Tower Hill Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in South Elgin, Illinois.
- Location
- 759 Kane Street, South Elgin, Illinois 60177
- CMS Provider Number
- 145795
- Inspections on file
- 40
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Tower Hill Healthcare Center during CMS and state inspections, most recent first.
A resident reported to an RN that clothes and money were missing and complained that nothing was being done, but the concern was not communicated to the social services staff member responsible for investigating missing items and filing grievances. The social services staff member stated she was unaware of the report and therefore did not initiate her usual process of searching for the items, filing a grievance form, or arranging replacement. Review of the grievance log over several months showed no entry for this resident’s missing items, despite a facility policy requiring that grievances be recorded, promptly addressed, and resolved within a specified timeframe.
Two residents were not protected from physical abuse when one resident in a wheelchair was punched in the face by another resident after a dispute over papers, and a cognitively impaired resident with dementia was found with facial bruising and a bloody nose after his roommate, who also had dementia and had repeatedly complained about being kept awake, was observed standing over his bed and making threatening statements. Staff observations, resident statements, and nursing documentation consistently described resident‑to‑resident hitting and unexplained facial injuries, despite the abused resident’s care plan identifying him as at risk for abuse.
The facility failed to prevent resident-on-resident physical abuse involving cognitively impaired residents with known behavioral issues. In one case, a male resident with dementia, wandering, and aggressive behaviors entered a female resident’s room; she attempted to remove him and a CNA witnessed him punch her in the chest. In another case, a confused, behaviorally disturbed resident in a wheelchair demanded a dining table seat and, after being refused, punched another resident in the face, causing immediate bruising and a black eye, as confirmed by an LPN and another resident witness. These events occurred despite a facility abuse policy that prohibits physical abuse such as hitting and striking.
A resident with severe cognitive impairment, poor safety awareness, prior falls with fractures, glaucoma, anxiety, psychotic disorder, and a cognitive communication deficit was transported in a wheelchair without the footrests in place. While being pushed by a restorative CNA, the resident planted her feet on the floor, causing her to fall forward out of the wheelchair onto the floor. Staff later acknowledged they had not ensured the resident’s feet were on the wheelchair pedals, contrary to the facility’s Safe Resident Lifting Policy requiring appropriate leg/footrests for residents using wheelchairs unless they self-propel.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in noncompliance with regulatory requirements.
Two residents with severe cognitive impairment were left unsupervised in a hallway, resulting in one physically striking the other and causing visible injuries. The incident was witnessed by a CNA, who alerted two LPNs to intervene. Both residents had no prior history of aggression, and the facility's lack of supervision led to the occurrence of physical abuse.
A resident who fell out of bed and hit their head did not receive neurological assessments according to facility protocol. Although staff stated that neuro checks should be performed for 72 hours post-fall and resumed after hospital return, documentation showed delayed initiation of checks and missed hourly assessments, with incomplete record-keeping of the incident timeline.
A resident with dementia experienced a delay in call light response, leading to her wetting herself and feeling embarrassed. Despite multiple requests for assistance, staff were occupied with lunch duties, resulting in a 40 to 60-minute wait. The facility lacks a system to track call light response times, and the resident's care plan did not address her toileting needs, contrary to the facility's dignity policy.
A resident with multiple health issues, including reduced mobility and dementia, was injured in an LTC facility after accessing an unlocked room labeled as an ice machine room. Inside, the resident attempted to retrieve ice, causing a wobbly IV pole to fall and injure her shin. The room contained unsecured medical equipment, and the lock on the door was broken, allowing resident access. The resident was treated for a contusion, and the facility acknowledged the room should have been locked and not used for equipment storage.
The facility failed to implement protocols for using an assessment tool for residents receiving antibiotics, affecting all 166 residents. The Infection Preventionist did not use an assessment tool or criteria to evaluate appropriate antibiotic use, and the facility's policy lacked a procedure for standardized assessment. The Director of Nursing acknowledged the need for such a tool, indicating a gap in antibiotic stewardship practices.
The facility failed to provide mechanical soft diets as ordered for residents requiring such consistency. The cook, V9, shredded BBQ pork instead of grinding it, resulting in residents receiving food that did not meet their dietary needs. The dietary manager and dietitian confirmed the inconsistency with the prescribed diet.
The facility failed to provide necessary grooming assistance to two residents who required extensive help with ADLs. One resident with cerebral infarction and functional quadriplegia had long, thick fingernails, while another resident with muscle weakness and difficulty walking had long facial hair and unclean nails. Despite care plans indicating the need for extensive assistance, these grooming needs were not met.
Two residents in the facility had their central venous catheter dressings not changed in a timely manner, risking infection. One resident's dressing had not been changed since early January, while another's was loose and detached. The LPN was unaware of the dressing change policy, and the DON confirmed the need for changes every 7 days or as needed. Facility guidelines stress the importance of aseptic technique and timely dressing changes.
A resident with chronic pain and a history of fractures experienced inadequate pain management due to the facility's failure to implement a care plan and administer prescribed medications consistently. Despite orders for Hydrocodone and Hydromorphone every four hours, the resident reported severe pain levels and significant delays in receiving medication. Nursing staff acknowledged the pain but did not follow the facility's pain management policy, leading to prolonged discomfort for the resident.
