The Pearl Of Downers Grove
Inspection history, citations, penalties and survey trends for this long-term care facility in Downers Grove, Illinois.
- Location
- 3450 Saratoga Avenue, Downers Grove, Illinois 60515
- CMS Provider Number
- 145657
- Inspections on file
- 38
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at The Pearl Of Downers Grove during CMS and state inspections, most recent first.
A resident who was quadriplegic, non-verbal, on hospice, and at high risk for pressure injuries developed a large left ischial pressure injury after staff failed to promptly assess, document, and treat a newly reported wound. A CNA reported a red, bleeding area on the buttocks to an RN, but the RN did not assess or document the wound and no dressing was applied. The wound nurse learned of the issue from an aide the next day and found a large deep tissue injury without a dressing, which later progressed to an unstageable pressure injury. The resident had a prior healed ischial ulcer, used a wedge and low air loss mattress, depended entirely on staff for repositioning, and staff acknowledged that new wounds should be immediately reported, assessed, documented, and managed according to facility policy.
A resident with multiple urologic and medical conditions was found with an indwelling urinary catheter drainage bag hanging from a bedside table drawer handle, with tubing not maintained below bladder level and the securement device not attached to the leg. The resident reported prior penile tearing related to lack of anchoring and infrequent emptying of the drainage bag and stated a request for a new anchoring device the previous day was not addressed. An LPN acknowledged the presence of a penile tear, had not assessed the area that morning, and reported the bag had contained 1600 cc of urine earlier, despite expectations that bags be emptied at least each shift. The ADON described required catheter care practices, including use of a stat lock and keeping the bag below bladder level, and the resident’s care plan included securing tubing and maintaining bag position but did not address the existing meatal tear, contrary to the facility’s catheter policy requiring securement and support of tubing.
A resident at moderate risk for pressure injuries developed a deep tissue injury (DTI) due to the facility's failure to implement and document appropriate preventive and treatment interventions. Despite being assessed as high risk, the care plan lacked specific measures to prevent pressure injuries while the resident was seated. Observations revealed that pressure-relieving boots were not used as ordered, and the resident's feet were not properly offloaded, contributing to the injury's development and persistence.
A resident with severe cognitive impairment sustained significant bruising and pain due to a fall while being transported in a wheelchair without leg rests by a CNA. The resident's foot got caught underneath the wheelchair, causing her to slide out and hit her head. Staff interviews confirmed that the use of leg rests could have prevented the fall.
The facility failed to provide adequate nursing staff, resulting in delayed call light responses and insufficient ADL care for residents. Several residents reported extended wait times for assistance, particularly during evening and overnight shifts. Staffing records showed a discrepancy between required and actual CNA numbers, with units often understaffed, affecting care quality.
The facility failed to employ a qualified food service manager for its 83 residents. The Food Service Manager had not enrolled in or completed a dietary manager course, although she held a Serve Safe Sanitation certification. The facility did not provide documentation verifying her qualifications.
The facility failed to serve meals according to the dietitian-approved menu, affecting 82 residents on oral diets. Mechanical soft diets were served without bread, and hamburger patties were underweight, providing insufficient protein. The dietitian confirmed the menu did not meet the expected protein requirements. Additionally, weekly menus consistently lacked required servings of grains, breads, vegetables, and fruits, indicating systemic issues in menu planning and execution.
The facility failed to maintain proper hand hygiene and sanitizing procedures in the dietary department. A dietary aide handled both soiled and clean dishes without washing hands or changing gloves, contrary to facility policy. Additionally, the sanitizing solution used for food contact surfaces was below the required concentration, failing to meet the manufacturer's instructions.
The facility failed to conduct comprehensive infection surveillance, maintain a complete water management program for Legionella, and adhere to Enhanced Barrier Precautions (EBP) and hand hygiene policies. The Director of Nursing did not complete McGeer's Criteria assessments for infections, and the Maintenance Director did not document water temperatures or perform chlorine testing. An LPN failed to wear PPE and perform hand hygiene during resident care, and a wound nurse was unaware of a resident's EBP order, failing to use PPE while examining a wound.
The facility failed to follow its antibiotic stewardship policy, affecting all residents. The DON did not use McGeer's Criteria to assess infections, leading to inappropriate antibiotic prescriptions. Monitoring of antibiotic use was incomplete, and staff were not instructed on using McGeer's Criteria, indicating systemic issues in training and communication.
The facility failed to develop comprehensive care plans for residents, leading to deficiencies in addressing specific care needs. A resident with an indwelling urinary catheter lacked a care plan for its use and infection prevention. Another resident with a pressure injury had inadequate care plan interventions for pressure relief. Additionally, residents with psychiatric and cognitive impairments had care plans that did not address their diagnoses or medication use.
