The Haven On The River
Inspection history, citations, penalties and survey trends for this long-term care facility in Grayville, Illinois.
- Location
- 320 South 2nd Street, Grayville, Illinois 62844
- CMS Provider Number
- 146119
- Inspections on file
- 32
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 12 (1 serious)
Citation history
Health deficiencies cited at The Haven On The River during CMS and state inspections, most recent first.
A resident with dementia, anxiety, depression, and Alzheimer’s disease received multiple PRN and routine Ativan orders with inconsistent and clinically questionable indications, such as nausea related to depression and comfort related to Alzheimer’s. The MAR showed repeated PRN Ativan administrations with progress notes documenting symptoms or reasons for use on only a small fraction of doses, while nursing staff stated they did not believe separate notes were necessary and could not recall the resident’s symptoms at the time of administration. A pharmacy review form requesting action on the PRN psychotropic order, including compliance with the 14‑day CMS guideline and documentation of indication and duration, was left entirely incomplete by the prescriber. Family members reported that Ativan had previously caused an opposite, aggressive reaction at home, stated they had stopped it before admission, and said they repeatedly requested that it not be given, yet Ativan was reordered and administered several times, and they were not informed when it was discontinued and restarted. Staff, including an RN and an LPN, reported that the resident became more aggressive and violent after receiving Ativan, but the facility did not ensure appropriate review, documentation, or response to these concerns.
The facility failed to maintain hot water temperatures within its own stated safe range of 100–110°F in multiple resident rooms and shower areas, resulting in consistently lukewarm or cold water at sinks and showers used for personal care. Surveyors measured water temperatures as low as the mid-60s°F at some sinks and showers, even after running the water for several minutes, and staff were observed relocating a resident to another shower room because the water was not warm enough. Several alert and oriented residents reported that the water in their sinks was too cold or not consistently warm for handwashing. The Maintenance Director acknowledged that he only checked faucet temperatures, not showers, and the Administrator confirmed that facility policy requires all resident sinks, showers, and tubs to remain within the 100–110°F range.
A resident with CHF, COPD, CKD, diabetes, dysphagia, and an indwelling catheter experienced poor oral intake, low urine output, and episodes of non‑responsiveness, yet staff did not complete ordered CBC, CMP, and TSH labs, did not timely act on a UA/culture later showing significant infection, and did not develop care plan focus areas for diabetes or catheter care. Despite physician orders for daily accuchecks, several blood glucose checks were not documented, and when the resident’s family reported blood sugars in the 60s and observed shaking and dyspnea, an RN gave instant glucose to the family to administer without first checking the resident’s glucose and did not assess the resident until after 911 was called. EMS found the resident hypoxic with cloudy, blood‑tinged minimal catheter output, and the resident was hospitalized with acute renal failure and hyperkalemia requiring emergent dialysis, after which he was transferred to another hospital and then hospice, where he died.
The facility failed to maintain adequate nursing staff and timely call-light response, resulting in multiple alert residents waiting 30–60 minutes for assistance, including while incontinent and lying in urine. On one evening, only two CNAs and an agency nurse unfamiliar with the facility were on duty, with one CNA taking residents outside to smoke while multiple call lights on a hall went unanswered and a resident yelled for help. Time records confirmed a period when only one CNA and one nurse were present to care for 45 residents. Several CNAs and an RN reported chronic short staffing due to call-ins and lack of agency CNA coverage, stating that some resident care needs were not completed, particularly on more demanding halls and night shifts, despite a written policy requiring adequate staffing ratios and relief coverage.
The facility failed to respond promptly to call lights, leading multiple residents who were incontinent and dependent for toileting and repositioning to wait 30–60 minutes or more for assistance, often while lying in urine. Cognitively intact or moderately impaired residents with complex conditions such as COPD, CHF, diabetes, Parkinson’s disease, hemiplegia, and chronic pain reported frequent evening delays and described being cold and soaked while waiting. Surveyors observed only one CNA covering a hall of 26 residents while taking residents outside to smoke, leaving multiple call lights unanswered and a resident yelling for help, as the DON and an agency nurse unfamiliar with the building managed the floor. The facility’s own call light policy required responding to residents’ requests and needs, but staff actions and staffing patterns did not ensure timely responses or dignified care.
A resident at high risk for falls, dependent on staff for transfers, experienced an unwitnessed fall that was not documented or properly assessed by staff. Despite reports of pain and visible leg abnormalities from family and staff, the nurse on duty did not assess the resident or notify the physician or family. The resident was later sent to the hospital, where fractures were diagnosed, revealing a delay in care due to lack of timely assessment and reporting.