A resident with end-stage renal disease was repeatedly observed without a dressing over their central venous catheter (CVC) site, contrary to the facility's infection control standards. Despite the facility's policy requiring the site to remain covered, the resident arrived at dialysis multiple times without a dressing, increasing the risk of infection. The facility's staff were aware of the issue, but the deficiency persisted.
The facility failed to ensure timely physician responses to pharmacist recommendations during monthly Medication Regimen Reviews (MRRs) for three residents. One resident's narcotic pain medication was not reviewed despite a recommendation for discontinuation. Another resident did not have MRRs conducted for six months, and a third resident's antipsychotic medication use lacked physician review. The facility's policy requires timely communication and response to pharmacist recommendations.
The facility failed to conduct required gradual dose reductions (GDR) for psychotropic medications for three residents. One resident had not had a GDR since June 2023 despite being on clonazepam and quetiapine. Another resident was on Restoril for insomnia without a documented GDR evaluation, despite pharmacist recommendations. A third resident on multiple psychotropic medications also lacked a documented GDR evaluation. The facility's policy mandates GDR attempts within the first year of admission and annually thereafter unless contraindicated, which was not followed.
The facility failed to use the correct scoop size for serving pureed diets, affecting three residents. The Dietary Manager used a #8 scoop instead of the required #6 scoop, leading to incorrect portion sizes. This was confirmed by the Dietitian, who emphasized the importance of using the correct scoop size to ensure residents receive adequate nutrition.
A resident with a history of stroke and dysphagia was served a regular texture meal instead of the prescribed pureed diet. The ADON confirmed the error, noting the meal belonged to another resident. The resident's care plan required a pureed diet for safety, which was not followed, as acknowledged by the DON.
The facility failed to follow infection control policies for norovirus and enhanced barrier precautions. A resident with norovirus was not isolated, and staff did not use PPE as required for residents on contact isolation and enhanced barrier precautions. The Infection Preventionist was unaware of a positive norovirus case, and staff entered rooms without proper protective measures.
Two residents with cognitive impairments engaged in a physical altercation during dinner, resulting in one resident sustaining scratches and the other being sent to the hospital. Staff intervened after hearing a commotion, but the incident was not directly witnessed, and the facility's investigation could not determine the aggressor. The facility's abuse prevention program was not effectively implemented, highlighting a deficiency in protecting residents from abuse.
A resident with multiple medical conditions and high fall risk fell during a transfer using a mechanical lift due to excessive movement and pain. Despite being assisted by two CNAs, the resident slid out of the sling and hit her head, although no injuries were reported. The facility's policy on safe transfers was not effectively followed, contributing to the incident.
The facility failed to follow infection control standards during dressing changes for two residents. A nurse used hand sanitizer instead of soap and water after handling a C. difficile case, and another instance lacked enhanced barrier precautions during wound care. The DON misunderstood the guidelines, leading to improper infection control practices.
A resident with cognitive impairments was physically assaulted by another resident in the dining room. The incident occurred when one resident attempted to sit at a table reserved for another, leading to an altercation. A CNA witnessed the event and called for assistance, and an LPN intervened to separate the residents. Both residents have dementia-related diagnoses, and the facility's Abuse Prevention Program prohibits such abuse.
A resident with dementia was physically abused by another resident during breakfast, resulting in scratches and a ripped shirt. The incident occurred when the resident with dementia attempted to take food from the other resident's tray, leading to a physical altercation. Staff intervened, and the police were notified, resulting in charges against the aggressor. The facility's failure to prevent this incident highlights a deficiency in protecting residents from abuse.
The facility failed to serve food at safe and appetizing temperatures for all 154 residents. Observations and interviews revealed that residents experienced issues with cold and unappetizing food. A test tray showed food temperatures below the required minimum, and the acting dietary manager confirmed that temperatures were not checked before serving, violating the facility's policy.
Two residents with mild cognitive impairment were found in rooms with inadequate cleanliness, including moldy curtains and damaged linens. Despite daily cleaning, issues were not thoroughly addressed, and previous complaints were ignored. The facility's policies on maintaining a clean and attractive environment were not followed.
The facility failed to protect residents from abuse, resulting in multiple incidents of resident-to-resident aggression. One resident experienced ongoing pain after being punched by another, while two other residents engaged in a physical altercation despite supervision. The facility's abuse prevention program was not effectively implemented to prevent these incidents.
A resident with dementia and other mental health conditions was involuntarily discharged to the hospital due to aggressive behavior. The facility failed to have a physician document the necessity of the immediate transfer, as confirmed by interviews with the Nurse Practitioner and Psychiatrist.