A facility failed to refer a resident with a new diagnosis of unspecified psychosis for a Level II PASRR, as required for significant changes in mental health conditions. The resident was initially admitted with major depressive disorder, anxiety disorder, and seizures. Staff interviews revealed confusion and lack of responsibility regarding the PASRR process, with the Admissions Coordinator unaware of the need for re-screening and the Social Services Director not involved in the process. The facility's policy mandates rescreening for new mental health diagnoses, but no documentation was found for this resident.
A facility failed to accurately complete a PASRR for a resident with mental health conditions, as the Admissions Coordinator, who was not a qualified healthcare professional, omitted the resident's mental health diagnoses and medications from the submission. This led to an incorrect Level I outcome, despite the resident's documented conditions and prescribed medications.
A facility failed to update a care plan with specific fall-prevention interventions for a cognitively impaired resident with a history of falls. The resident fell while being transported in a wheelchair without leg rests, resulting in a bruise and hospital evaluation. Despite prior falls, the care plan lacked updated interventions, and no root cause analysis was conducted. The Acting DON confirmed no care plan revision or targeted prevention measures were implemented.
A resident did not receive restorative therapy as per facility policy. The resident expressed a desire for therapy, and a referral was made to the DON, who was unaware of it. The facility's policy requires screening for restorative care, but understaffing led to CNAs not providing therapy.
The facility failed to provide adequate nail care to three residents who were dependent on staff for ADLs. Observations revealed long, untrimmed fingernails with debris, and some embedded into palms due to contracted hands. Despite care plans indicating a need for total assistance, these residents did not receive necessary nail care, compromising their comfort and hygiene.
The facility failed to provide necessary interventions and positioning devices for two residents with limited range of motion, leading to further contractures. One resident was found without a splint for her contracted hand, and her care plan lacked specific interventions. Another resident had a flexion contracture and was supposed to have a splint, but it was not provided. The facility's policy on mobility and range of motion was not followed.
A facility failed to document the justification for the continued use of an indwelling urinary catheter for a resident who developed a urinary tract infection. The resident, with multiple health issues and cognitive impairment, had an indwelling catheter without documented reasons or care instructions. The care plan lacked interventions for infection prevention, and the Acting DON admitted there was no documentation or policy for evaluating catheter use.
A facility failed to create a person-centered care plan for a resident with Alzheimer's disease, despite the resident's moderate cognitive impairment and multiple diagnoses. The care plan, completed in March, lacked specific interventions for dementia care, which was acknowledged by the Social Services Director.
A resident with multiple non-pressure wounds did not receive the prescribed wound care treatments as ordered by the wound physician. The Treatment Administration Record did not reflect the physician's orders for xeroform gauze and gauze roll, leading to inappropriate wound care. Observations and interviews confirmed the facility's failure to adhere to the prescribed treatment plans.
The facility failed to implement ordered pressure ulcer treatments for three residents. A resident with a Stage 4 pressure ulcer did not receive the prescribed xeroform gauze or silver sulfadiazine, and another resident's deep tissue injuries were not treated according to the physician's plan. Additionally, a third resident's treatment plan was not updated in the TAR, leading to improper care. The facility did not adhere to its policy on pressure injury prevention and management.
A facility failed to follow infection control protocols during wound care for a resident in isolation for MRSA and C. Striatum. An LPN brought a treatment cart into the isolation room and did not change gloves or perform hand hygiene during the dressing change, risking cross-contamination. The Infection Preventionist confirmed that such actions violate facility policies.
A facility failed to honor a resident's right to manage their financial affairs by applying to become the representative payee for the resident's Social Security income without the spouse's consent. Despite the spouse being the designated Power of Attorney, the facility's Business Office Manager proceeded with the application due to unpaid room and board fees, inaccurately stating that the resident owed no money. The facility's administrator acknowledged that family permission should have been obtained.
A resident with a history of knee fractures and dementia sustained left and right femoral fractures due to improper transfer assistance. The CNA performed a pivot transfer without a gait belt, leading to the injuries. The care plan was incomplete and not updated, contributing to the incident.
The facility failed to maintain clean and sanitary resident rooms for four residents. Observations showed full garbage containers, food debris, and soiled items in bathrooms and rooms. Staff interviews revealed insufficient housekeeping coverage, leading to some rooms not being cleaned daily as required. The administrator acknowledged recent complaints and confirmed the daily cleaning policy.
The facility failed to provide adequate incontinence care for two residents who required staff assistance. One resident was left in a saturated brief for over an hour despite complaints of pain, while another was found with a saturated brief that had leaked urine onto the bed sheet. The Director of Nursing stated that incontinence care should be provided every two hours, but this standard was not met.
