The Haven Of Ridgeview
Inspection history, citations, penalties and survey trends for this long-term care facility in Oblong, Illinois.
- Location
- 413 Ridge Lane, Oblong, Illinois 62449
- CMS Provider Number
- 146096
- Inspections on file
- 30
- Latest survey
- February 2, 2026
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at The Haven Of Ridgeview during CMS and state inspections, most recent first.
A resident with impaired mobility, morbid obesity, ESRD, and COPD, who required two-person assistance and a full-body mechanical lift for transfers, was being moved from bed to wheelchair using a bariatric sling and whole-body lift. Two CNAs placed the sling, attached the straps to the lift, raised the resident to obtain a weight, and then began moving the lift toward the wheelchair. While the resident was suspended and the lift was in motion, the bottom right sling strap slipped off the lift hook, causing the resident to slide out of the sling and fall to the floor. The resident was transported to the ER, where records documented a right hip fracture, distal femur fracture, and right tibia fracture resulting from the fall.
A resident with significant physical limitations and dependence on staff for transfers and toileting did not have access to a working call light after being moved to bed. Staff acknowledged the absence and suggested the resident rely on roommates to call for help, despite one roommate's hearing impairment and another's uncertainty. Facility policy required call lights to be accessible, but this was not followed.
A resident who was dependent on staff for mobility and required mechanical lift transfers sustained a skin tear and required emergency care after her leg struck an exposed, sharp bed frame edge that was missing a protective cap. Staff interviews and documentation confirmed the absence of the cap and the presence of sharp edges, which created an accident hazard and led to the injury during a transfer.
A resident developed multiple pressure ulcers due to the facility's failure to implement necessary interventions and provide adequate incontinence care. Despite being at high risk for pressure ulcers, the resident was not repositioned or changed frequently enough, as reported by CNAs who noted understaffing issues. The resident's condition worsened, leading to hospitalization, and the family chose to transfer the resident to another facility where their condition improved.
The facility failed to provide adequate staffing, resulting in insufficient care for residents, including a resident with severe cognitive impairment who developed pressure wounds due to infrequent repositioning. CNAs reported frequent understaffing, particularly during night shifts, leading to residents being left in soiled conditions. Another resident reported long wait times for call light responses, with complaints about staffing and care going unaddressed.
A resident with multiple health conditions developed several pressure ulcers, but the facility failed to notify the resident's POA of these changes. The Director of Nurses believed she had informed the POA but did not document the conversation, and the Wound Care Nurse Practitioner relied on nursing staff for communication. The facility's protocol for notifying significant changes was not followed.
The facility failed to provide adequate incontinence care and timely toileting assistance for two residents, leading to deficiencies in their care. One resident, with multiple medical conditions, was often left in bed without being repositioned or changed frequently enough, resulting in pressure wounds. Another resident experienced frequent delays in call light responses for toileting assistance due to staffing shortages. The facility's policies on incontinence care and repositioning were not adhered to, contributing to these deficiencies.
A resident was discharged from an LTC facility without notifying the physician or removing a PICC line used for IV antibiotics. The resident, who was cognitively intact and had osteomyelitis, left with the PICC line still in place, and no follow-up care was arranged. Facility staff were unsure if the PICC line was removed, and the Medical Director confirmed no discharge orders were given. The resident was later readmitted to a hospital with the PICC line, highlighting a deficiency in discharge planning.
A resident transferred from hospice to the facility without medications experienced severe pain and anxiety due to the facility's failure to assess and manage their condition. The resident, who had been on round-the-clock Ativan and Morphine, was not administered these medications upon admission, and their pain was not assessed until two days later. The Director of Nurses cited issues with obtaining prescriptions over the weekend. The resident was eventually sent to the ER for pain control.
The facility failed to provide adequate staffing, resulting in significant delays in call light responses for all 49 residents. Multiple residents, including those with conditions like CHF, COPD, and Parkinson's, reported waiting 30 minutes to over an hour for assistance, leading to discomfort and incontinence. The DON confirmed insufficient staffing, particularly during night shifts, despite policy requirements for timely responses.