Failure to Log and Address Resident Grievance About Missing Personal Items
Penalty
Summary
The facility failed to honor a resident’s right to voice grievances and to ensure that a grievance regarding missing personal items was reported, logged, and resolved according to policy. Nursing documentation dated 3/20/25 by an RN (V12) recorded that resident R5 stated he had clothes and money missing and that no one was doing anything about it. During a later interview, the RN stated she documented the note on 3/30/25 and indicated that her usual practice when a resident reports missing items is to report them to the social services staff member (V9), but she could not recall whether she actually reported R5’s missing items to V9. In a separate interview, V9 stated that when a resident reports missing money or clothes, she spends 48 hours attempting to locate the items and, if unsuccessful, files a grievance form and replaces the items, but she was not aware of R5’s report of missing items. Review of the facility’s Grievance Complaint Log from January 2025 through October 2025 showed no grievance filed for R5’s missing clothing or money, despite the resident’s report. The facility’s undated Grievance/Complaint Policy states that residents have the right to voice grievances without discrimination or reprisal, that prompt efforts will be made to resolve grievances, that the disposition of grievances will be recorded on the grievance and complaint log, and that grievances will have a disposition within seven working days of being filed. This deficiency centers on the facility’s failure to ensure that R5’s grievance about missing clothes and money was communicated to the appropriate staff, entered into the grievance log, and processed in accordance with the written grievance policy.
Failure to Protect Residents From Physical Abuse by Roommates
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse, as evidenced by two substantiated or suspected resident‑to‑resident physical abuse incidents. In the first incident, a resident in a wheelchair (R1) was struck in the face by another resident (R2). Multiple CNAs reported that R1 had papers in her hand that R2 was trying to retrieve, and that R2 then punched or swung and hit R1 in the right side of the face with a closed fist. The nurse on duty heard staff at the nurses’ station saying, “don’t hit her! He hit her!” and, upon assessment, observed a red mark on the right side of R1’s face near her temple and hairline. R1 later reported being hit in the face by a male person, appeared anxious with shaking hands, and described the event as scary. In the second incident, the facility failed to ensure that a cognitively impaired resident (R3), who had a care plan identifying him as at risk for abuse related to behavior problems and dementia, was free from potential physical abuse by his roommate (R4), who also had dementia and resided on the Memory Care unit. A CNA (V13) reported that around midnight R4 repeatedly complained that R3 was keeping him awake and stated that someone needed to keep R3 quiet. Later, around 5:00 AM, V13 observed R4 standing over R3’s bed, heard R4 say that R3 had kept him up all night making noises and that he should hit him, and then found blood around R3’s nose. V13 believed R4 had hit R3 and informed the LPN, who documented discoloration to the bridge of R3’s nose and later a bloody nose that was cleaned and assessed. Subsequent observations by other staff and R3’s wife further documented unexplained facial injuries consistent with trauma. Another CNA (V16) saw R3 shortly after coming on shift and noted bruising to the bridge of his nose, a split lip, and a runny, somewhat bloody nose, and reported being told by V13 that R4 had been standing over R3 and threatening to “kick his ass.” The day‑shift LPN (V17) documented a full body assessment with bruising to the bridge of R3’s nose and right temporal area, while the Administrator and Social Services Assistant both acknowledged bruising and blood on linens without a clear reason for the injury. R3’s wife was informed only that R3’s nose was bleeding and was told they thought he had bumped into something, but she observed a red mark across the bridge and right side of his nose and questioned whether someone had done something to him. These events demonstrate that the facility did not ensure residents were free from physical abuse as required by its Abuse Prevention Program Policy, which defines abuse as any physical injury inflicted upon a resident other than by accidental means, including hitting.
Failure to Prevent Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse when multiple resident-on-resident altercations occurred involving cognitively impaired residents with known behavioral histories. In one incident, a male resident with unspecified and vascular dementia, severe cognitive impairment, restlessness, agitation, generalized muscle weakness, osteoarthritis, wandering and exit-seeking behaviors entered the room of a female resident with severe cognitive impairment, psychotic disorder, major depressive disorder, generalized anxiety, glaucoma, and cognitive communication deficit. The female resident reported that the male resident repeatedly came into her room and would not leave, and that she scratched and grabbed him while trying to pull him out of her room, after which he punched her in the chest. A CNA responded to screams and witnessed the male resident strike the female resident in the chest, and an LPN later confirmed being informed that the male resident, who had a history of wandering, agitation, and difficulty with redirection, had punched the female resident while she was trying to shove him out of her room. Social services staff acknowledged that the male resident had a history of wandering and aggressive behaviors and that he should be monitored when out of his room, and also noted that the female resident had dementia, confusion, and a history of past abuse experiences. In a separate incident, the facility did not prevent physical abuse when one female resident with vascular dementia with behavioral disturbances, unspecified psychosis, muscle weakness, cognitive communication deficit, and a history of verbal and physical aggression struck another female resident with dementia, anxiety, insomnia, GERD, rheumatoid arthritis, and spinal stenosis. While a nurse was passing medications in the dining room, the victim resident reported that another resident had hit her in the face after becoming upset about wanting to sit at the same table when there was no room. The nurse observed immediate bruising and later dark purple discoloration to the left side of the victim’s face. Another resident at the table corroborated that the aggressive resident approached in a wheelchair, demanded the victim’s seat, and, after being told no, punched her in the eye, causing pain and a black eye. This witness also stated that the aggressor had a “mean streak” and prior verbal altercations with staff and residents. The administrator, serving as abuse coordinator, confirmed that the incident involving the two residents in the first event was witnessed and that physical abuse was substantiated. The facility’s abuse policy affirms residents’ rights to be free from abuse and defines physical abuse as the infliction of injury by non-accidental means, including hitting and similar acts.