Failure to Timely Identify, Assess, and Treat a High-Risk Resident’s New Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to timely identify, assess, document, and initiate treatment orders for a newly developed pressure injury in a resident who was quadriplegic, non-verbal, totally dependent on staff for all care, and at high risk for pressure injuries. The resident had a history of a facility-acquired Stage 2 ischial pressure ulcer that had healed and was on hospice care, with existing orders for a wedge cushion and low air loss mattress. Braden Scale assessments showed the resident progressed from moderate to high risk for pressure injury development, and the resident preferred lying on the left side, had a prior healed wound in the same area, and was dependent on staff for repositioning. On one night, a CNA reported to the night RN that the resident had a wound on the buttocks, described as red and bleeding on the ischium. The RN acknowledged being notified but did not assess the wound, did not apply or ensure a dressing was in place, did not document the wound in the medical record, and only verbally notified the wound nurse the following morning. The wound nurse later stated that any new wounds should be reported to her so she can assess, photograph, notify the physician and family, and obtain treatment orders, but confirmed she was not notified by nursing staff and instead learned of the wound from an aide. The EHR contained no documentation of the left ischial pressure area on the date the night RN was notified. When the wound nurse assessed the resident the next day, she found a large deep tissue injury on the left ischium measuring 12 cm by 9 cm, with maroon discoloration, blood-filled blister, moderate serosanguineous drainage, and peri-wound erythema, maceration, and bogginess, and noted there was no dressing on the area. Subsequent wound progress notes documented the injury as a deep tissue injury and later as an unstageable pressure injury with full-thickness skin and tissue loss. Staff interviews reflected confusion about how the wound became so large in a short time, acknowledgment that the resident was at great risk due to immobility and prior skin breakdown, and recognition that the resident should have had a protective dressing to the ischial area and that new wounds were to be immediately reported, assessed, documented, and communicated per facility policy on treatment and services to prevent and heal pressure injuries.
Improper Management of Indwelling Urinary Catheter and Lack of Securement
Penalty
Summary
Failure to provide appropriate catheter care occurred when a resident with an indwelling urinary catheter was observed with the drainage bag hanging from the top drawer handle of the bedside table, with the drainage tubing pulled back to the right side and not maintained below the level of the bladder. The resident’s anchoring device was folded around the tubing and not secured to his leg. The resident, who had multiple diagnoses including obstructive and reflux uropathy, benign prostatic hyperplasia, and other comorbidities, reported having tearing to his penis from a previous facility because staff were not using the anchoring device and were not emptying the drainage bag, allowing the weight of the bag to pull on his penis. He stated he had requested a new anchoring device the previous day, but staff did not act on his request. During interview, an LPN acknowledged the resident had a catheter, was followed by a urologist, and had a penile tear, which she attributed to poor hygiene, and stated she did not think the wound nurse was doing anything for it. She reported she had not assessed the area that morning and stated that 1600 cc of urine had been emptied from the drainage bag that morning, and that staff should empty the bag every shift and as needed. When the LPN entered the room, she questioned why the drainage bag was hooked on the top drawer handle, lifted the bag above the level of the bladder, and then handed it to an aide to reposition. The resident’s meatal tear was present at the catheter insertion site without a securement device in place, which the LPN confirmed should have been used to prevent pulling. The ADON stated catheter care should be done every shift and as needed, including emptying the bag at least every shift, using a privacy bag, and ensuring the stat lock is in working condition, and explained that a full bag can put pressure on the urethra and cause urine backflow and potential bacterial infections, and that stat locks are used to prevent trauma or tearing. The resident’s care plan included interventions to secure tubing to prevent pulling and to keep the drainage bag below bladder level, but did not address the existing meatal tear. The facility’s indwelling catheter policy required consideration of a securement device and support of catheter tubing to prevent tugging or inadvertent removal.
Failure to Prevent and Manage Pressure Injury
Penalty
Summary
The facility failed to implement appropriate interventions to prevent and treat a pressure injury for a resident identified as R59, who was at moderate risk for pressure injuries. R59 was admitted with multiple diagnoses, including pulmonary embolism, diabetes, and vascular dementia, and required substantial assistance for mobility. Despite being assessed as high risk for pressure injuries in October 2024, the care plan did not include specific interventions to prevent pressure injuries on her lower extremities while sitting in a chair. This oversight led to the development of a deep tissue injury (DTI) on her right plantar foot, which was unstageable due to necrotic tissue. Observations and interviews revealed that the facility's staff, including the wound nurse, were not consistently implementing the prescribed interventions. The resident's pressure-relieving boots were not being used as ordered, and her feet were not properly offloaded, contributing to the development and persistence of the DTI. The wound nurse acknowledged that the injury had been present for months and was caused by the resident's sitting position. The care plan lacked documentation of interventions for the diagnosed pressure injury and did not include enhanced barrier precautions related to the wound. The facility's policy on pressure injury prevention and management was not followed, as evidenced by the lack of proper assessment and documentation of interventions. The physician confirmed that the facility should have had preventive measures in place, such as repositioning and the use of pressure-relieving devices, which were not documented or consistently implemented. The failure to adhere to the facility's policy and the absence of a comprehensive care plan for pressure injury prevention and management resulted in the development of the DTI for R59.