The facility failed to ensure proper storage temperatures for medications, affecting all 49 residents. Temperature logs for the medication refrigerator were incomplete for September and missing for October. The DON was unaware of the issue, and the midnight nurse was responsible for logging temperatures, which was not done consistently. Medications requiring refrigeration were stored without proper temperature checks, violating FDA guidelines.
The facility failed to provide prescribed diets for residents at nutritional risk, with several residents not receiving double protein portions as ordered. One resident experienced significant weight loss without dietary recommendations being addressed, and another did not have an increase in Med Pass communicated to the physician. These deficiencies highlight a lack of adherence to dietary orders and communication protocols.
A facility failed to ensure proper cooking temperatures for meatloaf served to residents. During a lunch meal, some meatloaf patties were undercooked, with a pink and cool center, as observed in four residents' meals. The cook, V17, did not check the internal temperature of each patty, leading to the oversight. The facility's recipe requires a critical internal temperature of 155°F, which was not consistently met.
The facility failed to provide timely incontinence care for three residents, leading to long waits for call light responses and episodes of incontinence. Residents with conditions such as Congestive Heart Failure, COPD, and Diabetes Type 2 reported waiting up to an hour for assistance, despite being alert and oriented. The facility's policy requires call lights to be answered within a reasonable time, but this was not adhered to, compromising resident dignity.
A facility failed to notify a resident or their representative in writing about a hospital transfer, as required by policy. The resident was admitted to the hospital for observation due to elevated D-Dimer levels and redness in the lower extremities. The Business Office Manager, responsible for sending transfer notices, did not send the notification because she was unaware the resident was out of the facility for over 24 hours. This oversight violated the facility's discharge and transfer policy.
A facility failed to notify a resident or their representative in writing about the bed hold policy during a hospital transfer. The Business Office Manager did not send the required notification, as they were unaware the resident was out for 24 hours. The facility's policy requires written information about bed hold policies to be provided during transfers, but this was not done, and no copy was kept in the resident's medical record.
A resident with severe cognitive impairment and a recent CVA was prescribed Ertapenem for a UTI upon discharge from the ED. The facility failed to administer the medication timely due to the pharmacy being closed over the weekend and issues with reactivating the resident's status with the pharmacy. The medication was not administered until the following day, resulting in a delay in treatment.
A facility failed to ensure a resident was free from unnecessary medications by not implementing gradual dose reductions (GDR) for psychotropic medications. Despite recommendations from the consultant pharmacist to reduce dosages of Doxepin and Clonazepam, there was no documented physician response or evidence of communication to the physician. Observations showed the resident frequently sleeping during the day, and behavior tracking was incomplete, indicating inadequate monitoring and assessment.
A resident with multiple health conditions and a BIMS score indicating cognitive intactness did not receive necessary dental services, including dentures, despite repeated requests. The facility's administrator and business office manager were unaware of the resident's needs, and no appointment was scheduled, highlighting a lapse in communication and service provision.
A nurse failed to clean the glucometer between uses for three residents, contrary to facility policy. The glucometer was placed on a towelette on the med cart without proper disinfection. The DON confirmed the expectation for cleaning after each use, and the nurse admitted to not following the correct procedure. The residents involved had conditions requiring regular glucose monitoring.
The facility failed to provide adequate staffing, particularly during night shifts, affecting the care of 43 residents. The administrator and staff acknowledged the shortage, especially on weekends, with only two CNAs and one nurse available instead of the required five or six. Residents reported significant delays in call light responses, with some waiting up to an hour for assistance. Facility records confirmed multiple instances of understaffed night shifts, impacting residents needing assistance for transfers and daily activities.
Several residents experienced significant delays in receiving assistance due to the facility's failure to respond to call lights in a timely manner. Residents reported waiting times of 20 minutes to over an hour, attributed to staffing shortages, particularly during night shifts and weekends. CNAs confirmed the insufficient staffing levels, which hindered their ability to promptly assist residents, many of whom required two staff members for transfers. The facility's administrator acknowledged the staffing issues and the unsuccessful efforts to recruit additional care staff.
A cognitively intact resident's medications were left at the bedside by an RN, contrary to the facility's policy requiring licensed nurses to observe medication administration. A CNA found the medications and returned them to the resident, who then took them. The resident had not been assessed for self-administration, and the facility's policy mandates that medications be swallowed before the nurse leaves.
