Timber Point Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Camp Point, Illinois.
- Location
- 205 East Spring Street, Camp Point, Illinois 62320
- CMS Provider Number
- 145726
- Inspections on file
- 26
- Latest survey
- February 15, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Timber Point Healthcare Center during CMS and state inspections, most recent first.
A cognitively impaired male resident with significant psychiatric and behavioral diagnoses was not effectively assessed or supervised for abuse risk, despite facility policy requiring identification of residents with behaviors that might lead to conflict. One night, staff responded to yelling and found the male resident leaving a female resident’s room; the female resident reported he had climbed onto her bed and punched her, and another resident corroborated seeing him on top of her in bed. The female resident, who had a history of anxiety, later described prior unwanted advances and an attempted breast touching by the same resident, as well as ongoing fear, anxiety, and restlessness after the incident, requiring psychiatric follow-up and medication changes. Her care plan did not address the abuse allegations or include protective interventions, and an abuse risk review inaccurately stated she had no abuse allegations, resulting in no care plan updates.
The facility failed to conduct a thorough investigation of an alleged resident-to-resident physical abuse incident. An RN heard yelling, found a male resident leaving a female resident’s room, and documented that the female resident reported he had crawled on top of her in bed and punched her in the face three times, after which she punched him back and pushed him off; the male resident was later sent to the ED for psychiatric evaluation, and EMS reported he had allegedly hit another resident. The female resident’s assessment showed no visible injuries. Despite this, the Administrator’s abuse investigation only included two statements and did not document that one resident had been on top of the other or that both residents had hit each other, and the Administrator acknowledged not interviewing additional staff or residents and not being aware of the mutual hitting that the RN stated she had reported.
Three residents developed or experienced worsening of facility-acquired pressure ulcers due to the facility's failure to update care plans with pressure-relieving interventions, implement those interventions, conduct routine skin checks, and perform Braden Scale assessments as required. In each case, staff did not consistently apply or use appropriate pressure-relieving devices, and care plans were not followed or updated, resulting in painful and worsening pressure injuries.
Surveyors found that staff failed to monitor and record cool down temperatures for prepared meats, did not label opened food items in refrigerators and dry storage, and used incorrect test strips for dish machine sanitization. The Dietary Manager confirmed these lapses, and kitchen staff were not using a cool down log for meals prepared in advance. These failures were observed to potentially affect all residents in the facility.
The facility did not maintain any system for tracking infections among residents or employees, as confirmed by the DON, despite having a policy requiring such surveillance. This deficiency was identified through interviews and record review, affecting all individuals in the facility.
The facility did not have a full-time, qualified infection preventionist as required, following the termination of the previous IP. The individual currently assigned to the role had not completed the necessary training, leaving all residents without a designated, trained IP.
The facility did not ensure that all CNAs received the required 12 hours of annual in-service training, as confirmed by the DON and a review of training records. This deficiency has the potential to affect all 69 residents in the facility.
Multiple residents reported ongoing issues with missing clothing, filing repeated grievances that were not resolved by the facility. Despite the facility's grievance policy requiring investigation and written decisions, the missing clothing concerns persisted, and the administrator confirmed the problem was ongoing.
Surveyors found that the facility did not consistently change or date oxygen tubing weekly for several residents receiving oxygen therapy, as required by physician orders and facility policy. Observations and interviews confirmed that tubing was often not labeled or was overdue for replacement, and documentation did not reflect that changes were completed as scheduled.
A resident with a completed POLST form indicating DNR and comfort-focused treatment did not have a corresponding plan of care addressing these advanced directives. Facility guidelines require such directives to be documented and included in the care plan, but this was not done, as confirmed by the Care Plan Coordinator.
A registered nurse administered an IV bag of normal saline labeled for a former resident to a current resident, using medication from the storage room without proper authorization. The bag, which was clearly marked with another individual's name and an outdated date, was infused and later found in the resident's room. The DON was informed after the fact and was unaware of the details regarding the bag's origin and labeling.
Two residents who were transferred to the hospital did not receive the required bed hold notices as documented in facility policy. One resident was sent for chest pain and another for constipation, but in both cases, there was no evidence in the medical records that the bed hold policy was communicated at the time of transfer, as confirmed by staff and administrative interviews.
A resident with a physician's order for hospice admission was not accurately coded as receiving hospice services in the MDS assessment. The MDS Coordinator acknowledged the error, noting that the assessment should have indicated the resident's hospice status, as required by facility policy.
A resident diagnosed with Bipolar II Disorder and prescribed antipsychotic medication was not referred for a Level II PASRR assessment as required. Facility records and staff confirmed that the necessary referral was not made following the mental illness diagnosis, in violation of policy.