A resident with a history of falls and mobility issues was not properly assessed or treated for pain after a fall that resulted in hip and femur fractures. Despite orders for PRN pain medications, the resident did not receive pain relief, and staff failed to document or address pain complaints, leading to delayed recognition and treatment of serious injuries.
A resident who was dependent on staff for transfers due to lower extremity impairment was injured when a CNA, acting alone and contrary to facility policy, attempted to use a sit-to-stand lift for toileting. The resident slipped from the lift and sustained a head laceration requiring staples. Facility policy required two staff for such transfers, but this was not followed, leading to the incident.
The facility did not provide pharmaceutical services to meet the needs of each resident and failed to employ or obtain the services of a licensed pharmacist, resulting in noncompliance with regulatory requirements.
The facility did not provide surveyors with requested MARs showing medication administration times for two residents, after being instructed by the COO to withhold these records due to an ongoing internal QA investigation that began when the residents reported late medication administration.
Multiple residents with significant medical and mobility needs reported frequent and prolonged delays in receiving care, particularly during evening, night, and weekend shifts, due to insufficient staffing. Staff interviews and assignment records confirmed that the facility often operated with fewer CNAs and nurses than needed, resulting in missed or delayed care tasks such as toileting and showering. Facility leadership maintained that staffing was adequate, despite evidence to the contrary and the absence of a formal staffing policy.
A resident with chronic kidney disease and neuromuscular bladder dysfunction did not have their indwelling urinary catheter changed as ordered by the physician, with no documented catheter change for over two months. Multiple staff interviews confirmed the catheter was not changed within the required timeframe, despite clear orders and care plan interventions.
A resident with multiple medical and psychiatric diagnoses had an MDS annual assessment inaccurately coded, with the PASRR section marked as 'No' for serious mental illness despite active diagnoses of bipolar disorder, psychotic disorder, and schizophrenia. The LPN responsible at the time was not involved in the original assessment, and the administrator confirmed the absence of a specific policy for MDS accuracy, relying instead on the RAI Manual.
A resident with a stage 3 pressure ulcer did not receive wound care according to the most recent physician's orders due to the facility's failure to update the Treatment Administration Record and Physician Order Sheet. Nursing staff continued to provide the previous daily treatment regimen instead of the updated protocol, resulting in care not being delivered as ordered.
A resident with lower extremity impairment and multiple chronic conditions did not receive required range of motion (ROM) services. Despite documented dependence for self-care and mobility, there were no physician orders or restorative nursing interventions for ROM, and staff confirmed that no ROM care was provided or documented.
A resident with severe cognitive impairment and a history of Alzheimer's Disease experienced significant weight loss due to the facility's failure to consistently monitor and document meal intakes and weekly weights as ordered. Despite being at risk for malnutrition and requiring full staff assistance for eating, there were repeated gaps in meal intake records and no documentation of meal refusals, contributing to inadequate assessment and intervention for the resident's nutritional needs.
Two residents with pressure ulcers, both on enhanced barrier precautions, received wound care from an LPN who wore gloves but failed to don a gown as required by facility policy. Despite clear signage and staff awareness of the precautions, the proper use of personal protective equipment was not followed during high-contact care activities.
A facility failed to maintain adequate staffing levels, impacting resident care. A resident reported inconsistent care and missed showers due to staffing shortages, while another was observed not being repositioned as required. Staff interviews revealed systemic staffing issues, particularly after 2 P.M. and on weekends, with discrepancies in the staffing schedule and resident grievances about call bell response times.
The facility failed to provide adequate care for two residents, one of whom did not receive consistent repositioning, and another who experienced delays in call light responses and missed scheduled showers due to staffing shortages. The administration acknowledged staffing challenges, which affected the ability to meet residents' care needs.
A resident with chronic heart failure did not receive a prescribed Furosemide injection due to unavailability in the medication cart and emergency kit. The LPN failed to notify the physician or communicate the issue to the day shift, leading to a significant medication error. The facility's policy requires using the emergency kit and notifying the physician when medications are unavailable, which was not followed in this instance.