Improper Mechanical Lift Transfer Leads to Resident Fall and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to safely transfer a resident using a whole-body mechanical lift, resulting in the resident falling from the lift to the floor. The resident was admitted with diagnoses including dependence on dialysis, end stage renal disease, morbid obesity, and chronic obstructive pulmonary disease. An MDS dated 11/15/25 documented that the resident required two staff for all transfers and that staff were to use a full-body lift for transfers. The MDS also documented a BIMS score of 15, indicating no cognitive impairment. The resident’s care plan identified impaired physical mobility related to decreased strength, limited weight-bearing tolerance, and dependence on a mechanical lift for transfers. On the day of the incident, two CNAs entered the resident’s room to transfer the resident from bed to wheelchair using a whole-body mechanical lift and a bariatric sling. According to the facility’s serious injury incident report and staff interviews, the CNAs placed the sling under the resident, attached the sling straps to the lift, and raised the resident in the air over the bed to obtain a weight. They then began to move the lift to position the resident over the wheelchair. While the lift was moving with the resident suspended, the bottom right sling strap slipped or slid off the hook on the lift. Staff interviews indicated that one CNA operated the lift while the other prepared and maneuvered the wheelchair. One CNA reported hooking the bottom straps while the other hooked the top straps. During the transfer, as the lift was being moved with the resident elevated, the bottom right strap detached from the lift, causing the resident to slide out of the sling and fall to the floor. The CNAs and the nurse on duty confirmed that the resident fell when the sling strap came off the lift. The resident was subsequently transported by EMS to a local emergency room, where records documented that the resident sustained a right hip fracture, a distal right femur fracture, and a right tibia fracture as a result of falling from the mechanical lift.
Failure to Provide Accessible Call Light for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with a history of hemiplegia, hemiparesis following a CVA, diabetes, and hypertension, who was dependent on staff for transfers and toileting, was found without access to a working call light after being transferred to bed via mechanical lift. The resident's care plan specifically indicated the need for assistance with activities of daily living and toileting, and included an intervention to encourage the use of a call bell for requesting help. Despite this, the resident did not have a call light within reach, and staff acknowledged the absence, suggesting that the resident could ask roommates to activate their call lights instead. However, one roommate was not sure if they had done so, and another was severely hearing impaired, making this solution unreliable. Further interviews revealed that the resident was unsure how to summon help if needed and would likely have to wait until someone arrived. The facility's policy required that call lights be accessible to residents from their beds or chairs and from each toilet and bathing area, and that defective call lights be reported promptly. The deficiency was identified through observation, interviews with staff, residents, and family members, and review of facility records and policies.
Failure to Maintain Safe Environment During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when the facility failed to provide an environment free of accident hazards for a resident with multiple medical conditions, including lymphedema, cellulitis, type 2 diabetes mellitus, and cerebral palsy. The resident was cognitively intact but dependent on staff for mobility and required mechanical lift transfers. During an evening transfer, two CNAs attempted to reposition the resident in her wheelchair to prepare for a mechanical lift transfer. In the process, the resident's left leg went under her bed and struck the exposed, sharp edge of the bed frame, which was missing a protective black cap. The impact caused a skin tear and bleeding on the resident's left lower leg. Staff interviews confirmed that the bed frame's end was not covered and had sharp edges, which directly contributed to the injury. The wound nurse was called in to assess the injury and, after evaluation, recommended that the resident be sent to the local emergency room for further care. The emergency room physician documented a significant skin tear laceration that required one stitch to control bleeding. Facility documentation, including the incident report and staff statements, indicated that the environment was not adequately prepared to prevent accidents, as required by the facility's mechanical lift policy. The missing bed frame cap and the presence of sharp edges created an accident hazard that was not addressed prior to the incident, resulting in the resident's injury during a routine transfer.
