regular diet instead. This error persisted from R4's admission, as confirmed by the Certified Dietary Manager and the Director of Nurses, who acknowledged the incorrect entry of R4's diet order. Similarly, R9, who also has Diabetes Mellitus, was ordered a Consistent Carbohydrate diet with pureed texture and thin liquids. However, R9 was served a regular diet with a full portion of dessert, contrary to the physician's order, as observed by a Certified Nurse Aide and confirmed by an Agency Registered Nurse. The Regional Registered Dietician noted that the facility should have ensured the correct transcription of hospital discharge orders into the Electronic Medical Record (EMR) and communicated the correct diet to the dietary department. The Director of Nurses admitted that R4's diet order was entered incorrectly, and R9's diet was served incorrectly despite being transcribed correctly into the EMR. These failures in following physician-ordered diets could have led to adverse health outcomes for the residents, such as high blood sugar or hospitalization, as stated by the Regional Registered Dietician.
Failure to Report Change of Condition and Improper COVID-19 Testing
Penalty
Summary
The facility failed to report a resident's change of condition to the nurse before conducting a COVID-19 test and did not ensure that qualified staff performed the testing. A Certified Nursing Assistant (CNA) conducted a COVID-19 test on a resident, identified as R2, without notifying the nurse of the resident's change in condition. The CNA reported that the resident was not acting right and subsequently tested positive for COVID-19. However, the CNA did not inform the nurse about the resident's condition change, which is necessary for the nurse to assess the resident before any testing. The incident was documented in the nursing progress notes, where it was noted that the resident's temperature had increased from 98.2 to 101.4 degrees Fahrenheit. The Licensed Practical Nurse (LPN) and the interim Director of Nursing (DON) both confirmed that it is not within a CNA's scope of practice to conduct COVID-19 tests without first notifying a nurse. The facility's Acute Change of Condition Policy requires nursing assistants to communicate any changes in a resident's condition to the nurse, which was not followed in this case.
Resident Rights Violations and Inadequate Smoking Assistance
Penalty
Summary
The facility failed to protect a resident's right to be free from restricted access without clinical justification, affecting one resident out of three reviewed for seclusion. The resident, identified as R9, was cognitively intact and used a walker for ambulation. The facility's administrator restricted R9's movement within her own hallway due to a complaint from another resident's family member, which led to R9 expressing fear of being yelled at and threatened with a move to a locked Dementia unit. This restriction was enforced despite R9's medical history, which included conditions such as Cerebral Infarction, Alzheimer's Disease, and a recent hip replacement, necessitating mobility for recovery. The report also highlights the facility's failure to ensure that another resident, R6, was assisted to smoke breaks as required. R6, who was severely cognitively impaired and required supervision while smoking, was not consistently offered the opportunity to smoke at designated times. The facility's policy stated that residents had to reach the smoking area independently, which was not feasible for R6 due to his condition. As a result, R6 expressed frustration over not being able to smoke as frequently as allowed, which was an intervention for his behavioral issues. The facility's policies on resident rights and abuse were not adhered to, as evidenced by the actions of the administrator and the lack of staff support for R6's smoking needs. The administrator's actions towards R9 were described as mental abuse, involving threats and humiliation, while the lack of assistance for R6's smoking breaks demonstrated a failure to treat residents with dignity and respect. These deficiencies highlight significant lapses in the facility's adherence to resident rights and care standards.
Resident Subjected to Mental Abuse by Administrator
Penalty
Summary
The facility failed to protect a resident, identified as R9, from mental abuse by a staff member, V1, the Administrator. This incident involved V1 raising her voice and threatening R9 with a move back to the Dementia unit, which R9 found distressing and humiliating. The incident was witnessed by other staff members, including the Director of Nurses (V2) and the Social Service Director (V4), who confirmed that V1 raised her voice at R9, causing her to become visibly upset and cry. R9 expressed feelings of humiliation and fear, stating that she was yelled at for walking down her own hallway and was threatened with being moved back to a unit she disliked. R9, who has a history of cerebral infarction, Alzheimer's disease, and other medical conditions, was described as cognitively intact and using a walker for ambulation. The incident occurred after a complaint from another resident's family member about R9 walking past their room. Despite R9's explanation that she was merely admiring the room, V1's response was to confront R9 in a manner that was perceived as abusive by witnesses. R9 reported feeling humiliated and expressed a desire to avoid the hallway in the future to prevent further incidents. The facility's policy on abuse, which includes mental abuse such as humiliation and threats, was not adhered to in this situation. The Medical Director, V43, emphasized that staff should never raise their voices at residents and that verbal and mental abuse is a serious issue. The incident led to R9 withdrawing from activities she previously enjoyed, indicating a significant impact on her well-being. The report highlights a failure in the facility's responsibility to ensure residents are free from abuse and mistreatment.