Two residents who required staff assistance for personal hygiene did not receive routine fingernail care, resulting in long, jagged nails that extended past their fingertips. Both residents expressed a desire to have their nails trimmed, and facility documentation confirmed that nail care had not been provided for several months, despite facility guidelines requiring regular cleaning and trimming.
A resident with a documented DNAR order and multiple serious health conditions was found unresponsive, and staff initiated CPR before confirming code status, contrary to the resident's advance directive. The CNA performing compressions was unaware of the need to check code status, and the facility's process for communicating advance directives was not followed, resulting in the resident receiving CPR against her wishes.
A resident with an indwelling urinary catheter for urinary retention was observed with the catheter drainage bag resting on the floor next to the bed, contrary to facility policy requiring catheter bags to be kept off the floor. An LPN confirmed that catheter bags should be secured to the bed and never placed on the floor.
A resident did not receive their prescribed enteral nutrition formula via gastrostomy tube for several days, and the facility failed to notify the physician or seek an alternative. The DON confirmed that the nurses did not inform the physician about the unavailability of the ordered formula.
A facility did not complete an inventory of a resident's personal belongings upon admission, as required by their Admission's Contract. The resident, who is cognitively intact, reported that their belongings were taken for cleaning, but no inventory list was provided or completed. The facility's administrator confirmed this oversight.
A resident with severe malnutrition and a gastrostomy did not receive the prescribed enteral nutrition due to the facility receiving the wrong formula and nursing staff failing to notify the DON or administer any g-tube feeding. The resident was admitted with a prescription for Osmolite 1.5 at 45 ml/hr, but did not receive it for several days due to these oversights.
The facility did not provide readily available grievance forms or post grievance procedures in prominent locations, affecting all residents. Residents were unaware of how to file grievances, and an inspection confirmed the absence of official forms and posted procedures.
The facility did not provide written notices of transfer to residents or their representatives when transferring them to a hospital. This issue was confirmed by the DON and the Social Service Director, who both acknowledged a lack of awareness about the requirement for such notifications.
The facility failed to provide food items from the Always Available Menu to residents requesting meal substitutions. Residents reported only receiving limited options like peanut butter and jelly sandwiches or fruit plates, despite the menu listing various other items. They also expressed fear of requesting substitutions due to potential delays and cold meals. This deficiency affected all 70 residents in the facility.
The facility failed to document cool down temperatures for potentially hazardous foods, as required by their Two Stage Cool Down Process and HACCP Cooling Log. The Dietary Manager admitted to recently learning about the requirement and had instructed cooks to use the form, but it was not being utilized. This oversight could affect all 70 residents.
A resident with venous insufficiency and other medical conditions had a physician's order to wear compression stockings daily, but this was not documented in the care plan. The resident reported swelling in her legs and the need for compression stockings. The DON confirmed the absence of a care plan for this requirement, and the ADON/Wound Nurse added it after the deficiency was noted.
A resident with a history of skin integrity issues did not receive a physician-ordered Ketoconazole cream for 17 days due to a lack of order clarification and processing delays. The resident, at risk for skin issues due to multiple health conditions, expressed concerns about the facility's failure to complete medication orders timely. The DON confirmed the delay but was unsure of the reasons behind it.
A resident with End Stage Renal Disease did not receive comprehensive dialysis care, including physician-ordered yogurt with meals, daily weights, and lunch meals during dialysis sessions. The facility failed to communicate with the dialysis center and did not monitor the resident's central venous catheter port. Staff confirmed the lack of communication and documentation related to the resident's dialysis care.
A facility failed to monitor targeted behaviors for a resident on Abilify, an antipsychotic medication, and did not attempt a gradual dose reduction (GDR) in the past year. The resident's care plan lacked specific behaviors to monitor, and records showed no behaviors despite documentation of inappropriate comments and manipulative behaviors. The DON confirmed no GDR was conducted or recommended, citing a concurrent reduction in Buspirone as a reason.
A facility failed to implement Enhanced Barrier Precautions for a resident with a central venous catheter for dialysis. The facility's policy requires such precautions for residents with indwelling medical devices, but the resident's room lacked signage and personal protective equipment. The resident confirmed having the catheter since January, and the LPN/Infection Control Preventionist acknowledged the absence of precautions and documentation.