Failure to Prevent Pressure Ulcers Due to Inadequate Care
Penalty
Summary
The facility failed to implement necessary interventions to prevent the development of pressure ulcers for a resident, resulting in the resident developing multiple facility-acquired pressure ulcers and moisture-associated skin damage. The resident, who was at high risk for pressure ulcers due to conditions such as hemiplegia, diabetes, and severe cognitive impairment, was not repositioned or provided with adequate incontinence care as required. The resident's care plan included interventions like repositioning every two hours and monitoring incontinence, but these were not consistently followed. Interviews with staff revealed that the facility was often understaffed, particularly during the night shift, leading to residents not being repositioned or changed frequently enough. Certified Nursing Assistants (CNAs) reported that incontinent residents were often found soaked in urine and feces in the mornings, indicating a lack of proper care during the night. Despite these reports, the Director of Nurses claimed that all residents were being cared for appropriately, contradicting the observations and statements from multiple CNAs. The resident's condition deteriorated, leading to hospitalization for issues including a urinary tract infection and sepsis. The resident's family expressed concerns about the lack of care and decided to transfer the resident to another facility, where the resident's condition improved. The facility's failure to provide adequate care and staffing contributed to the development of the resident's pressure ulcers and overall decline in health.
Inadequate Staffing Leads to Resident Care Deficiencies
Penalty
Summary
The facility failed to provide sufficient direct care staff to meet the needs of all 50 residents, as evidenced by multiple accounts of inadequate care and staffing shortages. Resident 1, who has severe cognitive impairment and is at high risk for pressure ulcers, was not repositioned or changed frequently enough, leading to the development of pressure wounds. The resident's Power of Attorney and several CNAs reported that the facility was often understaffed, particularly during the night shift, resulting in residents being left in soiled conditions and not receiving timely care. Interviews with CNAs revealed that the night shift frequently operated with fewer staff than required, leading to inadequate care for incontinent residents. CNAs reported that residents were often found soaked in urine and feces in the mornings, indicating that they were not being changed or repositioned as needed. The Director of Nurses acknowledged the staffing issues, citing difficulties in attracting and retaining CNA staff, and confirmed that the facility did not always meet its staffing requirements. Resident 7, who requires moderate assistance for toileting and transfers, reported long wait times for call lights to be answered, sometimes up to an hour. This resident, along with others, had been complaining about staffing and call light response times for months, with no improvement. The facility's staffing policy and call light guidance were not being adhered to, as evidenced by the documented grievances and resident council meeting minutes highlighting these ongoing issues.
Failure to Notify POA of Resident's Pressure Ulcers
Penalty
Summary
The facility failed to notify a resident's Power of Attorney (POA) of a change in condition, specifically the development of pressure ulcers, for one of the residents reviewed. The resident, who had a history of Hemiplegia, Type 2 Diabetes, Chronic Kidney Disease, Morbid Obesity, Epilepsy, and Aphasia, was admitted and readmitted to the facility with these conditions. The resident developed multiple pressure injuries, including a stage 3 pressure injury on the coccyx and sacrum, and stage 2 and 3 injuries on the ischium. Despite these developments, there was no documentation in the resident's Nurses Notes for November and December indicating that the POA was informed of these pressure ulcers. The POA stated that they were first informed of the pressure ulcers on December 11, when the Director of Nurses called to report the resident's deterioration and hospitalization for a UTI. The Director of Nurses believed she had informed the POA earlier in December but acknowledged that the conversation was not documented. The Wound Care Nurse Practitioner also did not communicate with the POA, relying instead on the facility's nursing staff to do so. The facility's Change of Condition Protocol requires the interdisciplinary team to identify and communicate significant changes in a resident's condition, but this protocol was not followed in this instance.
Inadequate Incontinence Care and Delayed Toileting Assistance
Penalty
Summary
The facility failed to provide adequate incontinence care and timely toileting assistance for two residents, R1 and R7, leading to deficiencies in their care. R1, who has multiple medical conditions including hemiplegia, diabetes, and chronic kidney disease, was found to be at high risk for pressure ulcers. Despite documented care plans requiring regular repositioning and incontinence care, interviews with staff and R1's Power of Attorney revealed that R1 was often left in bed without being repositioned or changed frequently enough. Staff shortages were cited as a reason for the lack of care, resulting in R1 being found in urine-soaked and soiled conditions, which likely contributed to the development of pressure wounds. R7, who has Parkinson's Disease and diabetes, requires moderate assistance for toileting and transfers. Despite being cognitively intact, R7 reported frequent delays in call light responses, often waiting up to an hour for toileting assistance. Staff confirmed that call lights were not answered promptly due to staffing shortages, particularly during evening hours. This delay in response time is contrary to the facility's policy, which states that call lights should be answered within a reasonable time frame. The facility's policies on incontinence care and repositioning were not adhered to, as evidenced by the interviews with multiple CNAs who reported insufficient staffing levels, particularly during the night shift. This resulted in residents not being turned or changed every two hours as required, and incontinence care not being performed adequately. The failure to follow these procedures led to residents being left in soiled conditions, increasing the risk of skin breakdown and pressure ulcers.