Failure to Ensure Safe Wheelchair Transport
Penalty
Summary
The facility failed to ensure safe wheelchair transport for a cognitively impaired resident, resulting in the resident sustaining significant bruising and pain. The resident, who has severe cognitive impairment and requires substantial assistance during wheelchair transport, was being transported by a CNA without the use of wheelchair leg rests. This oversight led to the resident's foot getting caught underneath the wheelchair, causing the resident to slide out and fall, hitting her head and sustaining a bruise on the right side of her face, forehead, and orbital area. Interviews with staff, including LPNs and CNAs, confirmed that the fall could have been prevented if leg rests were used during transport. The facility's incident report and nurse's progress notes corroborate the details of the fall incident. Despite the absence of a formal policy for safe wheelchair transport, the skilled therapy department's practice of using leg rests was not followed, contributing to the accident.
Inadequate Staffing Leads to Delayed Care and Resident Concerns
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure timely response to call lights and adequate assistance with activities of daily living (ADL) care, affecting all 83 residents. During a resident meeting, several residents reported experiencing extended wait times for call light responses, particularly during the evening and overnight shifts. One resident expressed anxiety due to waiting 2 to 3 hours for call light responses, which delayed incontinence care and access to PRN medication. Another resident was unable to attend a meeting because a CNA did not assist him in getting up, despite his request to participate in activities. The Resident Council Meeting minutes from December 2024 to March 2025 consistently documented concerns about delayed call light responses, insufficient care on weekends, and delayed medication administration. The facility's staffing records revealed a significant discrepancy between the required and actual number of CNAs on duty. The facility assessment indicated a need for 30 CNAs in a 24-hour period, but daily assignment sheets showed only 20 CNAs were working. Units with residents requiring two staff assists were often staffed with only one CNA, leading to inadequate care. The staffing coordinator acknowledged that CNAs from other units or nurses could assist, but this could leave units understaffed. The administrator admitted that an evaluation of resident care needs in relation to CNA staffing was not conducted in response to the concerns raised in Resident Council Meetings.
Facility Lacks Qualified Food Service Manager
Penalty
Summary
The facility failed to employ a qualified food service manager, affecting all 83 residents. The Long Term Care Facility Application for Medicare and Medicaid indicated a census of 83 residents. On April 9, 2025, the Food Service Manager (V5) admitted during an interview that she had not enrolled in or completed a dietary manager course. Although she had recently received a link to register for the course, she had not yet enrolled. V5 possessed a Serve Safe Sanitation certification, valid from November 22, 2024, to November 22, 2029, but lacked any other certifications required for her role. As of April 10, 2025, the facility had not provided documentation to verify V5's qualifications as the Food Service Manager.
Deficiency in Menu Compliance and Nutritional Provision
Penalty
Summary
The facility failed to prepare and serve food to residents according to the planned and dietitian-approved menu, affecting all 82 residents receiving oral diets. During a lunch service, a dietary aide served ground meals without bread to residents on mechanical soft diets, contrary to the menu which specified a ground hamburger on a bun. Additionally, the hamburger patties served were underweight, providing less than the expected 3 ounces of protein. The food service manager confirmed the discrepancy in protein content and stated that the dietitian had instructed not to serve bread to residents on mechanical soft diets. The dietitian confirmed that mechanical soft diets should include a soft piece of bread equivalent to the regular menu's bread servings. The dietitian also noted that the menu did not provide the expected 6 ounces of high-quality protein per day, as the hamburger patty, omelet, and ravioli servings were insufficient. The facility's menu policy requires that menus are followed as written to meet residents' nutritional needs, but the served menu did not meet these requirements. Further review of the facility's weekly menus revealed consistent shortages in servings of grains, breads, vegetables, and fruits across multiple days. The facility's meal pattern document specifies daily servings for these food groups, but the approved menus fell short of these requirements. This indicates a systemic issue in menu planning and execution, leading to inadequate nutrition for the residents.