Failure to Assess Abuse Risk and Supervise Residents, Leading to Resident-to-Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to accurately assess a resident’s risk of abuse and to adequately supervise residents to prevent resident-to-resident physical abuse, resulting in one resident physically assaulting another. The facility’s Abuse and Retaliation Prevention Program Policy states that residents have the right to be free from abuse, neglect, exploitation, and mistreatment, and that staff will identify residents with increased vulnerability for abuse or behaviors that might lead to conflict through admission assessments, care plans, and MDS assessments. Despite this policy, a male resident with severe cognitive impairment and diagnoses including vascular dementia with behavioral disturbance, schizoaffective disorder, and delusional disorder was not effectively assessed or managed for behaviors that could lead to conflict or abuse. On the night of the incident, an RN heard yelling from the middle hall and found the cognitively impaired male resident wheeling out of a female resident’s room. The female resident reported that the male resident had crawled on top of her in bed and punched her on the right side of her face three times, after which she punched him back and pushed him off. Another resident in the room reported being awakened by the female resident yelling for help and observed the male resident crawling on top of the female resident in bed, with the female resident trying to get him off and striking him until he got back into his wheelchair. The RN documented that the male resident was showing signs of increased mania that night and was capable of transferring himself from his wheelchair into the female resident’s bed. The male resident was subsequently sent to the emergency department, where records noted he had allegedly hit another resident earlier that day. The female resident, who was cognitively intact with documented anxiety and insomnia, later described that the male resident had repeatedly pursued her for a relationship, followed her in the hallways, and on one occasion attempted to touch her breasts, which she blocked and reported to staff. She stated that on the night of the incident she awoke to the male resident rubbing her stomach while kneeling on her bed, and that when she yelled at him to get off, he began punching her in the head, causing pain and leaving her feeling stunned and traumatized. She reported ongoing fear of men, changes in how she dressed at night, and the need for therapy to cope with what occurred. Her psychiatric APN documented that this event triggered increased anxiety, fear, restlessness, and self-blame, leading to medication adjustments for anxiety. Despite these allegations and documented anxiety, her care plan did not address the abuse allegations or include interventions to protect her from the male resident or to address her increased anxiety and fear. Additionally, an Abuse Risk Review completed by the Social Service Director inaccurately documented that she had not experienced or made allegations of any type of abuse since the prior review, and therefore no further care plan recommendations were made, reflecting a failure to recognize and incorporate the abuse incident into her assessment and care planning.
Failure to Thoroughly Investigate Resident-to-Resident Physical Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of resident-to-resident physical abuse as required by its Abuse and Retaliation Policy Prevention Program. The policy dated 1/2026 states that any incident or allegation involving abuse, neglect, exploitation, retaliation, mistreatment, or misappropriation of resident property will result in an investigation, and that the appointed investigator will at a minimum attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident, and the resident if interviewable, as well as review written statements and pertinent records. On 1/2/26, an RN documented hearing yelling from the middle hall and then observing one resident wheeling out of another resident’s room. The second resident reported that the first resident allegedly crawled on top of her in bed and punched her on the right side of the face three times, after which she punched him back and pushed him off. The RN’s note also documented that the first resident was sent to the ED for psychiatric treatment due to increased agitation, and ED records indicated EMS reported that this resident had allegedly hit another resident earlier that day. The second resident’s progress note from the same date documented her report that a male resident allegedly crawled on top of her and punched her three times on the right side of her face, with an assessment showing no visible injuries or redness and no complaints of pain or distress. However, the abuse investigations and witness statements for both residents, dated 1/2/26 through 1/6/26 and signed by the Administrator, only included two statements from the RN and the roommate of the second resident and did not document that the first resident crawled on top of the second resident, hit her, or that she hit him back. In interview, the Administrator stated she did not know that the residents had hit each other, acknowledged she only had interviews from the RN and the roommate, and confirmed she did not interview other staff or residents who might have knowledge of the incident. The RN stated she had immediately reported to the Administrator that the second resident said the first resident was on top of her in bed and hit her in the head, and that she had hit him back. The investigation therefore did not capture or reflect the full allegation of mutual hitting and did not meet the facility’s own minimum investigative procedures.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevention for three residents, resulting in the development and worsening of facility-acquired pressure ulcers. For one resident with a history of diabetes, impaired mobility, and cognitive impairment, the care plan was not updated with pressure-relieving interventions prior to the development of a right heel pressure ulcer. The resident did not receive routine skin checks, and Braden Scale assessments were not completed quarterly as required by facility policy. The resident's pressure-relieving boots were not consistently applied, and when used, did not have a heel off-loading cavity, failing to relieve pressure. This led to the development of a painful, unstageable pressure ulcer that required surgical debridement. Another resident, who was dependent on staff for mobility and transfers and at risk for pressure ulcers due to decreased mobility, incontinence, and morbid obesity, developed two stage two pressure ulcers on the buttocks. The resident was observed on a standard foam mattress rather than a pressure-relieving mattress as ordered in the care plan and physician orders. Staff were unaware of the open areas, and there was no documentation of the pressure areas in the medical chart until the ulcers were identified by the Director of Nursing. A third resident, severely cognitively impaired and dependent on staff for all activities of daily living, developed an unstageable deep tissue pressure injury to the right heel that continued to worsen. The care plan did not include pressure-relieving interventions, and although orders were in place for heel protectors and regular repositioning, these interventions were not consistently implemented. The resident was observed without heel protectors in both bed and wheelchair, and staff failed to ensure pressure was relieved as directed, contributing to the progression of the pressure ulcer.