Failure to Notify Physician and Remove PICC Line Before Discharge
Penalty
Summary
The facility failed to notify the physician prior to a resident's discharge, which led to a deficiency in discharge planning. The resident, who was admitted with conditions including osteomyelitis of the left foot and ankle, was discharged without proper physician orders. The resident was cognitively intact and had a PICC line for IV antibiotics, which was supposed to be removed before discharge. However, there was no documentation of discharge orders or the removal of the PICC line in the resident's medical records. The resident left the facility with the PICC line still in place, and there was no follow-up care arranged for its management. The facility's staff, including the Director of Nursing and the Registered Nurse responsible for the resident on the day of discharge, were unsure if the PICC line was removed. The Medical Director confirmed that she did not provide discharge orders and expected the facility to discontinue the PICC line as part of standard care. The facility's policy requires physician orders for discharge, which were not obtained in this case. The resident was later readmitted to a hospital with the PICC line still in place, indicating a lack of proper discharge procedures. The hospital staff noted that the resident was living in unstable conditions and had been using a belt to secure the PICC line. This situation highlights the facility's failure to ensure appropriate discharge planning and communication with the physician, as required by their policy.
Failure to Manage Pain and Anxiety for Resident
Penalty
Summary
The facility failed to assess and manage pain for a resident, resulting in severe pain and anxiety that necessitated a transfer to the emergency room. The resident, who was admitted with diagnoses including Chronic Obstructive Pulmonary Disease and Anxiety Disorder, was transferred from a hospice facility where they were receiving round-the-clock medications for pain and anxiety. Upon admission, the resident's medications, Ativan and Morphine, were not administered as documented in the Medication Administration Record, and their pain was not assessed until two days later. The resident reported experiencing terrible abdominal pain and anxiety shortly after admission, which exacerbated their breathing problems. The Director of Nurses acknowledged that the resident arrived without medications and that there was no way to obtain them over the weekend due to the need for hard copy prescriptions and the pharmacy being closed. Despite contacting the Medical Director, the necessary documentation was not obtained, and the resident's pain was not assessed as per the facility's policy. The resident's family requested a transfer to the emergency room, where the resident received new medication orders for pain and anxiety. The facility's Management of Pain Policy emphasizes the importance of providing necessary comfort and dignity to residents, which was not adhered to in this case.
Inadequate Staffing Leads to Delayed Call Light Responses
Penalty
Summary
The facility failed to provide sufficient direct care staff to meet the needs of its residents, affecting all 49 residents. Multiple residents reported significant delays in response times to call lights, with waits ranging from 30 minutes to over an hour. These delays were particularly problematic for residents requiring assistance with toileting and transfers, leading to discomfort and incontinence episodes. Residents with conditions such as Congestive Heart Failure, Diabetes Type 2, Chronic Obstructive Pulmonary Disease, and Parkinson's Disease were among those affected, all of whom were alert and oriented at the time of the interviews. The Director of Nurses, responsible for scheduling, confirmed that staffing levels were inadequate, particularly during the 6pm to 6am shift, where only one nurse and two CNAs were scheduled, with an additional CNA from 6pm to 10pm. Despite requests for additional staff, corporate denied these requests. The facility's policies stated that call lights should be answered within 15 minutes, but this was not being met. The staffing policy allowed for schedule revisions to meet residents' needs, but this was not effectively implemented, contributing to the deficiency.