Failure to Manage and Document PRN Psychotropic (Ativan) Use and Respond to Family Concerns
Penalty
Summary
The deficiency involves the facility’s failure to appropriately manage and document the use of the psychotropic medication Ativan for one resident with dementia, anxiety, depression, and Alzheimer’s disease. The resident’s diagnoses included unspecified dementia with agitation, generalized anxiety disorder, Alzheimer’s disease, and depression. The resident’s care plan identified multiple behavior-related focus areas, including anxiousness, restlessness, destructiveness, potential physical aggression, delusional thinking, hallucinations, delirium, and acute confusion, with interventions that included administering psychotropic medications as ordered and monitoring for effects and effectiveness every shift. The Minimum Data Set documented that the resident was not cognitively intact, had frequent depressive symptoms, and exhibited behaviors such as hitting, scratching self, pacing, rummaging, public sexual acts, and public disrobing, and that the resident was on high-risk drug classes including an antipsychotic and an antidepressant. The facility’s records showed multiple Ativan orders with inconsistent and clinically questionable indications and inadequate documentation. An initial PRN Ativan order for 0.5 mg every 12 hours was entered with an indication of nausea related to depression, followed by a second PRN order for the same dose every 12 hours for comfort related to Alzheimer’s disease, and later a routine order every 12 hours for anxiety, aggression, and agitation related to generalized anxiety disorder. The nurse practitioner later stated that the first indication (nausea related to depression) was something she had only seen in hospice and not related to depression, and that neither the first nor second indication (comfort related to Alzheimer’s) was appropriate. The February MAR showed that the resident received PRN Ativan multiple times under these orders, but progress notes documented the symptoms or reasons for administration on only 1 of 7 PRN doses under the first order and 1 of 4 PRN doses under the second order. Nursing staff, including the DON and an LPN, stated they did not believe it was necessary to write a progress note each time a PRN medication was administered and believed the diagnosis on the MAR was sufficient, and one LPN could not recall the resident’s symptoms at the time she administered Ativan. The facility also failed to respond appropriately to a pharmacy review and to family concerns regarding Ativan use. A pharmacist’s medication review form for the PRN Ativan order requested that the prescriber choose among options to discontinue, add a stop date per CMS 14-day PRN psychotropic guidelines, or extend the order with a specified duration, indication, and rationale. None of these options were selected, and the prescriber response section was left blank, with no indication that the prescriber acknowledged or signed the review. The administrator acknowledged that PRN psychotropic medications should be reviewed within 14 days and either reordered or discontinued and was unsure why this review was missed. The resident’s power of attorney and another family member reported that Ativan had previously caused an idiosyncratic, opposite reaction at home, that they had stopped it before admission, and that they requested on multiple occasions that Ativan not be administered. They stated they were not informed when Ativan was discontinued and then reordered, and one family member denied giving verbal consent for Ativan use. Nursing staff, including an RN and an LPN, reported that each time the resident received Ativan he became more aggressive, violent, and agitated, and one RN stated she had voiced concerns to the DON. Despite these reports and the family’s requests, Ativan was reordered and administered multiple times, with inadequate documentation of indications and without clear evidence of prescriber review or acknowledgment of the pharmacist’s recommendations.
Failure to Maintain Safe Hot Water Temperatures for Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to provide adequately heated water for showers and personal care to all eight residents reviewed for environmental conditions. Surveyors verified thermometer accuracy and then documented multiple instances where hot water temperatures at resident sinks and in shower rooms were significantly below the facility’s stated safe range of 100–110°F. On several occasions, water at resident bathroom sinks did not exceed temperatures ranging from approximately 63°F to 96°F even after running for several minutes, and shower water temperatures in the North Hall shower rooms were recorded between 66°F and 85°F. Residents who were alert and oriented reported that the water in their sinks was too cold to wash their hands or was sometimes not warm, and a CNA was observed moving a resident from one shower room to another because the water was not warm enough. The Maintenance Director stated he only checks water temperatures at faucets and not in showers, relying on a loop system that he believed should keep temperatures consistent, and reported that temperatures appear fine when he checks them early in the morning before showers are given. The Administrator stated his expectation, consistent with the facility’s Water Temperature Safety Guideline, is that water temperatures in resident sinks, showers, and tubs remain between 100–110°F and be checked per protocol. The facility’s written guideline specifies that this temperature range is intended to help prevent resident burns and reduce the risk of bacteria growth by keeping water at safe temperatures, yet the documented observations show that resident care areas, including individual bathrooms and shower rooms, did not consistently meet these parameters during the survey.