Failure to Use Wheelchair Footrests Resulting in Resident Fall During Transport
Penalty
Summary
The facility failed to ensure safe wheelchair transport and adequate supervision to prevent a fall for one resident. The resident had a resident assessment indicating she was severely cognitively impaired and a care plan identifying her as at risk for falls due to poor safety awareness and impulsiveness related to impaired cognition. Her care plan also noted glaucoma, prior falls with fractures, anxiety, unspecified psychotic disorder, and a cognitive communication deficit, all contributing to an increased fall risk. Despite these identified risks, the resident was transported in a wheelchair without proper use of the wheelchair footrests. A progress note documented that while a restorative CNA was pushing the resident in her wheelchair, the resident suddenly planted her feet on the ground as the wheelchair was moving, causing her to fall forward out of the wheelchair, landing on her knees and then rolling onto her back. She was sent to a local hospital and was found to have no injuries and returned the same day. Staff interviews later confirmed that the wheelchair foot pedals were not down and in place, and the CNA did not realize the resident’s feet were dragging on the floor under the wheelchair. The facility’s Safe Resident Lifting Policy required that all residents using a wheelchair have appropriate leg/footrests during transfers unless they self-propel, which was not followed in this incident.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent an incident of physical abuse between two residents, both of whom were severely cognitively impaired and had no prior history of aggressive behavior. The event occurred in the early morning hours when a CNA, after providing care to another resident, observed the two residents engaged in a physical altercation at the end of a hallway. The CNA witnessed one resident striking the other in the face and immediately called for assistance. Two LPNs responded, separated the residents, and performed assessments. The resident who was struck sustained a small laceration and redness to the left eye/eyebrow area, as well as a bruise to the left hand and reported forearm pain. The other resident did not have any injuries and denied pain. Both residents were unable to provide coherent accounts of the incident due to their cognitive impairments. Staff interviews confirmed that neither resident had a documented history of aggression, although one was noted to become agitated with care. The incident was witnessed by staff, and the facility's own investigation substantiated that physical abuse had occurred. At the time of the incident, the CNA was occupied in another room, and the LPNs were preparing medications in the medication room, leaving the residents unsupervised in the hallway. The facility's abuse prevention policy prohibits physical abuse, including hitting and striking, and affirms the right of residents to be free from such harm. Despite these policies, the lack of supervision allowed the altercation to occur, resulting in injury to one resident.
Failure to Complete Neurological Assessments After Resident Fall
Penalty
Summary
The facility failed to complete neurological assessments as required following a resident's fall. A resident reported falling out of bed, hitting his head, and being sent to the hospital, after which he returned to the facility the same day. According to facility staff, neurological checks are to be performed for 72 hours after a fall involving a head injury or an unwitnessed fall, and these checks should continue upon the resident's return from the hospital. However, the neurological assessment documentation did not begin until late in the evening on the day of the fall, and two hourly checks were missed in the early afternoon after the resident's return. The documentation also lacked an initial incident time, indicating incomplete monitoring and record-keeping as per facility protocol.
Delayed Call Light Response Compromises Resident Dignity
Penalty
Summary
The facility failed to maintain a resident's dignity by not responding to a call light in a timely manner, resulting in the resident, who has dementia, wetting herself. On the day of the incident, the resident's great-granddaughter reported that upon arriving at the facility, the resident needed to use the bathroom and had activated her call light. Despite multiple requests for assistance at the nurse's station, staff did not respond promptly, citing that they were busy with lunch duties. Consequently, the resident had to wait for 40 to 60 minutes before receiving help, during which time she wet herself, causing embarrassment. Interviews with the resident's family and facility staff revealed that call light response times varied significantly, sometimes taking up to 45 minutes. The Director of Nursing acknowledged the lack of a system to track call light response times and stated that such delays were unacceptable. The resident's care plan did not include specific provisions for her toileting needs, despite her requiring maximum assistance for mobility and transfers. The facility's dignity policy emphasizes prompt response to toileting requests, which was not adhered to in this case.
Resident Injured by Falling IV Pole in Unsecured Equipment Room
Penalty
Summary
The facility failed to prevent residents from accessing a room where medical equipment in need of repair was stored, leading to an accident involving a resident. The resident, who has multiple diagnoses including cerebral infarction, reduced mobility, and dementia, was able to enter an unlocked room labeled as an ice machine room. Inside, the resident attempted to retrieve ice and accidentally caused an IV pole to fall, resulting in an injury to her right shin. The room contained several pieces of medical equipment, including wobbly IV poles and oxygen concentrators, which were not secured or stored properly. The resident, who is cognitively intact but requires assistance with various activities of daily living, reported the incident to staff, indicating that the pole fell and hit her leg. The Director of Nursing (DON) confirmed the resident's account and observed a bright red area on the resident's shin, consistent with the reported injury. The resident was subsequently treated at a hospital for a contusion, and X-rays confirmed no fractures or dislocations. The Maintenance Director acknowledged that the room was not supposed to be accessible to residents and that the lock on the door was broken. Additionally, the IV poles were identified as wobbly due to loose screws, which had not been addressed. The DON confirmed that the room should have been locked and that storing equipment in the ice machine room was not appropriate, contributing to the unsafe environment that led to the resident's injury.