Improper Medication Storage Temperatures
Penalty
Summary
The facility failed to ensure that medications were stored at appropriate temperatures, which could potentially affect all 49 residents. During an observation on October 4, 2024, it was found that the temperature logs for the vaccine and medication refrigerator were incomplete for September and entirely missing for October. The Director of Nursing (V2) was unaware of the missing temperature checks and stated that the facility's medication storage policy did not specifically address refrigerator temperature checks. The midnight nurse was identified as responsible for documenting the temperature logs, which had not been done consistently. The medications stored in the refrigerator included promethegan suppositories, an Ozempic pen, a liraglutide insulin pen, a Novolog insulin vial, insulin lispro vials, a Humulin insulin vial, and locked narcotic boxes. According to the FDA, these medications should be stored at temperatures between 36°F and 46°F. The facility's policy, revised in August 2022, requires that drugs and biologicals be stored under proper temperature controls. However, the lack of recorded temperatures indicates a failure to adhere to these guidelines, potentially compromising the safety and efficacy of the medications.
Failure to Provide Prescribed Diets for Residents at Nutritional Risk
Penalty
Summary
The facility failed to provide diets as ordered for residents at nutritional risk for malnutrition. Four residents, each with specific dietary needs due to medical conditions such as diabetes, chronic kidney disease, and anemia, did not receive the prescribed double protein portions during meals. For instance, one resident with a diet order of consistent carbohydrate and double protein received only one slice of meatloaf and pizza instead of the required portions. Another resident, who was noted for significant weight loss and had dietary recommendations for liberalization and an appetite stimulant, did not have these recommendations addressed by the physician, and there was no documentation of follow-up by the staff. Additionally, a resident with a diet order that included Med Pass for malnutrition did not have the recommended increase in Med Pass communicated to the physician. The dietary manager confirmed the discrepancies in meal portions, and the Director of Nursing acknowledged the lack of communication with the physician regarding dietary recommendations. These failures in adhering to dietary orders and communication protocols contributed to the deficiency in providing adequate nutrition to residents at risk for malnutrition.
Undercooked Meatloaf Served to Residents
Penalty
Summary
The facility failed to ensure proper cooking temperatures were reached when preparing meals for four residents. During a lunch meal observation, the cook, identified as V17, was preparing meatloaf and initially recorded a temperature of 128 degrees Fahrenheit, which was below the required 160 degrees Fahrenheit. Despite placing the meatloaf back in the oven, some patties were served to residents with a pink and cool center, indicating they were undercooked. Residents R18, R20, R23, and R27 received these undercooked meatloaf patties, with R18 and R20 specifically noting the cool, pink center. The cook, V17, later explained that the meatloaf was prepared as single-serving patties rather than a loaf, and while a patty from each tray was checked for internal temperature, not every patty was individually checked. This oversight likely resulted in some patties being undercooked. The facility's recipe for meatloaf specifies a critical control point of reaching an internal temperature of 155 degrees Fahrenheit for 17 seconds, which was not consistently achieved for all patties served.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to promote resident dignity by not providing timely incontinence care for three residents. Resident 1, who has diagnoses including Congestive Heart Failure and Diabetes Type 2, reported that staff are slow to respond to call lights, often waiting 30 minutes to an hour. This resident requires partial assistance for toileting and transfers and is alert and oriented. Resident 198, with Chronic Obstructive Pulmonary Disease and Anxiety Disorder, also reported long waits for call light responses, sometimes up to an hour, causing discomfort while holding urine or feces. This resident is dependent on staff for toileting and transfers and is also alert and oriented. Resident 21, diagnosed with COPD and Diabetes Type 2, is totally dependent on staff for toileting and transfers and experiences occasional urinary incontinence. This resident reported having four incontinence episodes in one day while waiting for call light responses. The Director of Nurses stated that call lights should be answered within 15 minutes, but the facility's policy indicates that call lights should be responded to within a reasonable amount of time. The facility's failure to adhere to these guidelines resulted in a deficiency in promoting resident dignity and timely incontinence care.