Deficiencies in Food Storage, Labeling, and Dish Sanitization Practices
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food service operations, including failure to monitor and record cool down temperatures for prepared meats, lack of labeling on opened food items in both refrigerators and dry storage, and improper use of dish machine sanitizing test strips. Observations revealed that opened hot dog buns were left undated and unsealed on a kitchen counter, and several opened, undated food items such as liquid eggs, onion, shredded cheese, and a bottle of soda not belonging to a resident were found in the refrigerator. The Dietary Manager confirmed these items should have been dated and that the soda should not have been stored there. Further, the kitchen staff were not using a cool down log for meals cooked ahead of time, as confirmed by the Dietary Manager when a pork loin was being prepared for a future meal. Additionally, the Dietary Manager was observed using incorrect quaternary test strips instead of the required 160 EF sanitizer test strips to check the dish machine, and admitted to not knowing which test strips to use or having the correct ones available. These failures were found to be contrary to the facility's own policies and have the potential to affect all 69 residents residing in the facility.
Failure to Track Infections per CMS Requirements
Penalty
Summary
The facility failed to track infections among individuals who enter or reside in the facility, as required by CMS regulations. According to the facility's own Infection Prevention and Control Manual, there should be a system in place for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and contracted service providers. However, during an interview, the Director of Nursing confirmed that there was no current or past tracking of infections for residents or employees. This deficiency was identified through interview and record review, and it was noted that 69 residents were residing in the facility at the time.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate or hire a full-time infection preventionist (IP) as required by CMS, which affected all 69 residents currently residing in the facility. According to the facility's own Infection Prevention and Control Manual, an IP should be designated who is qualified by education, training, experience, or certification, and who has completed specialized training in infection prevention and control. The manual also requires the IP to work at least part-time and participate in the facility's quarterly assessment and assurance committee. Interview with the Administrator confirmed that the previous IP was terminated and the individual currently assigned to the role has not completed the required training, resulting in the facility being without a full-time, qualified IP since the termination.
Failure to Provide Required Annual In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nursing Assistants (CNAs) received the required 12 hours of annual in-service training. A review of CNA training records from January 1, 2024, through June 2, 2025, showed that none of the CNAs had completed the mandated annual training hours. This was confirmed by the Director of Nursing, who acknowledged that all currently employed CNAs had not met the annual in-service training requirement. The deficiency has the potential to affect all 69 residents residing in the facility, as documented on the CMS Form 671 signed by the Administrator. No information was provided regarding the medical history or condition of individual residents at the time of the deficiency.
Failure to Resolve Repeated Resident Grievances Regarding Missing Clothing
Penalty
Summary
The facility failed to resolve multiple repeated grievances related to missing clothing items for eight residents, as documented through interviews and record reviews. Grievance forms for these residents, spanning several months, consistently reported missing clothing, and the facility's own Resident Council Grievance form indicated that this was an ongoing issue. During a resident council meeting, all eight affected residents confirmed that they had filed numerous grievances regarding their missing clothes, but the issue remained unresolved and their clothing was never found. The facility's grievance policy requires a written decision for each grievance, including investigation steps, findings, and any corrective actions, but the records reviewed did not show resolution of the grievances. The administrator acknowledged that missing laundry is a persistent problem in the facility. There is no mention in the report of any corrective actions taken or resolution provided to the residents regarding their missing clothing.
Failure to Change and Date Oxygen Tubing Weekly for Residents on Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care by not ensuring that oxygen tubing was changed weekly and properly dated for five residents who required oxygen therapy. Observations, interviews, and record reviews revealed that oxygen tubing and cannulas were not changed as ordered by physicians and facility policy, which required weekly changes and labeling with the date. In several cases, the tubing was not labeled at all, and in one instance, the tubing was found to be dirty and had not been changed for several weeks. Documentation on treatment administration records and flowsheets also showed missed or unsigned entries for required tubing changes. Residents affected included individuals with diagnoses such as emphysema, acute and chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease. At the time of observation, these residents were using oxygen via nasal cannula or concentrator, but their equipment was either not dated or had outdated labels. Staff interviews confirmed that all oxygen tubing should be dated and changed weekly, but this was not consistently done according to both facility policy and physician orders.