Failure to Implement Antibiotic Assessment Protocols
Penalty
Summary
The facility failed to implement protocols for utilizing an assessment tool or management algorithm for residents who may receive antibiotics, affecting all 166 residents. The Infection Preventionist (V4) admitted to not using an assessment tool or criteria when evaluating if a resident is appropriately receiving an antibiotic. Instead, V4 reviews antibiotic orders with providers to ensure there is an indication for use. However, V4 did not have an assessment tool for any antibiotics prescribed during December 2024, January 2025, and February 2025, and did not discuss inappropriate antibiotic use at Quality Assurance and Performance Improvement meetings. The facility's policy on Antibiotic Stewardship, dated December 2016, states that antibiotics will be prescribed and administered under the guidance of the facility's Antibiotic Stewardship Program. The policy emphasizes monitoring antibiotic use and educating staff on the importance of stewardship. However, the policy lacks a procedure for utilizing a standardized tool and criteria for assessing antibiotic use. The Director of Nursing (V2) acknowledged that V4 should be using an assessment tool to ensure antibiotics are required, highlighting a gap in the facility's antibiotic stewardship practices.
Failure to Provide Mechanical Soft Diets as Ordered
Penalty
Summary
The facility failed to prepare mechanical soft consistency diets for residents who had a diet order for such. On February 4, 2025, the facility's cook, V9, was observed preparing BBQ pork for residents on a mechanical soft diet. Instead of grinding the pork as required, V9 shredded it into small pieces and mixed it with broth and barbeque sauce, believing this would suffice for a mechanical soft consistency. However, the final product was not ground as specified in the facility's menu and recipe for mechanical soft diets. During the tray line service, V9 mistakenly mixed the shredded pork with the regular consistency diets, resulting in residents on mechanical soft diets receiving food that did not meet their dietary needs. This affected four residents who were on a mechanical soft diet. The dietary manager, V8, was informed of the inconsistency, and the dietitian, V12, confirmed that the mechanical soft diets should have received ground meat as per the menu. The failure to adhere to the prescribed diet consistency was a clear deviation from the facility's dietary guidelines.
Failure to Provide Grooming Assistance to Residents
Penalty
Summary
The facility failed to provide necessary grooming assistance to residents who required extensive help with activities of daily living (ADLs). One resident, diagnosed with cerebral infarction and functional quadriplegia, was observed with long, thick fingernails on her right hand, which were curling and rubbing against her palms. Despite being dependent on staff for personal hygiene, her care plan indicated she should receive extensive assistance from one person. However, her fingernails remained untrimmed, and she expressed a desire for them to be cut. Another resident, who required substantial maximal assistance for personal hygiene due to muscle weakness and difficulty walking, was observed with long facial hair and nails with a blackish substance underneath. The resident's Power of Attorney mentioned having previously assisted with grooming but indicated that the facility staff could perform these tasks. Despite the care plan specifying the need for extensive assistance, the resident's grooming needs were not adequately addressed. The Director of Nursing acknowledged that CNAs should provide personal hygiene assistance every shift or as needed.
Failure to Timely Change Central Line Dressings
Penalty
Summary
The facility failed to change the central venous catheter dressings for two residents, R310 and R309, in a timely manner, which is crucial to prevent the spread of infection. R310, a female resident with a history of infection following a procedure and other medical conditions, was observed with a central line dressing that had not been changed since January 8, 2025. The dressing was dingy, loosened, and detached from her skin. Despite the resident's statement that the dressing was only reinforced and not changed, the Licensed Practical Nurse (LPN) was unaware of the facility's policy for changing central line dressings. The resident's care plan required daily checks of the dressing, and a physician's order mandated checking the intravenous site every 8 hours. Similarly, R309, a male resident with multiple sclerosis and other diagnoses, was observed with a central line dressing that was loose and detached from his arm. The dressing, dated February 3, 2025, was not changed despite its condition worsening over time. The Director of Nursing (DON) stated that central line catheter dressings should be changed every 7 days or as needed if they become loose or soiled. The facility's guidelines also emphasized the importance of aseptic technique and timely dressing changes to prevent infections. However, these protocols were not followed, leading to the deficiency.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to manage a resident's severe pain effectively, as evidenced by the lack of a care plan for pain management and inconsistent administration of prescribed pain medications. The resident, a female with a history of fractures, chronic pain, and osteoarthritis, reported severe pain levels of 10/10 on multiple occasions. Despite having orders for Hydrocodone and Hydromorphone to be administered every four hours as needed, the resident experienced significant delays in receiving her medication, with gaps of up to 11 hours between doses. The resident and her daughter repeatedly informed the staff about the inadequacy of pain management, but the facility did not address these concerns promptly. Nursing staff, including a nurse identified as V23, acknowledged the resident's persistent pain but failed to document or administer pain medication as prescribed. The Medication Administration Record did not reflect timely administration of pain relief, and the staff did not consistently assess or document the resident's pain levels. The Director of Nursing stated that pain levels over 5/10 should be addressed with stronger medication, yet this protocol was not followed. The facility's pain management policy emphasizes a commitment to resident comfort and the need for effective pain management strategies, which were not implemented in this case.