Failure to Notify Resident of Hospital Transfer
Penalty
Summary
The facility failed to provide timely written notification to a resident or their representative regarding a hospital transfer. This deficiency was identified for one resident, who was admitted to the facility in January 2023. On August 2, 2024, the resident was transported to a hospital for observation due to elevated D-Dimer levels and redness in the lower extremities. The resident returned to the facility the following day, transported by their daughter. However, the Business Office Manager, responsible for sending out transfer notices, did not send the required notification because she was unaware that the resident had been out of the facility for over 24 hours. The facility's policy, revised in August 2022, mandates that written information regarding bed hold policies and transfer notifications be provided to residents and their representatives when a resident is transferred to a hospital. The Business Office Manager admitted to not keeping copies of the bed hold or transfer notifications, which contributed to the oversight. This failure to notify the resident or their representative in writing of the hospital transfer constitutes a deficiency in the facility's adherence to its discharge and transfer policy.
Failure to Notify Resident of Bed Hold Policy
Penalty
Summary
The facility failed to notify a resident or their representative in writing about the bed hold policy during a transfer to a hospital. This deficiency was identified for one resident out of four reviewed for hospitalization in a sample of 34. The resident was initially admitted to the facility on January 12, 2023, and was transported to a hospital for observation on August 2, 2024, due to D-Dimer elevation and redness in the lower extremities. The resident returned to the facility the following day, transported by their daughter. The Business Office Manager, responsible for sending out bed hold and transfer notices, admitted to not being aware that the resident was out of the building for 24 hours and consequently missed sending the required notifications. The facility's policy mandates providing written information about the bed hold policy to the resident and their representative during transfers. However, the Business Office Manager did not keep a copy of the notification, which is against the facility's policy that requires a copy to be placed in the resident's medical record until readmission.
Delayed Medication Administration Due to Pharmacy Closure
Penalty
Summary
The facility failed to acquire medications timely from the pharmacy for a resident who was admitted with diagnoses including Hemiplegia, Hemiparesis, and Aphasia following a Cerebral Vascular Accident. The resident's cognition was documented as severely impaired. Upon discharge from the Emergency Department, the resident was prescribed Ertapenem for a Urinary Tract Infection, to be administered every 24 hours starting the following day. However, the medication was not available at the facility upon the resident's return. The Director of Nurses stated that the resident did not receive the Ertapenem because the pharmacy that provides IV medications was closed over the weekend. The facility contacted the pharmacy, which initially did not recognize the resident as active and required reactivation by sending a facesheet and order. Despite these actions, the medication was not administered until the following day, resulting in a delay in treatment for the resident.
Failure to Implement Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications, as evidenced by the lack of implementation of gradual dose reductions (GDR) and non-pharmacological interventions for psychotropic medications. The resident, who was admitted with diagnoses including unspecified dementia, anxiety disorder, bipolar disorder, major depressive disorder, and insomnia, was prescribed multiple psychotropic medications, including Clonazepam, Doxepin, Olanzapine, and Venlafaxine. Despite the facility's care plan indicating the need for GDR and monitoring for adverse effects, there was no documented evidence of attempts to reduce the dosages of these medications. Observations of the resident showed that they were frequently sleeping in their recliner during the day, which could indicate over-sedation or other side effects of the medications. The facility's consultant pharmacist had recommended GDR for Doxepin and Clonazepam to reduce fall risk, as these medications are on the Beers List for potentially inappropriate medications for older adults. However, there was no response from the physician to these recommendations, and the facility could not provide documentation that the recommendations were communicated to the physician. The facility's policy requires the consulting pharmacist to review residents' charts monthly and notify the Director of Nursing (DON) of any recommendations, which should then be communicated to the physician. However, the Director of Nursing admitted that some physicians do not respond to these requests, and there was no documentation of the facility sending the recommendations for the resident to the physician. Additionally, behavior tracking for the resident was incomplete, with several shifts not documented, further indicating a lack of proper monitoring and assessment of the resident's condition and medication effects.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental services for a resident, identified as R31, who was admitted with diagnoses including Diabetes Mellitus, Hypertension, Polycystic Kidney Disease, and Gout. Despite being cognitively intact, as indicated by a BIMS score of 12, R31's care plan did not address any dental concerns. The resident reported not having dentures since admission and expressed difficulty eating and potential weight loss due to this issue. R31 stated that he had communicated his need for dental services to the facility's administrator, business office manager, and previous social worker, but no action was taken. The administrator, identified as V1, claimed to be unaware of R31's request for a dentist appointment and mentioned plans to arrange for a dentist to visit the facility. The business office manager, V3, also confirmed having no record of R31's request and was in the process of finalizing a contract with a dentist to provide monthly services. Despite these discussions, no attempt had been made to schedule a dental appointment for R31, and the previous social worker, V8, who might have been informed, was no longer employed at the facility.