Failure to Obtain Ordered Labs and Monitor Decline Leading to Acute Renal Failure
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders, obtain and act on ordered laboratory tests, and adequately assess and monitor a cognitively intact resident with multiple serious comorbidities, including acute on chronic heart failure, COPD, acute kidney failure, CKD stage IIIa, and insulin‑dependent type 2 diabetes. The resident was admitted with dysphagia, poor intake, and an indwelling catheter, and the MDS documented substantial/maximal assistance for toileting and use of an indwelling catheter. The care plan included psycho‑social and delirium focus areas, with an intervention to report abnormal lab results to the MD, and a nutritional problem related to dysphagia with instructions to monitor and record intake every meal; however, there were no care plan focus areas for diabetes mellitus or the indwelling catheter. On 12/28, nursing documentation showed the resident was not taking food or thickened liquids, was non‑verbal, and had a firm bladder; a Foley catheter was inserted with 450 ml of clear yellow urine obtained, and the MD was notified. Later on 12/28, the MD ordered Megace, CBC, CMP, TSH, UA and urine culture, protein supplements, and nutrition and psychiatry consults. The order summary reflected one‑time orders for CBC, CMP, TSH, and UA with culture starting 12/29, as well as an order for morning accuchecks for diabetes and, later, an order to record catheter output every shift starting 01/07. The DON later stated the CBC, CMP, and TSH were never completed because the nurse entered them on the wrong flowsheet so they did not populate to the EMAR, and the facility did not discover this until after the incident. The DON also acknowledged that the UA was completed but the results, which ultimately showed >100,000 CFU/mL Pseudomonas fluorescens and >100,000 CFU/mL Enterococcus faecalis, were not available in the chart until they were printed weeks later; the Administrator stated the lab was supposed to deliver results and that nurses should have followed up. Staff interviews showed that, despite the presence of an indwelling catheter and poor intake, the facility’s practice was not to monitor intake or output unless there was a specific physician order, and the Administrator and DON confirmed they did not routinely monitor outputs with a catheter unless ordered. From 01/07 through 01/11, the treatment record documented catheter outputs that nephrology later characterized as not good outputs and potential indicators of renal problems or poor intake, with several shifts showing low volumes and some shifts with no output recorded. CNAs and nurses reported the resident was not drinking well, was a poor eater, had very little urine in the catheter bag, complained of needing to urinate, and had shortness of breath at times. The MAR showed ordered morning accuchecks for diabetes, but there were no documented blood glucose checks on several days, including 01/11. On 01/11, the family member, using a continuous glucose monitor, reported blood sugars in the 60s throughout the day and found the resident shaking and struggling to breathe. The Assistant DON gave the family member a tube of instant glucose to administer, did not check the resident’s blood sugar at that time, and later stated she did not know why she allowed the family member to give it. The family member reported the nurse “threw” the glucose and spoon at her without instructions and did not enter the room until after 911 was called. EMS documented that the nurse said she had not called 911 and saw no reason to send the resident out, that the nurse refused to assist EMS in the room, that the resident’s SpO2 was 89% and improved with 3 L O2, and that the catheter drainage was cloudy with specks of blood and minimal output. The resident was transported to the hospital, where he was diagnosed with acute renal failure and hyperkalemia requiring emergent dialysis, and was later transferred to another hospital for higher‑level nephrology care and ultimately to hospice, where he died. The surveyors determined that the facility failed to obtain ordered labs, failed to follow up on UA and culture results, and failed to notify the physician of the resident’s decline, resulting in delayed medical treatment and constituting Immediate Jeopardy beginning 12/28.
Failure to Maintain Adequate Nursing Staff and Timely Call-Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs and to ensure timely response to call lights. Multiple alert and oriented residents reported waiting 30 minutes to an hour for assistance, particularly on evening and night shifts. One resident stated she intentionally activated her call light to see which staff were working and waited over 30 minutes before the administrator answered her light, noting this type of delay happens frequently in the evenings when there is often only one CNA per hall. Another resident reported waiting over half an hour on several nights for staff to answer her call light, including an occasion when her bed was soaked and she was freezing from lying in urine. A third resident stated she had to wait 30–45 minutes for staff to respond when she needed to be changed and had to lie in urine during the wait, and that this occurs often on both day and evening shifts. A fourth resident reported being on her call light for over 30 minutes after an incontinent episode and ultimately called the nurses’ station before the DON came to assist her, stating that evening call light response can take 30–45 minutes or up to an hour. Surveyor observations on one evening documented that only two CNAs were initially working the floor, with an agency nurse on duty who had never been at the facility before. One CNA was observed taking residents outside to smoke on the North Hall, leaving no other CNA on that hall. During this time, four call lights were observed going off in separate rooms on the North Hall and remained unanswered for an extended period. The DON directed the CNA to obtain vital signs equipment and assess a sick resident in the dining room while the call lights continued to sound. The CNA then answered the phone and reported that a resident was calling for help. A resident’s voice was later heard yelling for help from the North Hall while the same call lights remained on. It was not until approximately 7:21 p.m. that the CNA entered one of the rooms, followed by the administrator entering another room, and call lights in the affected rooms were gradually turned off. Another CNA arrived later in the evening to assist. Time clock records and staff interviews further demonstrated staffing shortages. Punch records showed that from just before midnight until 1:42 a.m. on one date, only one CNA and one agency nurse were in the building to care for 45 residents. Multiple CNAs and an RN stated the facility did not have enough staff to adequately care for all residents, describing frequent call-ins, no-shows, and the lack of agency CNAs to cover open shifts. Staff reported that when they worked short, some resident care needs were not completed and that on some nights there was only one CNA on the North Hall and one CNA on the South or memory care unit with one nurse. One CNA confirmed being called in at 1:40 a.m. because only one CNA and one nurse were on duty. Another CNA stated that North Hall was more demanding and that, although the schedule called for multiple CNAs, call-ins often left the facility short without coverage. Despite this, the administrator stated he felt call lights were answered timely and that the facility had enough staff, although he also stated he did not think a single CNA on a hall should be taking residents out to smoke and leaving no staff on the hallway, and he was not aware of the period when only one CNA and one nurse were working overnight. The facility’s undated staffing policy stated that it is the policy of the facility to provide an adequate number of staff to meet resident needs and to maintain adequate staffing ratios, including scheduling relief staff during vacations, holidays, and relief periods. However, the documented resident reports of prolonged call light response times, observations of unanswered call lights and residents calling out for help, verified periods with only one CNA and one nurse on duty for the entire facility, and staff statements that resident care needs sometimes could not be completed due to insufficient staffing, all occurred despite this written policy.