Failure to Maintain Dialysis Catheter Site
Penalty
Summary
The facility failed to maintain the central venous catheter (CVC) dialysis access site for a resident, identified as R119, in accordance with infection control standards and their policy. R119, who was admitted with multiple diagnoses including end-stage renal disease, was observed on multiple occasions without a dressing over the CVC insertion site. This was despite the facility's policy requiring the site to remain covered, clean, and dry at all times. On February 3, 2025, R119 was seen manipulating the catheter without a dressing, and on February 4, 2025, the site was again observed uncovered. The facility's staff, including a Licensed Practical Nurse (LPN) and a Registered Nurse (RN), were informed of the situation, but the issue persisted. The dialysis RN confirmed that R119 frequently arrived at dialysis without a dressing on the catheter site, which is critical to prevent infection. The facility's communication tool, used to share clinical information between facility nursing staff and dialysis staff, emphasized the importance of maintaining an intact dressing. Despite this, R119's dialysis treatment records indicated repeated instances of arriving without a dressing. The resident had a history of sepsis due to MRSA, highlighting the critical need for proper catheter site management. The Director of Nursing (DON) acknowledged the requirement for the CVC site to always be covered, yet the deficiency continued, indicating a lapse in adherence to the facility's dialysis protocol.
Failure to Address Pharmacist Recommendations and Conduct Monthly Reviews
Penalty
Summary
The facility failed to adhere to its policy requiring timely physician responses to pharmacist recommendations during monthly Medication Regimen Reviews (MRRs). This deficiency was identified in three residents. For one resident, the pharmacist recommended discontinuing a narcotic pain medication due to non-use for over 30 days, but there was no documentation showing that the physician was notified or that the recommendation was addressed. The Director of Nursing confirmed the lack of documentation and that the medication order remained active. Additionally, the facility did not conduct MRRs for another resident over a six-month period, despite the resident's use of multiple psychotropic medications. For a third resident, the pharmacist's recommendations regarding the use of an antipsychotic medication lacked physician review or documentation of action taken. The facility's policy requires that the consultant pharmacist's recommendations be communicated to the Director of Nursing and/or Administrator, and that the attending physician and/or Medical Director be provided with copies of the recommendations for timely response.
Failure to Conduct Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to adhere to its policy of attempting gradual dose reductions (GDR) for residents on psychotropic medications, as evidenced by the cases of three residents. Resident R73, who was admitted with multiple diagnoses including dementia and psychosis, had not had a GDR attempted or documented since June 14, 2023, despite being on clonazepam and quetiapine. The care plan indicated that a GDR was contraindicated in June 2023, but there was no further documentation to support ongoing evaluations or attempts at dose reduction. Resident R91, diagnosed with insomnia and other conditions, was prescribed Restoril for insomnia. Despite recommendations from the consultant pharmacist for a GDR evaluation on multiple occasions, there was no documentation of such an evaluation being conducted. Similarly, Resident R128, with diagnoses including Alzheimer's and major depressive disorder, was on multiple psychotropic medications. The facility's records showed that a GDR evaluation was due, but no documentation was provided to confirm that it had been conducted. The facility's policy requires GDR attempts within the first year of admission and annually thereafter unless contraindicated, but this was not followed for the residents in question.
Improper Portion Sizes for Pureed Diets
Penalty
Summary
The facility failed to adhere to the prescribed portion sizes for pureed diets as specified on the menu, affecting three residents. During an observation of the tray line in the facility kitchen, it was noted that the Dietary Manager used a #8 scoop instead of the required #6 scoop to serve pureed chicken and pasta to residents on pureed diets. This discrepancy was confirmed by the Dietary Manager, who admitted to not checking the menu before selecting the scoop size. The facility's Portion Control Chart indicated that a #8 scoop equates to 4 oz, while a #6 scoop equates to 5 1/3 oz, which is necessary to ensure residents receive adequate calories and protein. The Dietitian confirmed that the correct scoop size should be used to meet the nutritional needs of the residents.
Failure to Provide Prescribed Pureed Diet to Resident
Penalty
Summary
The facility failed to provide a resident with a pureed diet as prescribed by the attending physician. On February 4, 2025, a resident identified as R14 was observed in the dining room with a meal tray that contained regular texture food, including barbecue pulled pork, tater tots, and cornbread, instead of the prescribed pureed diet. A Certified Nursing Assistant (CNA) assisted R14 by cutting up the food, and the resident began eating the meal. The Assistant Director of Nursing (ADON) acknowledged that R14 had an order for a pureed diet and confirmed that the tray served was incorrect, as it belonged to a different resident. R14's medical records indicated a history of stroke, dementia, dysphagia, and facial weakness, necessitating a pureed diet for safety reasons. The resident's order summary and nutrition care plan specified a general pureed diet with thin fluids and aspiration precautions, including no straws. The Director of Nursing (DON) confirmed that the facility staff should have provided the correct meal tray to R14, emphasizing that the resident was on a pureed diet for safety precautions.