Deficiencies in Hand Hygiene and Sanitizing Procedures in Dietary Department
Penalty
Summary
The facility failed to adhere to proper hand hygiene and sanitizing procedures in the dietary department, affecting all 83 residents. During an observation in the dish machine room, a dietary aide, identified as V15, was seen handling both soiled and clean dishes without washing hands or changing gloves as required by the facility's policy. V15 removed gloves after handling dirty dishes but did not wash hands before touching clean, sanitized bowls and other dishware, which were then placed into storage. This practice was contrary to the facility's policy, which mandates handwashing between glove use to prevent cross-contamination. Additionally, the facility did not maintain the correct concentration of sanitizing solution for food contact surfaces. During a lunch meal preparation, a dietary aide, V6, used a sanitizing solution with a concentration of 100 ppm, which was below the required 150-400 ppm as per the facility's chemical manufacturing product information. The Food Service Director, V5, confirmed that the sanitizing solution should be within the specified range, indicating a failure to comply with the manufacturer's instructions for maintaining proper sanitizing standards.
Inadequate Infection Control and Water Management in LTC Facility
Penalty
Summary
The facility failed to conduct comprehensive infection surveillance for resident infections, as evidenced by the Director of Nursing (V2) not completing McGeer's Criteria assessments for residents with infections. Instead, V2 relied on a monthly list of residents who received antibiotics to track infection trends, which did not provide accurate surveillance. The Order Listing Reports for January, February, and March 2025 showed that anti-infectives were prescribed, but no surveillance was completed. This lack of comprehensive infection surveillance was acknowledged by the facility's Administrator (V1), who stated that V2 should have been conducting surveillance for all infections identified in the facility. The facility also failed to maintain a complete water management program for Legionella. The Maintenance Director (V23) admitted to not documenting water temperatures of hot water heaters or tanks, not performing chlorine testing, and not maintaining documentation of running water in vacant resident rooms. V23 was unaware of the control measures for the facility's water management plan for Legionella and did not know how to respond if control measures were not met. The facility lacked documentation to show a water management plan containing areas at risk for Legionella growth, control measures, or routine safety logs for control measures. Additionally, the facility failed to adhere to Enhanced Barrier Precautions (EBP) and hand hygiene policies. An LPN (V28) did not wear the required PPE gown while administering medications and flushing a gastric tube for a resident on EBP status. V28 also failed to perform hand hygiene before and after glove use during medication administration and insulin injection procedures. Another resident (R29) with multiple infections did not have appropriate contact precautions signage outside their room, and a wound nurse (V12) was unaware of a resident's order for EBP, failing to use PPE while examining the resident's wound. These actions were not in compliance with the facility's policies on EBP, hand hygiene, and infection precautions.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to adhere to its antibiotic stewardship policy, affecting all 83 residents. The Director of Nursing (DON), who also served as the Infection Preventionist, admitted to not using McGeer's Criteria to assess infections since starting in November 2024. This oversight led to the inappropriate prescription of antibiotics, as evidenced by a resident who was prescribed antibiotics based on laboratory results without exhibiting any symptoms. The DON acknowledged that the resident's laboratory results did not meet McGeer's Criteria, indicating a failure to ensure antibiotics were necessary. Further investigation revealed that the facility's antibiotic use monitoring was incomplete. The DON only reviewed antibiotic use for residents currently residing in the facility at the time of report generation, rather than for all residents who received antibiotics each month. This resulted in inaccurate monitoring of antibiotic use, as shown by the Order Listing Reports for January, February, and March 2025, which indicated that no surveillance was completed for the prescribed anti-infectives during these months. Interviews with nursing staff, including agency RNs, revealed a lack of instruction and awareness regarding the use of McGeer's Criteria for assessing suspected infections. Several nurses were unaware of what McGeer's Criteria was or how to apply it, indicating a systemic issue in the facility's training and communication regarding infection assessment protocols. The facility's policy emphasized the importance of using McGeer's Criteria to classify infections, but this standard was not communicated effectively to the staff, leading to the deficiency.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed and implemented for several residents, leading to deficiencies in addressing their specific care needs. One resident, admitted with multiple diagnoses including chronic atrial fibrillation and morbid obesity, was observed with an indwelling urinary catheter but lacked a care plan addressing its use, care, or infection prevention. Additionally, the resident's care plan inaccurately described their continence status and did not address their dependence on staff for activities of daily living (ADL) such as bathing and dressing. Another resident, diagnosed with conditions including pulmonary embolism and vascular dementia, had a facility-acquired pressure injury that was not adequately addressed in their care plan. Despite having physician orders for wound care and offloading interventions, the care plan did not include pressure-relieving interventions for the resident's sitting position, which contributed to the development of the pressure injury. Furthermore, the care plan failed to incorporate enhanced barrier precautions related to the resident's wound. Additional deficiencies were noted for residents with psychiatric and cognitive impairments. One resident with bipolar disorder and major depressive disorder was receiving multiple psychotropic medications, yet their care plan did not address these diagnoses or the use of such medications. Another resident with Alzheimer's disease had a care plan that lacked individualized interventions for dementia care, despite the diagnosis being known and discussed during care plan meetings. These omissions highlight the facility's failure to develop person-centered care plans that meet the residents' comprehensive medical, nursing, and psychosocial needs.