Failure to Report Alleged Mental Abuse
Penalty
Summary
The facility failed to report an allegation of mental abuse involving a resident, identified as R9, by a staff member, V1, to the appropriate authorities in a timely manner. The incident occurred when V1, the Administrator, allegedly yelled at R9 in a conference room, causing visible distress to the resident. Despite witnessing the event, V4, the Social Service Director, did not report the incident, citing uncertainty about whom to report to since the Administrator was involved. V2, the Director of Nursing, also witnessed the incident but failed to report it, later acknowledging that the situation should have been reported immediately. R9, who has a medical history including cerebral infarction, Alzheimer's disease, and other conditions, was described as cognitively intact and ambulatory with a walker. The failure to report the incident was further compounded by the fact that neither the Medical Director nor the Ombudsman was informed of the allegation. This oversight in reporting violated the facility's abuse policy, which mandates immediate reporting of any abuse allegations to the State Agency, Ombudsman, Power of Attorney, and Physician.
Inadequate Incontinence Care and Hygiene Practices
Penalty
Summary
The facility failed to provide appropriate incontinence care for a resident, identified as R12, who was severely cognitively impaired and dependent on staff for various activities, including toileting and personal hygiene. On the day of the observation, R12 was left sitting in a wheelchair for an extended period without staff intervention, despite calling out for assistance. When incontinence care was finally provided, the resident's brief was found to be thoroughly saturated with urine and feces, and the absorbent material had broken apart. The resident's buttocks were dark red with lines from sitting on the saturated brief, indicating prolonged exposure. During the incontinence care procedure, the Certified Nursing Assistant (CNA) failed to change gloves or perform hand hygiene after handling contaminated items, such as reaching into a garbage can to retrieve a new garbage bag. This lack of proper hand hygiene and glove use during the procedure posed a risk of cross-contamination and potential infection. The CNA acknowledged the mistake, and the Director of Nurses confirmed that staff should change gloves and wash hands when contaminated during incontinence care. The facility's policy on hand hygiene was not followed, contributing to the deficiency.
Facility Fails to Maintain Safe Equipment for Residents
Penalty
Summary
The facility failed to maintain safe and functioning equipment, affecting two residents. One resident, who is cognitively intact and dependent on staff for transfers using a total body mechanical lift, experienced a malfunction during a transfer. The lift broke while the resident was suspended in the air, requiring the use of an emergency release knob to lower the resident onto the bed. Additionally, the resident's bed remote control was broken and sparking, posing a potential fire hazard, especially concerning given the resident's use of oxygen. The maintenance team took weeks to replace the remote due to difficulties in finding a compatible replacement. Another resident, who is severely cognitively impaired and dependent on staff for various activities, had a siderail stuck in the up position since August. This issue was not reported to the facility administrator until December, despite the resident's spouse and staff being aware of the problem. The stuck siderail complicated the resident's transfer to the hospital and posed a risk of injury, as the resident attempted to use it to get out of bed independently. The facility's failure to address these equipment issues in a timely manner contributed to the deficiencies noted in the report.
Failure to Provide Privacy During Incontinence Care
Penalty
Summary
The facility failed to provide privacy for a resident, identified as R5, during incontinence care. R5, who has severe cognitive impairment and multiple medical diagnoses including hemiplegia, Parkinson's disease, and vascular dementia, was assisted by a CNA, V8, to the toilet. During this process, V8 did not close the bathroom or room door, nor did they pull the privacy curtain, leaving R5 exposed from the waist to ankles. This lack of privacy was observed by another resident, R14, who walked by and looked into the bathroom, and by another CNA, V12, who entered the room unannounced and stood outside the bathroom watching the procedure. V8 also failed to change gloves during the entire procedure. The Director of Nursing, V2, confirmed that staff should always provide privacy during perineal care and acknowledged that V8 should have closed the doors and changed gloves. V2 also noted that V12 should not have entered the room unannounced. The incident was described as embarrassing and contrary to the basic principles of CNA care, which emphasize the importance of privacy.