Failure to Incorporate Advanced Directives into Care Plan
Penalty
Summary
The facility failed to develop a plan of care addressing advanced directives for one resident reviewed for advanced directives. According to the facility's own guidelines, staff are required to identify, clarify, and review existing care instructions during the quarterly Resident Assessment Instrument (RAI) process and with any significant changes in condition. These guidelines also require that any changes to a resident's advanced directives be documented, included in the resident's care plan, and communicated to staff. However, for one resident, although a completed and signed POLST form indicated a Do Not Resuscitate (DNR) order and a preference for comfort-focused treatment, there was no corresponding plan of care addressing these advanced directives in the resident's current care plan. During an interview, the Care Plan Coordinator confirmed that the resident did not have a current care plan addressing advanced directives. This omission was identified through record review and staff interview, demonstrating that the facility did not follow its own procedures for ensuring that residents' advanced directives are incorporated into their care plans and communicated to staff.
Misappropriation of IV Medication Administered to Wrong Resident
Penalty
Summary
A deficiency occurred when a registered nurse (RN) administered an intravenous (IV) bag of normal saline labeled for a former resident to a current resident. The RN obtained the IV bag from the medication storage room, where it was stored with other extra bags of fluids. The bag was clearly labeled with the former resident's name and a date from several months prior. The RN infused the entire bag into the current resident and later notified the Director of Nursing (DON) about using the bag intended for a different resident. The DON instructed the RN to remove the former resident's name from the bag but was not aware of the date on the bag or that it remained in the resident's room. The facility's Abuse Prevention Policy prohibits the misappropriation of resident property, including the wrongful use of a resident's belongings or medications without consent. In this incident, the RN knowingly used IV fluids prescribed for a former resident and administered them to another resident without proper authorization or consent. The event was confirmed through observation of the labeled empty IV bag in the resident's room, interviews with the resident, RN, and DON, and review of the facility's documentation.
Failure to Provide Bed Hold Notices Upon Hospital Transfer
Penalty
Summary
The facility failed to provide required bed hold notices to two residents who were transferred to the hospital. According to the facility's Bed Hold and Readmission Policy, residents or their representatives must be informed of the bed hold policy at admission and at the time of transfer to a hospital, with written notification provided at the time of transfer. In cases of emergency hospitalization, notification by telephone or in person is required within 24 hours, with documentation in the medical record. However, for both residents reviewed, there was no evidence in their electronic health records that a bed hold notice was given upon their transfer to the hospital. One resident, who had a history of chest pain, was sent to the hospital for observation and reported not receiving a bed hold notice at the time of transfer. The administrator confirmed that the medical record did not contain evidence of the notice being provided. Another resident, with diagnoses including Type 2 Diabetes Mellitus with Diabetic Neuropathy, Dementia, Chronic Kidney Disease (Stage 3), and Malignant Neoplasm of the Uterus, was sent to the emergency room for constipation, and similarly, there was no documentation of a bed hold notice being issued. Staff interviews confirmed that the required notifications were not completed for these hospital transfers.
Inaccurate Coding of MDS Assessment for Hospice Services
Penalty
Summary
The facility failed to accurately code a Minimum Data Set (MDS) assessment for one of 17 residents reviewed for MDS accuracy. According to the facility's policy, all assigned disciplines are required to participate in the completion of the MDS assessment and verify the accuracy of their respective sections. In this case, a resident had a physician's order for hospice admission, but the corresponding MDS assessment did not indicate that the resident was receiving hospice services in Section O, which covers special treatments, procedures, and programs. The MDS Coordinator confirmed that the assessment was inaccurately coded and should have reflected the resident's hospice status. This deficiency was identified through record review and staff interview, specifically noting the discrepancy between the physician's order and the information documented in the MDS assessment.
Failure to Refer Resident for Level II PASRR After Mental Illness Diagnosis
Penalty
Summary
The facility failed to refer a resident for a Level II Preadmission Screening and Resident Review (PASRR) after the resident was diagnosed with Bipolar II Disorder. According to the facility's PASRR policy, the facility is required to comply with federal and state standards by requesting and maintaining complete PASRR materials, including Level II assessments, for residents with qualifying mental health diagnoses. Record review showed that the resident was admitted with a diagnosis of Depression Disorder and later diagnosed with Bipolar II Disorder, for which antipsychotic medication was prescribed. Despite this, there was no evidence in the medical record that a Level II PASRR was obtained following the new diagnosis. The Social Service Director confirmed that the PASRR II was never requested after the diagnosis of Bipolar II Disorder, as required by policy.