Failure to Conduct Level II PASRR for Resident with New Mental Health Diagnosis
Penalty
Summary
The facility failed to refer a resident with a new mental health diagnosis for a Level II PASRR, which is required when there is a significant change in a resident's mental health condition. The resident, identified as R19, was admitted with diagnoses including major depressive disorder, anxiety disorder, and seizures. On October 5, 2024, R19 was diagnosed with unspecified psychosis, a condition that necessitates a Level II PASRR referral. However, the facility did not complete a rescreening for R19 following this new diagnosis. Interviews with facility staff revealed a lack of clarity and responsibility regarding the PASRR process. The Admissions Coordinator, V26, stated she had never submitted a re-screening for a resident's Level I PASRR following a new mental health diagnosis. The Social Services Director, V24, indicated he was not involved in the PASRR process and could not access the necessary system. The Director of Nursing, V2, acknowledged the new diagnosis but stated she was not involved in PASRRs. The facility's policy requires a new screen to be submitted if changes occur or new information refutes previous findings, but there was no documentation of a rescreening for R19 after the diagnosis of psychosis.
Inaccurate PASRR Completion for Resident with Mental Health Conditions
Penalty
Summary
The facility failed to adhere to its policy for completing an accurate PASRR (Preadmission Screening and Resident Review) for a newly admitted resident, identified as R19. The deficiency was identified during an interview and record review, revealing that the facility did not have a qualified healthcare professional complete the Level I PASRR for R19. The resident was admitted with diagnoses including major depressive disorder, anxiety disorder, and seizures, and was prescribed medications such as sertraline, olanzapine, and venlafaxine for mental health conditions. However, the PASRR completed by the Admissions Coordinator, V26, inaccurately reported that there were no mental health diagnoses or medications, which was contrary to the resident's medical records. V26, who holds an associate degree in medical coding and is not a nurse or social worker, was responsible for completing the Level I PASRR. She admitted to not including R19's mental health medications in the PASRR submission, following instructions from a previous admissions coordinator. The facility's policy requires that PASRR submissions be completed by qualified healthcare professionals, such as nurses or social workers, and that all relevant diagnoses and medications be accurately reported. The inaccurate submission led to a Level I outcome indicating no need for a Level II PASRR, despite the presence of serious mental health conditions.
Failure to Revise Care Plan for Fall Prevention
Penalty
Summary
The facility failed to timely revise the care plan with specific fall-prevention interventions for a cognitively impaired resident who required staff assistance. The resident, who had a history of repeated falls and was diagnosed with dementia, psychosis, anxiety disorder, major depressive disorder, and other conditions, experienced a fall on March 15, 2025, while being transported in a wheelchair without leg rests. This incident resulted in a bruise on the resident's forehead and face, and the resident was subsequently transported to the hospital for evaluation. Despite the resident's history of falls, the care plan was not updated with specific interventions to prevent future incidents, and no root cause analysis was conducted after each fall to address contributing factors. The Acting Director of Nursing confirmed that the fall on March 15, 2025, did not prompt a care plan revision, and no targeted prevention measures were implemented, highlighting a deficiency in the facility's response to the resident's fall risk.
Failure to Provide Restorative Services to a Resident
Penalty
Summary
The facility failed to provide restorative services to a resident as per its policy. A resident expressed that he did not receive restorative therapy, which he desired. A Licensed Practical Nurse confirmed not having seen the resident receiving any restorative therapy. The Rehabilitation Manager stated that the resident was not receiving skilled therapy services because he was evaluated to be at his prior level of functioning during the initial assessment. However, the therapy department recommended that the resident receive restorative therapy, and a referral was made to the Director of Nursing. The Director of Nursing was unaware of the referral and confirmed that the resident was not receiving restorative therapy. It was also noted that when the facility was understaffed, Certified Nursing Assistants did not provide restorative therapy. The facility's policy requires all residents to be screened for restorative care under specific conditions, including termination from active therapy, significant change in status, quarterly assessment progress, and nursing referral.
Failure to Provide Adequate Nail Care to Dependent Residents
Penalty
Summary
The facility failed to provide adequate nail care to residents who are dependent on staff assistance with Activities of Daily Living (ADLs). Three residents, identified as R44, R47, and R485, were observed with long, untrimmed fingernails, some with debris underneath, and others embedded into their palms due to contracted hands. These observations were made over multiple days, indicating a lack of routine nail care as required by the facility's policy. The policy mandates that nursing staff or qualified activity team members perform routine nail care, including daily cleaning and regular trimming, to prevent infections and skin problems. Resident R485, who was moderately cognitively impaired and dependent on staff for personal hygiene, was observed with long, dirty fingernails and expressed a desire for nail care. Similarly, residents R44 and R47, both with self-care deficits due to left hemiplegia and other medical conditions, were observed with long, jagged fingernails embedded into their palms. Despite their care plans indicating a need for total assistance with hygiene and personal care, these residents did not receive the necessary nail care, compromising their comfort and hygiene.