Failure to Respond Timely to Call Lights Resulting in Prolonged Incontinence and Loss of Dignity
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to timely care and dignified treatment by not responding promptly to call lights, particularly on the North Hall. Multiple cognitively intact or moderately impaired residents who were dependent on staff for toileting and repositioning reported extended delays, often 30–60 minutes, before staff responded to their requests for assistance. These delays occurred despite care plan interventions that emphasized keeping call lights within reach and encouraging residents to use them for help, as well as documentation that several residents were incontinent and required extensive or total assistance with ADLs and toileting. One resident with chronic respiratory failure, type 2 diabetes, morbid obesity, chronic kidney and heart disease, and a history of moisture-associated skin damage reported that on an evening shift she waited over 30 minutes for her call light to be answered, and that such delays of 30 minutes to an hour happened frequently, especially in the evenings. This resident was bedbound, dependent on staff for toileting and repositioning, always incontinent of bowel, and at risk for impaired skin integrity, yet she reported that often only one CNA was assigned to her hall and one CNA to the other hall. Another resident with Parkinson’s disease, COPD, panic disorder, and fibromyalgia, who required assistance with ADLs and was occasionally incontinent, stated she had to wait over an hour on an evening shift for her call light to be answered while lying in a soaked bed and feeling cold from being in her urine. She reported that when still in her wheelchair, she would sometimes wheel into the hall to look for staff because of the delays. A third resident with permanent atrial fibrillation, chronic respiratory failure, type 2 diabetes, unsteadiness on feet, and chronic pain, who was always incontinent and dependent for toileting hygiene, stated she had her call light on several times one night and had to wait 30–45 minutes each time for staff to respond, during which she lay in urine while waiting to be changed. A fourth resident with hemiplegia, type 2 diabetes, COPD, morbid obesity, neurocognitive disorder with Lewy bodies, dementia with behavioral disturbance, Parkinson’s disease, and multiple other comorbidities, who was always incontinent and dependent for toileting and transfers, reported being on her call light for over 30 minutes one night, even calling the nurses’ station for help, while waiting to be changed after an incontinent episode. She stated that such delays in the evening occurred often and that it could take 30–45 minutes, sometimes an hour, for call lights to be answered. Surveyor observations and staff interviews corroborated these reports of delayed responses. On one evening, the DON stated that only two CNAs were working the floor, one CNA had called in, another had not shown up or called, and an agency nurse unfamiliar with the facility was the nurse on duty. The DON also stated another CNA was coming in later to help. During this time, the CNA assigned to the North Hall was observed taking residents outside to smoke, leaving no other CNA visible on that hall. Multiple call lights were observed activated in four separate rooms on the North Hall for an extended period while the CNA was outside and then occupied with other tasks, including taking vital signs on a resident in the dining room and answering the phone. An unknown resident was heard yelling for help from the North Hall while call lights continued to sound. The Administrator later stated he felt staff answered call lights in a timely manner but acknowledged that if only one CNA was on a hall, that CNA should not be taking residents out to smoke and leaving no staff on the hallway. The facility’s policy on answering call lights stated that the purpose of the procedure was to respond to residents’ requests and needs, but the observed and reported delays demonstrated a failure to follow this policy.