Failure to Honor Residents' Right to Refuse Electronic Monitoring Devices
Penalty
Summary
The facility failed to honor the rights of two residents, identified as R11 and R16, to refuse treatment, specifically the use of electronic monitoring devices. R11, who is cognitively intact and his own responsible party, expressed a desire to have the electronic monitoring device removed, stating that it made him feel imprisoned and restricted his freedom to go outside. Despite his request, the device was not removed, and staff continued to check its placement as per physician orders. R11's medical history includes conditions such as Hemiplegia, Diabetes Mellitus Type II, and Vascular Dementia, but he is noted to be independent in certain activities and requires only moderate assistance in others. Similarly, R16, also cognitively intact and his own responsible party, repeatedly removed the electronic monitoring device, expressing frustration and feeling treated like an animal. The facility's records did not document a Physical Restraint Assessment or consent for the use of the device on R16. Both residents were described as alert, oriented, and ambulatory, and the facility's Regional Clinical Nurse acknowledged that there was no reason for them to wear such devices, as the facility only had one door with the electronic monitoring system. The devices were eventually removed after the residents' complaints were acknowledged.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal and physical abuse by another resident and failed to protect another resident's right to be free from verbal abuse by a staff member. In the first incident, a resident with severe cognitive impairment and a diagnosis of dementia with agitation grabbed another resident's arm and used abusive language. This incident occurred in the smoking tent, where the aggressor resident was known to be verbally aggressive and disruptive. The affected resident, who is cognitively intact but has impaired range of motion due to a stroke, reported feeling abused and considered retaliating physically. In the second incident, a housekeeper verbally abused a resident with severe cognitive impairment and unspecified dementia with agitation. The housekeeper was overheard by multiple staff members telling the resident to "shut up" in a loud and hateful manner. The resident did not remember the incident, but the verbal abuse was witnessed by several staff members, leading to the immediate separation of the housekeeper from the resident. Both incidents highlight the facility's failure to protect residents from abuse, as outlined in their abuse policy. The policy affirms residents' rights to be free from physical and verbal abuse, yet these incidents demonstrate a breach of that policy, affecting the well-being of the residents involved.
Failure in Pressure Ulcer Care and Assessment
Penalty
Summary
The facility failed to adhere to its Pressure Ulcer Policy, which mandates daily skin assessments for residents at high risk for skin breakdown. A resident, identified as being at high risk, did not have documented daily skin assessments in their October medical record. Additionally, the facility's policy requires notifying a physician when a pressure ulcer develops or deteriorates, but there is no indication in the report that this protocol was followed. During a wound care procedure, the Wound Nurse attempted to remove a sponge from the resident's stage four tunneling wound using soiled gloves and unsanitized scissors, which was unsuccessful. The Director of Nursing (DON) intervened and used clean tweezers to remove the sponge, noting significant deterioration in the wound since the last observation. The DON acknowledged that using fingers or unsanitized tools in a wound could lead to infection or further damage, indicating a need for staff education.
Deficient Call Light System Leads to Resident Fall
Penalty
Summary
The facility failed to ensure a working call light system for a resident, leading to a fall incident. The resident, identified as R5, experienced a fall while attempting to go to the bathroom due to a non-functional call light. The incident report noted that the root cause of the fall was attributed to the resident's impulsivity, drowsiness, and gait imbalance. Despite being reminded to use the call light and a urinal, the resident reported that the call light was unreliable and not within reach, which contributed to the fall. Observations confirmed that the call light was malfunctioning, as it only lit up once out of three attempts. It was later replaced with a different button, which functioned correctly. The Maintenance Assistant confirmed the call light was replaced after the incident, and the Director of Nursing acknowledged the expectation for call lights to be operational at all times, expressing uncertainty as to why the issue was not addressed sooner.
Improper Perineal and Catheter Care Leads to Deficiency
Penalty
Summary
The facility failed to provide proper hygienic perineal and catheter care for a resident with an indwelling urinary catheter, which is crucial to prevent urinary tract infections (UTIs). The facility's Perineal Care Procedure and Indwelling Catheter Care policy outline the correct method for cleaning, which includes washing from front to back and ensuring the catheter is cleaned from the urethra down the tubing. However, during an observation, a Certified Nursing Assistant (CNA) began cleaning the resident's rectal area first and cleaned the catheter incorrectly by moving from the bottom toward the body. The CNA admitted to not cleaning the front perineal area, citing difficulty in reaching it and a routine of only cleaning the backside. The resident involved in this deficiency has a high risk for UTIs due to the presence of an indwelling urinary catheter and a stage four wound on the sacrum. The resident's care plan highlights this risk, and the progress notes document three UTIs since admission, each requiring antibiotic treatment. Despite previous education on proper cleaning techniques, the facility staff reverted to incorrect practices, as confirmed by the Wound Nurse, who acknowledged the improper care and the need for re-education.