Failure to Provide Interventions for Residents with Limited Range of Motion
Penalty
Summary
The facility failed to provide necessary interventions and positioning devices for two residents with limited range of motion, leading to further decrease in their range of motion and contractures. One resident, admitted with multiple diagnoses including hemiplegia and hemiparesis, was found without a splint for her contracted left hand, despite her care plan identifying limited range of motion. The care plan lacked specific interventions for passive or active assisted range of motion exercises and did not specify the use of a positioning device to prevent further contractures. Another resident, also with hemiplegia and hemiparesis, was found with a flexion contracture in her left hand and stated she was supposed to have a splint, which was not provided. Her occupational therapy evaluation noted a contracture but indicated that nursing was managing it, yet her care plan did not address interventions for her decreased range of motion or the need for a positioning device. The facility's policy on resident mobility and range of motion was not followed, as it required treatment and services to prevent further decrease in range of motion and the provision of necessary equipment.
Lack of Justification for Indwelling Catheter Use
Penalty
Summary
The facility failed to document the justification for the continued use of an indwelling urinary catheter for a resident who experienced a urinary tract infection. The resident, who was admitted with multiple diagnoses including chronic atrial fibrillation, morbid obesity, sepsis, and benign prostatic hyperplasia, was moderately cognitively impaired and dependent on staff for various activities. Despite having an indwelling urinary catheter, the resident's admission assessment did not identify its use, and the physician's order lacked a reason for the catheter or instructions for its care and maintenance. The resident's care plan did not include the presence of the indwelling catheter or interventions for infection prevention. A urine culture revealed a significant infection, and the resident received antibiotic treatment. The Acting Director of Nursing acknowledged the absence of documentation or evaluation justifying the catheter's continued use and was uncertain about the reason for its use. Additionally, there was no facility policy regarding the evaluation for the justification of indwelling urinary catheter use.
Failure to Develop Dementia Care Plan for Resident
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident diagnosed with dementia, specifically Alzheimer's disease. The resident, who was admitted with multiple diagnoses including Alzheimer's, ventricular tachycardia, and arthritis, was found to have moderate cognitive impairment according to the MDS dated March 7, 2025. However, as of April 9, 2025, the resident's care plan did not include any specific interventions or considerations for dementia care. The Social Services Director acknowledged that the comprehensive care plan, completed on March 14, 2025, should have addressed the resident's Alzheimer's diagnosis and included a tailored care plan for dementia care needs.
Failure to Follow Wound Care Orders
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident's non-pressure wounds as ordered by the wound physician. The resident, identified as R2, had multiple wounds including a non-pressure trauma wound on the left first toe, a wound on the right lower lateral leg, and skin tears on the left leg and hip. The wound physician had prescribed specific treatments for these wounds, including the use of xeroform gauze and gauze roll daily. However, the Treatment Administration Record (TAR) for January and February did not reflect these orders, and the prescribed treatments were not administered as required. On observation, R2's left first toe was found without a dressing, contrary to the physician's orders. Additionally, the wound on the right lower lateral leg was treated with silver sulfadiazine and calcium alginate instead of the prescribed xeroform gauze. The skin tears on the left leg and hip also lacked documented treatment orders in the TAR. Interviews with the wound physician and the wound LPN confirmed that the treatment plans were not followed, highlighting a failure in the facility's adherence to the prescribed wound care protocols.
Failure to Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to ensure that ordered pressure ulcer treatments were in place and properly implemented for three residents with pressure ulcers. For Resident 2, the treatment plan for a Stage 4 pressure ulcer on the left heel was not followed as prescribed by the wound physician. The treatment administration record (TAR) did not reflect the physician's orders for xeroform gauze or silver sulfadiazine, and the wound care provided did not match the prescribed treatment. Additionally, the treatment for a deep tissue injury on the right ankle was not consistent with the physician's orders, as the TAR did not document the required daily application of xeroform and gauze roll. Resident 3's care was also deficient, as the wound care provided did not align with the physician's treatment plan for unstageable deep tissue injuries on the buttocks. The TAR only documented the use of bordered foam dressings, while the physician's plan called for skin prep and gauze island with border. During an observation, the resident's wounds were found without dressings, and the care provided did not match the prescribed treatment. For Resident 1, the facility failed to update the TAR to reflect changes in the treatment plan for an unstageable pressure injury on the left heel. The physician's orders for betadine and alginate calcium with silver were not documented in the TAR, and the care provided did not follow the updated treatment plan. The facility's policy on pressure injury prevention and management was not adhered to, as the wound consultant's recommendations were not accurately reflected in the residents' medical records.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols during wound care for a resident under strict contact isolation for MRSA and C. Striatum. A Licensed Practical Nurse (LPN) brought the treatment cart into the resident's isolation room, which is against the facility's infection control policy. During the dressing change, the LPN did not change gloves or perform hand hygiene after handling soiled dressings and before accessing the treatment cart for additional supplies. This action risked cross-contamination and the spread of infection. The Infection Preventionist confirmed that treatment carts should not enter isolation rooms and that supplies brought into such rooms should remain there for use only with the specific resident. The facility's hand hygiene policy mandates that staff perform hand hygiene when moving from a contaminated body site to a clean body site during resident care. The LPN's failure to follow these protocols during the dressing change for the resident with wound infections led to the identified deficiency.