Failure to Provide Timely Post-Fall Assessment and Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident who experienced a fall. The resident, who was at high risk for falls and dependent on staff for all transfers, was found on the floor in her room after an unwitnessed fall. There was no documentation in the progress notes of the fall or a post-fall evaluation on the date of the incident, despite facility policy requiring such documentation. Staff did not perform or document a timely assessment, and the fall was not reported to the physician or the resident's family as required. Following the fall, the resident exhibited signs of pain and swelling in her leg, which were noticed by family members and reported to staff. Multiple staff interviews revealed that the resident's pain was reported to the nurse on duty, but no action was taken to assess or address the resident's condition. The nurse involved did not assess the resident after the fall, nor did she notify the family or physician, and the resident continued to display symptoms over the following days. The resident was eventually sent to the hospital at the request of her family, where she was diagnosed with fractures in her left femur and right hip. The lack of timely assessment, monitoring, and reporting after the fall resulted in a delay in treatment for the resident's injuries. The facility's failure to follow its own fall guidelines and professional standards of care led to the deficiency cited in the report.
Failure to Assess and Manage Pain Following Resident Fall
Penalty
Summary
A deficiency occurred when a resident who was at risk for falls and dependent on staff for all transfers was not properly assessed for injury and pain following a fall. The resident, who had a history of muscle weakness, abnormal gait, and prior knee replacements, was found to have sustained a hip and femur fracture. Despite having physician orders for as-needed pain medications, the resident did not receive any pain relief between the dates surrounding the incident, and pain assessments documented minimal or no pain, even though family members and staff observed signs of pain and physical abnormalities in the resident's leg. Family members reported that the resident appeared to be in pain and had visible leg deformities, prompting them to request further evaluation. Staff interviews revealed that pain and injury were reported to a nurse, but there was no evidence that the nurse conducted a thorough assessment, notified the physician or family, or administered pain medication. Documentation in the resident's medical record did not reflect the pain complaints or the fall, and pain assessments were inconsistent with the observations of pain by family and staff. When the resident was eventually sent to the hospital, x-rays confirmed fractures in the left femur and right hip. Hospital records indicated that the resident and her family had reported pain for several days prior to transfer, but the facility's records did not document these complaints or provide appropriate pain management. The facility's fall policy required consistent identification, evaluation, and treatment of residents who fall, which was not followed in this case.
Improper Mechanical Lift Transfer Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for all transfers and toileting due to lower extremity impairment and other medical conditions, was improperly transferred using a mechanical lift. The resident had a BIMS score indicating cognitive intactness and required two staff members for safe transfer according to facility policy. On the day of the incident, a CNA responded to the resident's call light and, despite knowing the policy, attempted to transfer the resident alone using a sit-to-stand lift. During the transfer, the resident slipped out of the straps and fell, resulting in a head injury and a 1.2 cm laceration that required three staples. The facility's investigation and interviews confirmed that the CNA did not wait for a second staff member before using the mechanical lift, which was against established policy. The resident's emergency room records corroborated the account of the fall and injury. The root cause analysis identified improper use of the mechanical lifting device as the cause of the incident. Facility policy clearly stated that at least two nursing assistants are required for such transfers, but this protocol was not followed in this instance.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Medication Administration Records During Survey
Penalty
Summary
The facility failed to provide requested medical records, specifically the July 2025 Medication Administration Records (MARs) for two residents, which were needed to assist the survey process. The MARs reviewed in the Electronic Health Records did not document the actual time medications were administered. When the surveyor requested MARs with documented and timestamped medication administration times, the Director of Nursing (DON) stated he was instructed by the Chief Operating Officer not to provide these records or allow the surveyor to view them, citing an ongoing internal Quality Assurance investigation. The internal investigation had been initiated after the two residents reported that their medications were being administered outside of the ordered time ranges.
Failure to Provide Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the care needs of all residents, as evidenced by multiple resident and staff interviews, observations, and record reviews. Several residents with complex medical conditions, including diabetes, morbid obesity, chronic obstructive pulmonary disease, chronic pain, and mobility impairments, reported frequent and prolonged delays in receiving assistance, particularly with activities of daily living (ADLs) such as toileting, showering, and repositioning. Residents consistently described long wait times for call light responses, especially during evening, night, and weekend shifts, with some reporting waits of up to two hours. Staff interviews corroborated these accounts, with multiple CNAs and nurses stating that the facility was regularly short-staffed, particularly on night shifts and weekends. Staff reported difficulty completing required rounds and providing timely care, with some stating that showers and other essential care tasks were often missed due to inadequate staffing. Assignment records confirmed that on several occasions, only one nurse and two CNAs were present to care for all 47 residents during overnight shifts, which was below the facility's own assessment of required staffing levels. Despite these findings, facility leadership, including the Administrator and DON, maintained that staffing was adequate, though they acknowledged occasional reliance on agency staff and admitted to shifts with only two CNAs and one nurse. The facility did not have a formal staffing policy in place. The deficiency was identified through direct resident and staff testimony, review of care plans and assignment sheets, and census data, all of which demonstrated a pattern of insufficient staffing that affected the ability to meet residents' care needs.