Failure to Clean Glucometer Between Uses
Penalty
Summary
The facility failed to properly clean the glucometer between resident uses, as observed during a survey. A registered nurse, identified as V4, was seen obtaining blood glucose samples from three residents without cleaning the glucometer between uses. After each test, the glucometer was placed on a towelette on the medication cart, and the same towelette was used for multiple residents without proper disinfection. This practice was contrary to the facility's policy, which requires the glucometer to be cleaned with a Sani-Wipe after each use and to remain wrapped for three minutes. The Director of Nursing, V2, confirmed that the expectation was for nurses to clean the glucometer after each use according to the policy. V4 admitted to not cleaning the glucometer correctly during the blood glucose checks. The residents involved had various medical conditions, including diabetes, heart failure, and hypertension, which necessitated regular blood glucose monitoring. The facility's policy and the Sani-Cloth container instructions both emphasized the importance of cleaning and disinfecting reusable equipment after each use to prevent the transmission of bloodborne diseases.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the care needs of its 43 residents, particularly during the night shift. The administrator acknowledged the shortage, especially on weekends, where the night shift often operated with only two CNAs and one nurse, instead of the required five or six care staff. This staffing inadequacy was confirmed by interviews with staff and residents, who reported significant delays in responding to call lights, with some residents waiting up to an hour for assistance. The facility's records for June and early July 2024 corroborated these reports, showing multiple instances of understaffed night shifts. Residents requiring assistance for transfers and activities of daily living experienced prolonged wait times, impacting their care and safety. Several residents, who were alert and oriented, expressed concerns about the delays in receiving help, particularly during the night shifts on weekends. The facility's census indicated that 19 residents required a minimum of two staff for safe transfers, yet the staffing levels were insufficient to meet these needs, leading to delays and potential risks for the residents.
Delayed Response to Call Lights Due to Staffing Shortages
Penalty
Summary
The facility failed to respond to call lights in a timely manner for several residents, leading to significant delays in receiving necessary assistance. Residents R2, R5, R6, R8, and R9, all of whom have self-care deficits requiring assistance with activities of daily living, reported waiting times ranging from 20 minutes to over an hour for their call lights to be answered. These delays were attributed to a shortage of staff, particularly during night shifts and weekends, as noted by both residents and staff members. The residents expressed frustration and concern over the prolonged wait times, which affected their ability to receive timely care and assistance. Interviews with Certified Nursing Assistants (CNAs) V5 and V6 confirmed the staffing shortages, stating that typically only two CNAs were available during night shifts, with occasional increases to three. This staffing level was insufficient to meet the needs of residents, many of whom required assistance from two staff members for transfers. The facility's administrator, V1, acknowledged the staffing issues and the unsuccessful efforts to recruit additional care staff. The deficiency in timely response to call lights compromised the residents' right to a dignified existence and self-determination, as they were unable to receive prompt assistance for their needs.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered according to current standards of practice for a resident who was not assessed for self-administration of medication. The incident involved a cognitively intact resident who had a cup of medications left at their bedside, which was discovered by a CNA. The Director of Nursing was informed of the situation and confirmed that the resident had not been screened for self-administration of medication. The Registered Nurse responsible for the resident on that day admitted to leaving the medications at the bedside, assuming the resident would take them, and was later reminded by the Director of Nursing to ensure residents take their medications in her presence. The facility's policy on medication administration requires licensed nurses to observe residents taking their medications and to ensure medications are swallowed before leaving. Despite this policy, the CNA, who is not a licensed nurse, found the medications and returned them to the resident, who then took them. The facility's administrator confirmed that the expectation is for licensed nurses to observe medication administration and that the resident had not been assessed for self-administration. The resident's medical history includes conditions such as hemiplegia, type 2 diabetes with diabetic neuropathy, hypertension, and hyperlipidemia.
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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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