Failure to Honor Resident's Financial Management Rights
Penalty
Summary
The facility failed to honor a resident's right to manage their financial affairs, as evidenced by the actions taken regarding the resident's Social Security payments. The resident, who has Alzheimer's disease, dementia, and other significant health conditions, was admitted to the facility with their spouse designated as the Power of Attorney for both care/medical and financial matters. The spouse was responsible for handling the resident's finances, including payments to the facility. However, the facility's Business Office Manager applied to become the representative payee for the resident's Social Security income without the spouse's consent, citing that the spouse was not paying the facility the required portion of the resident's income for room and board. The Business Office Manager proceeded with the application despite the spouse's disagreement, arguing that the facility had the legal right to do so after exhausting attempts to collect the owed payments. The facility's administrator acknowledged that permission should have been obtained from the family before applying for representative payee status. The application form submitted by the facility inaccurately stated that the resident did not owe any money to the facility, despite an outstanding balance of $13,266.50. The facility's collection policy indicated that initiating a representative payee application was applicable for unpaid balances, but the process was not followed with the necessary consent from the resident's spouse.
Failure to Provide Safe Transfer Assistance
Penalty
Summary
The facility failed to provide safe transfer assistance, resulting in a resident sustaining left and right femoral fractures. The resident, who had a medical history including right and left periprosthetic fractures around both artificial knee joints, dementia, and physical disability, was bedbound and unable to bear weight. On the day of the incident, a CNA performed a pivot transfer without using a gait belt, which caused the resident to become dead weight and led to swelling in both knees. Subsequent X-rays confirmed fractures in both legs. The care plan for the resident was incomplete and did not specify individualized transfer needs. The Director of Nursing acknowledged that the care plan was not updated, which contributed to the lack of proper transfer instructions. The Physical Therapist emphasized that a gait belt should always be used for transfers, and the Medical Director suggested that the injuries might have resulted from a forceful transfer. The facility's policy on mobility assistance was not followed, leading to the resident's injuries.
Failure to Maintain Clean and Sanitary Resident Rooms
Penalty
Summary
The facility failed to maintain resident rooms in a clean and sanitary manner for four of the seven residents reviewed. Observations revealed that the bathroom shared by one resident had a full garbage container, stool in the toilet, soiled washcloths, food debris in the sink, and tissues on the floor. The family member of this resident reported that the bathroom had not been cleaned for at least two days. Additionally, other resident rooms were found with full garbage containers, food debris on the floor, and a large dried stain on a chair. These conditions were observed over several hours on the same day. Interviews with staff revealed that the facility had only two housekeepers on the day shift and none on the evening or night shifts, leading to some rooms not being cleaned daily as required. The housekeeper interviewed had only been working at the facility for three weeks and admitted that he sometimes could not complete all his assigned tasks. The facility's administrator acknowledged receiving complaints about the cleanliness of rooms and confirmed that each occupied room was supposed to be cleaned daily. The facility's policy and housekeeping checklist also mandated daily cleaning and disinfecting of resident rooms and bathrooms.
Failure to Provide Adequate Incontinence Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for two residents who required staff assistance for toileting and incontinence care. Resident R2, who was dependent on staff for toileting and incontinent of urine and stool, was found in bed with a saturated brief and complained of pain in her buttocks. Despite her complaints, staff members V8 and V9 did not change her soiled brief immediately and left her in the same condition. R2 remained in the soiled brief for over an hour before V8 CNA finally changed it, revealing that her buttocks and vaginal area were bright red. Resident R3, who was cognitively impaired due to a cerebral vascular accident and cerebral hemorrhage, was also dependent on staff for toileting and incontinence care. R3 was found in bed with a saturated brief that had leaked urine onto the bed sheet. R3's family member, V10, expressed frustration over the lack of care, stating that R3 was often found dirty and wet. V8 CNA confirmed that no care had been provided to R3 that day until the observation. The Director of Nursing (V2) stated that incontinence care should be provided every two hours, but this standard was not met for R2 and R3.
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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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