Failure to Change Indwelling Urinary Catheter per Physician Orders
Penalty
Summary
A deficiency occurred when a resident with chronic kidney disease, benign lipomatous neoplasm of the kidney, and neuromuscular dysfunction of the bladder did not have their indwelling urinary catheter changed according to physician orders. The resident's care plan and physician orders specified that the catheter should be changed once monthly and as needed for infection prevention. However, review of the Treatment Administration Records (TAR) for three consecutive months showed no documentation that the catheter was changed during this period. The last documented catheter change was on 3/28/25, and both the resident and multiple nursing staff confirmed that no catheter change had occurred in the subsequent two months. Interviews with the Medical Doctor, Director of Nursing, and other nursing staff confirmed that the expectation was for the catheter to be changed every thirty days as ordered. Despite this, none of the nurses interviewed recalled changing the catheter for the resident during the required timeframe, and the Director of Nursing was unable to identify any staff who had performed the change. The deficiency was identified when the catheter was finally changed on 6/16/25, more than two months after the previous change, and the physician was notified that this was the first change in over two months.
Inaccurate MDS Assessment Coding for Resident with Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for one resident. The resident, a 71-year-old individual with multiple diagnoses including unspecified atrial fibrillation, type 2 diabetes mellitus, edema, osteoarthritis, obesity, venous insufficiency, and psychiatric/mood disorders, had an MDS annual assessment completed with discrepancies. Specifically, Section A1500 of the MDS, which addresses the Preadmission Screening and Resident Review (PASRR), was marked as 'No' for serious mental illness or intellectual disability, despite the resident having active diagnoses of bipolar disorder, psychotic disorder, and schizophrenia as indicated in Section I of the same assessment. Interviews revealed that the LPN responsible for MDS at the time of the survey was not the one who completed the July MDS and was not employed at the facility during that period. The LPN acknowledged that Section A1500 was not documented appropriately. The facility administrator confirmed there was no specific policy for accurately completing MDS assessments and stated that staff are expected to follow the RAI Manual for guidance.
Failure to Update and Follow Physician's Orders for Pressure Ulcer Care
Penalty
Summary
A deficiency occurred when the facility failed to provide pressure wound treatment according to the physician's updated orders for one resident with a stage 3 pressure ulcer. The resident, who had diagnoses including chronic kidney disease, polyneuropathy, and peripheral vascular disease, was admitted with a stage 3 pressure injury to the right buttock/ischium. The initial physician's order directed daily wound care with wound cleanser, barrier wipe, calcium alginate, and bordered gauze. However, a new order was issued by the wound care nurse practitioner to change the treatment to cleansing, application of collagen, and covering with bordered gauze three times per week and as needed. Despite the updated order, the Treatment Administration Record (TAR) and Physician Order Sheet (POS) were not updated to reflect the new treatment regimen. Nursing staff continued to provide the previous daily treatment, as observed during wound care, and the documentation showed the outdated treatment was administered. The Director of Nursing acknowledged that the new order had not been entered into the medical record, resulting in the resident not receiving wound care as per the most recent physician's instructions.
Failure to Provide Range of Motion Services for Resident with Impairment
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including osteoarthritis, obesity, and lower extremity impairment, did not receive range of motion (ROM) services as required. The resident's Minimum Data Set (MDS) documented significant functional limitations and dependence on staff for activities of daily living, including self-care and mobility. Despite these documented needs, there were no physician orders for ROM or restorative nursing programs, and the care plan interventions focused only on assistance with daily activities, not on maintaining or improving ROM. Interviews with facility staff confirmed that the resident had not received any active or passive ROM services, and there was no documentation in the electronic medical record to indicate that such care was provided. The Director of Nursing acknowledged the absence of restorative CNA services and related charting, while the Director of Therapy stated the resident had only been verbally screened and had not received therapy services. The facility's policy required contacting the physician for treatment orders if none existed, but this was not done prior to the survey findings.