Infection Control Deficiencies in Norovirus and Barrier Precautions
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies, particularly concerning norovirus, contact precautions, and enhanced barrier precautions. Resident R14, who tested positive for norovirus, was not placed in contact isolation as required by the facility's policy. Despite the positive test result, R14 continued to interact with other residents in communal areas such as the dining room and therapy department. The Infection Preventionist was unaware of R14's positive test result, and the Director of Nursing confirmed that R14 should have been isolated upon receiving the test results. Resident R124, who had a physician order for enhanced barrier precautions due to a urinary catheter and wound, was not properly managed according to the facility's protocols. The Wound Care Nurse and a CNA entered R124's room without donning the required gown, despite the presence of a sign indicating the need for enhanced barrier precautions. They proceeded to perform wound care and reposition the resident without adhering to the necessary protective measures. Resident R7, who was on contact isolation for norovirus, was not managed according to the facility's contact isolation protocols. An LPN entered R7's room multiple times without performing hand hygiene or donning the required gown and gloves, despite the presence of a contact isolation sign and PPE bin outside the room. The LPN acknowledged the oversight when questioned by a surveyor. The Director of Nursing confirmed the necessity of following contact isolation protocols to prevent the spread of infection.
Failure to Prevent Resident-on-Resident Abuse
Penalty
Summary
The facility failed to prevent an incident of abuse between two residents, identified as R1 and R2, during a dinner service. R1, who has a history of aggressive behavior and cognitive impairments, attempted to take food from R2's tray, leading to a physical altercation. R2, also cognitively impaired, reported that R1 hit him first, prompting R2 to retaliate. Staff intervened after hearing a commotion, but the altercation had already resulted in R1 sustaining scratches and R2 being sent to the hospital for evaluation. Interviews with staff members, including the Social Service Director and CNAs, revealed that the incident was not directly witnessed by any staff, as they were occupied with other duties at the time. The Director of Nursing acknowledged the incident as physical abuse and emphasized the facility's responsibility to protect residents from such occurrences. Despite the intervention, the facility's investigation could not conclusively determine the aggressor or victim due to conflicting accounts and the lack of direct witnesses. Both residents have documented histories of cognitive impairments and behavioral issues, with R1 diagnosed with dementia and R2 with Alzheimer's disease and violent behavior. The facility's abuse prevention program, which prohibits physical abuse, was not effectively implemented in this instance, as evidenced by the altercation and subsequent injuries. The report highlights the need for improved supervision and intervention strategies to prevent similar incidents in the future.
Failure to Safely Transfer Resident Using Mechanical Lift
Penalty
Summary
The facility failed to safely transfer a resident using a mechanical lift, resulting in a fall. The incident involved a resident who was categorized as high risk for falls and required a two-person assist for transfers. During a transfer from a wheelchair to a bed, the resident, who had a history of pressure ulcers and was experiencing pain, moved excessively in the sling, causing her to slide out and fall to the floor. Despite the presence of two CNAs, the resident's movement was not adequately controlled, leading to the fall. The resident, who had multiple medical conditions including cerebral infarction, muscle weakness, and pressure ulcers, was on a blood thinner, which increased the risk of injury from falls. During the transfer, the resident complained of pain, which may have contributed to her movement in the sling. The CNAs attempted to adjust the sling, ensuring all hooks were secured, but the resident continued to move, ultimately tipping out of the sling. The fall resulted in the resident hitting her head, although no injuries were reported after hospital evaluation. The facility's policy on transfers using a mechanical lift emphasizes the need for safe and comfortable transfers, but the incident highlights a failure to adhere to these guidelines. The resident's care plan included interventions to remind her not to move during transfers and to educate her about safety, but these measures were not effective in preventing the fall. The incident report and interviews with staff indicate that the resident's movement and pain were not adequately managed during the transfer, leading to the deficiency.
Infection Control Deficiencies During Dressing Changes
Penalty
Summary
The facility failed to adhere to proper infection control standards during a pressure dressing change for two residents. In the first instance, a wound nurse performed a dressing change on a resident with C. difficile, a condition requiring contact isolation precautions. The nurse washed her hands with soap and water initially, but after removing gloves, she used hand sanitizer instead of washing with soap and water, which is necessary to kill C. difficile spores. Additionally, after washing her hands, she removed her dirty gown, which compromised hand hygiene, and did not wash her hands with soap and water before leaving the room. In the second instance, the facility did not implement enhanced barrier precautions during a pressure dressing change for another resident. The nurse and an assisting LPN did not wear gowns, and there was no sign indicating enhanced barrier precautions outside the resident's room. The Director of Nursing mistakenly believed that enhanced barrier precautions were only necessary if the wound was weeping, which was not the case. The facility's guidelines require the use of gowns and gloves during high-risk activities involving multi-drug resistant organisms, such as wound care, regardless of wound condition.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent physical abuse of a resident, identified as R3, by another resident, R2. The incident occurred in the dining room when R2 approached R3's table and attempted to sit down. R3 informed R2 that the space was reserved for another resident, which led to R2 becoming upset and physically assaulting R3. R3 attempted to block the attack but was struck on the left side of the face, resulting in redness and pain. A Certified Nurse Aide (CNA) witnessed the altercation and called for assistance, after which a Licensed Practical Nurse (LPN) intervened to separate the residents. R2, who was not interviewable, has diagnoses of encephalopathy, dementia, and Alzheimer's disease, with moderately impaired cognitive skills. R3 also has Alzheimer's disease, dementia, schizoaffective disorder, anxiety disorder, and delusional disorders, with similarly impaired cognition. The facility's Abuse Investigation Report and nursing progress notes confirm that R2 struck R3 unprovoked. The facility's Abuse Prevention Program, revised in 2019, emphasizes the residents' right to be free from abuse and outlines that physical abuse includes hitting and other forms of corporal punishment. Despite these policies, the incident occurred, and the facility's response involved separating the residents and contacting the police to file a report. The report does not mention any injuries requiring medical attention, although R3 experienced pain from the assault.