Failure to Provide Routine Fingernail Care for Dependent Residents
Penalty
Summary
The facility failed to provide proper fingernail care for two residents who required assistance with activities of daily living. One resident, who required substantial to maximal staff assistance for personal hygiene, had not had her fingernails trimmed for several months, as documented in her shower sheets. Upon observation, her fingernails were found to be long, jagged, and extended past her fingertips, and she could not recall the last time they were clipped, expressing a desire for them to be trimmed. Another resident, who was severely cognitively impaired and required staff assistance for personal hygiene, also had not had his fingernails trimmed during a similar timeframe. His fingernails were observed to be long, jagged, and extended past his fingertips, and he also expressed a desire for them to be cleaned and trimmed. The facility's own guidelines require routine cleaning and regular trimming of nails, and the DON confirmed that all residents should have their nails cleaned and trimmed as needed with all showers.
Failure to Honor Advance Directive Resulting in Unwanted CPR
Penalty
Summary
The facility failed to follow the advance directive for one resident who had a documented Do Not Attempt Resuscitation (DNAR) order. The resident, who had multiple serious diagnoses including end stage renal disease, heart failure, and cancer, was found unresponsive with no pulse or respiration. Despite the presence of a completed POLST form indicating no CPR, staff initiated cardiopulmonary resuscitation (CPR) before confirming the resident's code status. The nurse directed a CNA to call 911 and began CPR while checking the resident's DNR status, and the CNA also performed compressions until being told to stop when the DNR was confirmed. The CNA involved stated she was unaware of the need to verify code status before starting CPR and expressed concern about the lack of a clear system to identify residents' code status. Documentation in the medical record and the CPR checklist confirmed that CPR was performed on the resident in contradiction to her advance directive. The facility's policy required staff to review and communicate advance directives, but this was not followed in this instance, resulting in the resident receiving unwanted resuscitative efforts.
Catheter Bag Not Properly Secured and Left on Floor
Penalty
Summary
The facility failed to ensure proper care and management of an indwelling urinary catheter for one resident who was admitted with a 16 French indwelling catheter for urinary retention. During observation, the resident was found lying in bed with the catheter drainage bag resting on the floor next to the bed. According to the facility's Urinary Catheter Care policy, catheter tubing and drainage bags are required to be kept off the floor to prevent infection. Interview with a Licensed Practical Nurse confirmed that catheter bags should be secured to the side of the bed and never placed on the floor. This deficiency was identified through observation, interview, and record review.
Failure to Notify Physician of Missed Enteral Nutrition
Penalty
Summary
The facility failed to notify the physician about a resident not receiving a physician-ordered enteral nutrition formula via gastrostomy tube. The resident, who was discharged from the hospital with orders for Osmolite 1.5 at a goal rate of 45 ml per hour, did not receive the prescribed nutritional tube feeding from the date of admission through several days. The medical record lacked documentation of any physician notification regarding the failure to administer the ordered nutrition. The Director of Nursing confirmed that the nurses did not inform the physician or gastroenterology specialist about the unavailability of Osmolite, nor did they seek an order for a substitute formula.
Failure to Complete Inventory of Resident's Belongings
Penalty
Summary
The facility failed to adhere to its Admission's Contract by not performing an inventory of a resident's personal belongings upon admission. The contract specified that an inventory sheet should be provided to the resident or their family to document all belongings, with assistance available if needed. However, for one resident, identified as R3, this process was not followed. R3, who is cognitively intact according to their Minimum Data Set (MDS) assessment, reported that upon admission, their belongings were taken by staff for cleaning to prevent bugs, but no inventory list was completed or provided. The facility's administrator confirmed that the inventory sheet was not completed for this resident.
Failure to Administer Prescribed Enteral Nutrition
Penalty
Summary
The facility failed to administer a physician-ordered enteral nutrition formula via gastrostomy tube for a resident who was admitted with several medical conditions, including alcoholic cirrhosis of the liver, severe protein-calorie malnutrition, and a gastrostomy. The resident was prescribed Osmolite 1.5 at a rate of 45 ml per hour, but did not receive this feeding from the time of admission on November 21 through November 25. The facility's Gastric Tube Feeding policy requires compliance with physician orders, including product volume and infusion rate, but this was not adhered to in this case. The deficiency occurred because the pharmacy sent the wrong formula, Jevity, and the nursing staff failed to notify the Director of Nursing or take action to ensure the correct formula was provided. Interviews with the Director of Nursing and nursing staff revealed that the facility did not have the prescribed Osmolite in-house, and the nurses did not administer any g-tube feeding to the resident during this period. The lack of communication and failure to follow up on the physician's order resulted in the resident not receiving the necessary enteral nutrition as prescribed.