Failure to Monitor and Document Nutrition for Resident with Significant Weight Loss
Penalty
Summary
The facility failed to adequately monitor and document the weights and meal intakes for a resident with significant weight loss. The resident, who had diagnoses including early onset Alzheimer's Disease and osteoarthritis, was identified as being at risk for altered nutrition and required at least partial or moderate assistance with eating. Despite physician orders for a regular diet with puree texture, thin liquids, and weekly weights, there were multiple instances in April and May where meal intake documentation was missing, with no indication if meals were refused. The resident's weight showed a significant downward trend, with a loss of over 12% in three months, triggering concern for malnutrition. The registered dietician noted the resident averaged 25-75% meal intake and was refusing some meals, and recommended nutritional supplements and fortified foods to address the weight loss. Observations confirmed the resident required full staff assistance for eating and had severe cognitive deficits. Interviews revealed that the registered dietician was not responsible for ordering weekly weights and assumed the primary care physician had done so. The facility's policy required the multidisciplinary team to monitor and intervene for undesirable weight loss, with specific thresholds for significant and severe weight loss. However, the lack of consistent documentation of meal intake and adherence to weight monitoring orders contributed to the failure to properly assess and address the resident's nutritional status.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to follow its Enhanced Barrier Precautions (EBP) policy for two residents who had pressure ulcers and were on EBP due to their wounds. For both residents, signage was posted on their doors instructing that all staff must clean their hands before entering and leaving the room, and that providers and staff must wear gloves and a gown during high-contact care activities such as wound care. Despite these instructions, a Licensed Practical Nurse (LPN) was observed entering the rooms of both residents to provide wound care while only donning gloves and not a gown. Both residents had significant medical histories, including chronic kidney disease, polyneuropathy, peripheral vascular disease, chronic obstructive pulmonary disease, and traumatic brain injury. Each had a documented pressure ulcer, with one resident having a stage 3 ulcer and the other an unstageable ulcer. The LPN acknowledged that both residents were on enhanced barrier precautions due to their wounds and confirmed that staff are required to don both gown and gloves before providing care. The Director of Nursing also confirmed that the LPN should have worn a gown in addition to gloves during the observed wound care activities.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing levels to meet the needs of all residents, as evidenced by the experiences of two residents, R5 and R9. R5, who is cognitively intact and requires extensive assistance with activities of daily living due to multiple health conditions, reported inconsistent care, including delays in call light responses and missed showers due to staffing shortages. R5 noted that the facility was particularly short-staffed on weekends, leading to missed showers and inadequate care. R9, who is severely cognitively impaired and dependent on staff for basic care needs, was observed over two days to remain in the same position in bed without being repositioned, contrary to the care plan that required repositioning every two hours. Despite the Director of Nursing's expectation for regular repositioning, observations indicated that R9 was not receiving the necessary care, highlighting a failure in staff adherence to care protocols. Interviews with staff, including the Director of Nursing and various CNAs, revealed systemic staffing issues, with reports of insufficient staff to cover shifts, particularly after 2 P.M. and on weekends. The facility's staffing policy was unclear, and there were discrepancies in the staffing schedule, leading to inadequate care for residents. The facility's grievance summary also documented resident concerns about call bell response times, further indicating the impact of staffing shortages on resident care.
Deficiency in Resident Care and Staffing Issues
Penalty
Summary
The facility failed to provide adequate care and assistance for activities of daily living for two residents, R5 and R9, as observed during the survey. R5, who is cognitively intact and requires extensive assistance due to reduced mobility and other health conditions, reported inconsistencies in receiving ice water and delays in call light responses, sometimes waiting up to two hours. R5 also mentioned not receiving scheduled showers on weekends due to staffing shortages, which was corroborated by the facility's staffing records showing insufficient CNA coverage on those days. R9, who is severely cognitively impaired and dependent on assistance for daily activities, was observed over two days to remain in the same position on his back without being repositioned every two hours as required. Despite the facility's policy and the Director of Nursing's expectations for regular repositioning, R9 was not turned or repositioned, and staff were unsure of when repositioning occurred. This lack of adherence to care plans and facility policies highlights a deficiency in providing necessary care to maintain residents' health and comfort. The facility's administration acknowledged issues with staffing, noting that corporate decisions had led to reduced staffing levels, impacting the ability to provide consistent care. The Director of Nursing and other staff members admitted to challenges in maintaining adequate staffing, particularly on weekends and during night shifts, which contributed to the failure in meeting residents' care needs. Despite efforts to cover shifts and assist on the floor, the facility's staffing practices were insufficient to ensure compliance with care plans and policies, resulting in the observed deficiencies.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Furosemide (Lasix) injections. The resident, who has a complex medical history including chronic diastolic heart failure and chronic kidney disease, was prescribed Furosemide to be administered intramuscularly twice a week. On one occasion, the medication was not administered because it was not available in the medication cart or the emergency kit. The Licensed Practical Nurse (LPN) on duty did not notify the physician or pass the information to the day shift, resulting in the resident missing a dose of the critical medication. The Director of Nursing (DON) and other nursing staff confirmed that the facility has an emergency medication kit to prevent such occurrences, and it is expected that nurses utilize this resource when medications are not available. However, the LPN did not follow the facility's policy, which requires notifying the attending physician and obtaining alternative orders when a medication is unavailable. The failure to administer the medication and the lack of communication with the physician or pharmacy were identified as significant deficiencies in the facility's medication administration process.
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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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