Failure to Prevent Resident-on-Resident Abuse
Penalty
Summary
The facility failed to prevent the physical abuse of a resident, identified as R1, by another resident, identified as R2, during a breakfast incident. R1, who has diagnoses including dementia and severe cognitive impairment, was involved in a physical altercation with R2, who is cognitively intact and has a history of a motor-vehicle accident resulting in the loss of a leg. The altercation occurred when R1 allegedly attempted to take food from R2's breakfast tray, leading R2 to hit R1 on the chin and grab his shirt, resulting in scratches on R1's chest and a ripped shirt. Staff, including an LPN, intervened to separate the residents and assess the situation, noting the injuries to R1 and the absence of injuries to R2. The incident was reported to the police, and R2 was charged with a Class A Misdemeanor for Battery. Interviews with both residents and the LPN confirmed the occurrence of the altercation, with R2 admitting to overreacting and hitting R1. The facility's Abuse Prevention Program, revised in 2019, prohibits abuse and outlines that physical abuse includes actions such as hitting and slapping. Despite this policy, the facility did not prevent the altercation, resulting in a deficiency in protecting residents from abuse.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food and drink were served at a palatable, attractive, and safe temperature for all 154 residents consuming meals from the kitchen. Observations and interviews revealed that residents experienced issues with the food being cold and unappetizing. One resident described the food as inedible, while another mentioned that the food was not warm and was often cold. A third resident noted that while the food was generally okay, there were issues with it being cold and not appetizing. During an observation of the kitchen tray service, the pork roast was found to be watery and unappetizing. A review of the food temperature log indicated that temperatures were not checked before lunch service. The acting dietary manager confirmed that the temperatures were not taken before serving, which is against the facility's policy. A test tray showed that the food temperatures were below the required minimum of 135°F for hot foods, with items such as mixed vegetables, pureed meat, and mashed potatoes all below this threshold. The facility's policy, revised in 2017, mandates that hot foods be held at a minimum of 135°F and cold foods at 41°F or below.
Failure to Maintain a Clean and Home-like Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and home-like environment for two residents, both with mild cognitive impairment. During an observation, one resident was found in a room with a bed sheet that had holes, window curtains with mold buildup, and a bathroom plumbing leak causing stains on the floor and wall. The resident reported that although the room was cleaned daily, it was not done thoroughly, and previous complaints to the nursing staff about the mold and stains were ignored. The housekeeping supervisor stated that the staff is instructed not to use linen with holes or stains, and the maintenance director mentioned that room checks are conducted monthly, with issues addressed immediately if reported. However, the mold on the curtains was attributed to air conditioner condensation, and the maintenance director claimed the plumbing issue was previously fixed but not reported again. The facility's housekeeping policies emphasize maintaining a clean, safe, and attractive environment, which was not upheld in this instance.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse as per their abuse prevention program, resulting in multiple incidents of resident-to-resident aggression. Resident 1 (R1) reported ongoing pain in her head, neck, and shoulders after being punched by Resident 2 (R2). R2, who has severe cognitive impairment and a history of aggressive behavior, admitted to hitting R1 after a verbal altercation. Despite staff intervention, R1 continued to experience pain, which required medical treatment and monitoring. The facility's investigation substantiated the abuse, and R2 was sent to the hospital for evaluation and placed under 1:1 supervision. In another incident, Resident 3 (R3) and Resident 4 (R4), both with moderate cognitive impairments, engaged in a physical altercation. R3 attempted to get into R4's bed, leading R4 to yell and subsequently hit R3. Despite the presence of a CNA assigned to supervise both residents, R3 managed to strike R4 in the nose, and R4 retaliated by hitting R3 in the chest. Both residents were sent to the hospital for evaluation, and the facility's investigation substantiated the abuse. The facility's abuse prevention program, which prohibits all forms of abuse, was not effectively implemented to prevent these incidents. The program defines abuse as the willful infliction of injury or harm, and both incidents involved deliberate physical aggression between residents. The facility's failure to protect residents from abuse resulted in physical harm and ongoing pain for the affected residents.
Failure to Document Necessity of Immediate Transfer
Penalty
Summary
The facility failed to have a physician document the necessity of an immediate transfer for a resident. A [AGE] year-old male resident with diagnoses including dementia, anxiety, mental disorder, depression, and Alzheimer's was involuntarily discharged to the hospital due to aggressive behavior towards another resident. A review of the clinical documentation revealed no evidence of physician documentation to justify the necessity of the transfer. Interviews with the Nurse Practitioner and Psychiatrist confirmed that the required documentation was not completed, as the Psychiatrist was unaware of the need to document the necessity of the immediate transfer.
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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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