Failure to Develop Pressure Ulcer Care Plan
Penalty
Summary
The facility failed to develop a care plan for a resident with pressure ulcers, as identified during a survey. The resident had an open area on the left buttock documented in a nursing note, initially described as superficial. A subsequent wound assessment by a nurse practitioner revealed stage three pressure ulcers on both buttocks and moisture-associated skin damage. Despite these findings, the resident's care plan, which had been in place since April, did not include any interventions or strategies to address the pressure ulcers. The Director of Nursing acknowledged that the care plan should have included measures to heal the pressure ulcers.
Failure in Pressure Ulcer Management Leads to Severe Health Issues
Penalty
Summary
The facility failed to adequately monitor and treat pressure ulcers for three residents, leading to significant health issues. Resident 1, who had a history of osteomyelitis and diabetes, developed a pressure ulcer on the right heel that was not properly managed. Despite having a care plan that included daily skin checks and off-loading of the ulcer site, the treatment orders were not consistently followed. The wound deteriorated, resulting in a maggot infestation and hospitalization for osteomyelitis and sepsis. Staff failed to notify the wound nurse practitioner of the strong odor and drainage, which were clear signs of infection. Resident 2, diagnosed with diabetes and severe morbid obesity, had a coccyx wound that required specific treatment. However, the treatment was not documented as completed on several occasions, indicating a lack of adherence to the prescribed care plan. This oversight in treatment documentation suggests a failure in ensuring consistent wound care, which could potentially lead to worsening of the resident's condition. Resident 3, with multiple health issues including severe protein-calorie malnutrition and a stage 4 sacral pressure ulcer, also experienced lapses in care. The treatment for the sacral and heel wounds was not consistently signed off as completed, and the resident was observed without necessary heel protectors, contrary to the care plan. This lack of proper wound care and preventive measures highlights a systemic issue in the facility's ability to manage pressure ulcers effectively.
Infection Control Deficiencies in Wound Care Procedures
Penalty
Summary
The facility failed to prevent potential cross-contamination during pressure ulcer dressing changes for two residents, R2 and R3, and did not complete effective handwashing in a contact isolation room. For R2, who had diagnoses including Type 2 Diabetes Mellitus, Severe Morbid Obesity, and Extended Spectrum Beta Lactamase (ESBL) Resistance, the dressing change was performed by V5, a Licensed Practical Nurse, who repeatedly washed her hands without access to paper towels or cloth towels to dry them. This lack of proper hand hygiene supplies led to V5 using a washcloth to dry her hands initially and then continuing the procedure without drying her hands properly. Additionally, V6, another staff member, handled contaminated items without gloves and used bare hands to assist with the procedure, further increasing the risk of cross-contamination. For R3, who had diagnoses including Type 2 Diabetes Mellitus with Diabetic Polyneuropathy and a Stage 4 Pressure Ulcer, V6, a Registered Nurse, used her gloved fingers to pack the wound with collagen dressing after the initial dressing fell out, instead of using a clean cotton-tipped swab. This action was confirmed by V6 as inappropriate, as she acknowledged the need for a new cotton swab. These actions demonstrate a failure to adhere to infection control protocols, particularly in maintaining proper hand hygiene and using appropriate techniques during wound care procedures.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, leading to potential cross-contamination and foodborne illness risks for all 85 residents. During an initial kitchen tour, a cook was observed plating food without a beard cover, which is against the facility's standards for hair restraint in food preparation areas. Additionally, the dishwasher area had trays of wet, stacked plastic drink glasses, and the area was covered in dust and paint chips, indicating a lack of cleanliness. The facility's dishwashing machine was not properly calibrated to dry dishes, and the area above the clean dish station was in disrepair, with dust and paint chips present. Further inspection revealed that the facility's commercial can opener was rusted and had a grease-like substance in its gears, with the blade's veneer peeling off. The plate warmer used to hold clean plates was also in poor condition, with rust, grease, and broken glass fragments present. The facility's cleaning standards, as outlined in their manual, were not adhered to, as evidenced by the unsanitary conditions of the kitchen equipment and the lack of proper hair restraints worn by staff during food preparation.
Incomplete Facility Assessment Documentation
Penalty
Summary
The facility failed to maintain the required documentation in their Facility Assessment, which is essential for determining the necessary resources to care for residents competently during both day-to-day operations and emergencies. The assessment, dated on an unspecified date, lacked critical information such as the types of diseases for which services are provided, the department and job structure, overall acuity, competencies needed to provide the required level and types of care, ethnic and cultural factors affecting care, and personnel education, training, and competencies related to resident care. This deficiency was confirmed during an interview with the Administrator on 7/24/24, who acknowledged the incomplete assessment. The facility's application for Medicare and Medicaid, dated 7/22/24, confirmed that there are 85 residents residing in the facility.
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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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