Failure to Provide Grievance Forms and Procedures
Penalty
Summary
The facility failed to provide readily available grievance forms and did not post grievance/complaint procedures in prominent locations throughout the building, potentially affecting all 70 residents. The facility's grievance policy, dated November 2016, requires that grievance procedures be posted prominently and include contact information for the grievance official. During a resident council meeting, several residents expressed that they were unaware of how to file a grievance. An inspection revealed a wooden box near the activity director's office with a note indicating that grievances could be placed there, but no official grievance forms were available. Additionally, a tour with the Administrator confirmed that there were no posted grievance procedures in any prominent locations within the facility.
Failure to Provide Written Notice of Transfer
Penalty
Summary
The facility failed to provide residents and their representatives with a written notice of transfer, which is a requirement when transferring or discharging residents. This deficiency was identified through interviews and record reviews, revealing that two residents, R43 and R56, were transferred to a local hospital without receiving the necessary written notification. The Director of Nursing (DON) confirmed the absence of such notifications and admitted to being unaware of the requirement for a written notice of transfer form. Additionally, the Social Service Director also stated a lack of awareness regarding the form, indicating a systemic issue within the facility's procedures for handling resident transfers.
Failure to Provide Always Available Menu Options
Penalty
Summary
The facility failed to provide food items listed on the Always Available Menu to residents who requested substitutions for their meals. This deficiency was identified during a Resident Council Meeting where several residents reported that they could only receive a peanut butter and jelly sandwich or a fruit plate as substitutes, despite the menu listing a variety of other options such as grilled cheese, cheeseburgers, and salads. The residents expressed that when they requested other items from the Always Available Menu, the cook refused to prepare them, and they were not aware of the menu's existence or its offerings beyond the limited options they received. Additionally, residents reported feeling hesitant to request menu substitutions due to fear of receiving their meals late and cold. This indicates a lack of communication and transparency regarding the Always Available Menu, as well as a failure to honor residents' dietary preferences and needs. The facility's documentation confirmed that 70 residents were residing in the facility at the time of the survey, highlighting the potential widespread impact of this deficiency on the resident population.
Failure to Document Cool Down Temperatures for Hazardous Foods
Penalty
Summary
The facility failed to utilize Cool Down Temperature Logs for potentially hazardous foods, which could affect all 70 residents. The facility's Two Stage Cool Down Process, dated 2015, requires potentially hazardous foods to be cooled from 135 degrees Fahrenheit to 70 degrees Fahrenheit within two hours, and then from 70 degrees Fahrenheit to 41 degrees Fahrenheit within four hours. Additionally, the Hazard Analysis Critical Control Point (HACCP) Cooling Log, dated 2024, mandates recording temperatures every hour during the cooling cycle. However, during an observation on July 8, 2024, the HACCP Cooling Log was found to be blank for the month of July, and there were no Cool Down Temperature Logs for previous months. The Dietary Manager acknowledged that potentially hazardous foods are sometimes prepared a day in advance and admitted to recently learning about the requirement to record cool down temperatures. Although the manager had instructed the cooks to start using the HACCP form, it was not being utilized. The meals for the day of the observation were prepared on the same day, but the lack of documentation for previous days indicates a failure to adhere to the established cooling procedures, potentially compromising food safety for the residents.
Failure to Document Compression Stockings in Care Plan
Penalty
Summary
The facility failed to develop a personalized care plan for a resident with multiple medical conditions, including venous insufficiency, sciatica, major depressive disorder, anxiety disorder, hypertensive heart disease without heart failure, and localized edema. The resident, who was admitted with these diagnoses, had a physician's order to wear vascular compression stockings daily from 6:00 AM to 6:00 PM. However, the care plan did not document this requirement. During an interview, the resident expressed that her legs had been swelling and she needed to wear compression stockings daily. The Director of Nursing confirmed the absence of a care plan for the compression stockings, and the Assistant Director of Nursing/Wound Nurse acknowledged the oversight and added the requirement to the care plan after the deficiency was identified.
Delay in Administration of Antifungal Cream
Penalty
Summary
The facility failed to provide timely administration of a physician-ordered Ketoconazole cream for a resident with a known topical yeast growth. The resident, who has a history of diabetes mellitus, heart failure, weakness, obesity, and COPD, was at risk for skin integrity issues and had a previous pressure ulcer and yeast growth. Despite a physician's order for the antifungal cream on June 11, 2024, the medication was not administered until 17 days later, on June 28, 2024. The delay was due to a lack of clarification on the order's specifics, such as the percentage, application site, and dosage, which were not documented in the resident's electronic medical record until the follow-up. The resident expressed concerns about the facility's failure to process and complete medication orders as required. The Director of Nursing confirmed the delay but was unsure of the reasons behind the confusion or delay in starting the treatment. The facility's Drug Order Policy mandates timely processing of medication orders, but this was not adhered to in this case, resulting in a significant delay in the resident receiving the necessary treatment for their condition.
Deficiencies in Dialysis Care Coordination and Documentation
Penalty
Summary
The facility failed to provide comprehensive and coordinated dialysis care for a resident with End Stage Renal Disease, as evidenced by multiple deficiencies in the care and services provided. The resident, who required hemodialysis three times a week, did not receive physician-ordered yogurt with all meals, and daily weights were not obtained as prescribed. Additionally, the facility did not provide lunch meals when the resident was out of the facility for scheduled hemodialysis sessions, and there was a lack of communication with the dialysis center before and after treatments. The resident's care plan was inadequate, lacking detailed documentation of dialysis care and required services. The care plan did not include emergency central venous catheter care, complications to watch for at the site, protocols and procedures for venous catheter dressing changes, or a specific plan of care for the resident's individualized renal dialysis treatment. Observations revealed that the resident's central venous catheter port was not being monitored or documented in the medical record, and there was no evidence of communication between the facility and the dialysis center regarding the resident's treatments. Interviews with facility staff, including the Licensed Practical Nurse/Infection Control Preventionist, Dietary Manager, Cook, Assistant Director of Nursing, and Director of Nursing, confirmed the lack of communication and documentation related to the resident's dialysis care. The staff acknowledged that there was no documented communication plan with the dialysis center, and the resident's dialysis catheter port was not being assessed or cared for as required. The dietary staff also failed to consistently provide the resident with the prescribed yogurt and sack lunches for dialysis appointments.
Failure to Monitor and Reduce Antipsychotic Medication
Penalty
Summary
The facility failed to identify and monitor targeted psychotic behaviors to justify the use of the antipsychotic medication Abilify for a resident diagnosed with bipolar disorder, current episode depressed, severe, with psychotic features. The resident's care plan, dated March 2024, did not specify the behaviors to be monitored for the use of the antipsychotic medication, despite documenting behaviors such as inappropriate comments, manipulative behaviors, and manic behaviors like trouble sleeping. The Behavior/Intervention Monthly Flow Record and Medication Flowsheet for June and July 2024 indicated monitoring for verbalized sadness, anxiety, and irritability, but noted no behaviors. Observations of the resident during this period also showed no behaviors. The facility's Antipsychotic Medication Use policy requires the attending physician and staff to gather and document information on a resident's behavior and symptoms to determine the necessity of antipsychotic medications. However, the resident's electronic medical record lacked evidence of a gradual dose reduction (GDR) for Abilify or a pharmacy recommendation for a GDR in the past twelve months. The Director of Nursing confirmed that a GDR had not been conducted or recommended, despite acknowledging that a GDR should occur at least annually. The Director also mentioned an attempt to reduce the Abilify dosage was hindered by a concurrent reduction in the resident's Buspirone medication.
Failure to Implement Enhanced Barrier Precautions for Dialysis Resident
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions for a resident with a Central Venous Catheter dialysis port. The facility's policy requires Enhanced Barrier Precautions, in addition to Standard and Contact Precautions, during high-contact resident care activities for residents with an increased risk of acquiring a multi-drug-resistant organism (MDRO). This includes residents with wounds, indwelling medical devices, or those with infection or colonization with an MDRO. The policy specifies that signage should be posted outside the resident's room, and an isolation cart with personal protective equipment should be provided immediately outside the room. The deficiency was identified for a resident who required dialysis three times a week and had a central venous catheter in his upper left chest. During an observation, it was noted that the resident's room did not contain any signage or personal protective equipment to indicate that Enhanced Barrier Precautions were in place. The resident confirmed having the central venous catheter since January, and the Licensed Practical Nurse/Infection Control Preventionist acknowledged that the resident was not on enhanced barrier precautions, despite having the catheter line since January. The nurse also mentioned that the central venous catheter was not charted anywhere, and the resident had not been on any recent isolation.
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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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