Tri-state Village Nrsg & Rhb
Inspection history, citations, penalties and survey trends for this long-term care facility in Lansing, Illinois.
- Location
- 2500 East 175th Street, Lansing, Illinois 60438
- CMS Provider Number
- 145879
- Inspections on file
- 41
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Tri-state Village Nrsg & Rhb during CMS and state inspections, most recent first.
The facility failed to properly assess, monitor, and treat pressure ulcers for two high-risk residents who were dependent on staff for care and had multiple comorbidities and low Braden scores. For one resident, staff observed a new dark sacral wound and changes in responsiveness, but weekend wound care practices did not include measuring or staging the wound, and the NP ordered hospital transfer without personally assessing the wound that day, contrary to facility policy requiring detailed documentation and wound assessment at first observation. For another resident, surveyors observed open buttock areas during incontinence care that had not been timely reported to or assessed by the wound care nurse, despite a CNA stating she had previously notified the nurse and been told only to apply barrier cream. This resident had documented risk for skin breakdown and a care plan requiring weekly systemic skin inspection, staging, and measurement of pressure areas, yet the buttock wounds were not promptly identified, staged, or measured as required by the facility’s pressure ulcer prevention and wound management policies.
A resident with dementia, Parkinson's disease, bilateral LE edema, and gait/mobility abnormalities, identified as high fall-risk and care planned for sit-to-stand mechanical lift transfers, was left sitting on the side of the bed unattended while a CNA went to retrieve the lift. The resident, who had a documented history of multiple prior falls, began sliding and was lowered to the floor. The Restorative Nurse/Fall Coordinator later stated the resident should not be left alone on the bed edge, and the DON stated that high fall-risk residents are expected to be monitored and not left alone on the side of the bed.
A resident experienced a recurrence and worsening of a stage 3 sacral pressure ulcer due to the facility's failure to consistently assess, document, and provide wound care as ordered. Gaps in wound care orders, missed documentation of treatments, and inconsistent weekly wound assessments contributed to the decline in the resident's wound condition.
The facility did not ensure that an effective training program was developed, implemented, or maintained for all new and existing staff members, resulting in a deficiency related to staff training requirements.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. Surveyors observed that the environment did not meet safety standards and lacked proper oversight.
A cognitively impaired male resident with a history of wandering was able to leave the facility unsupervised through a locked dining room door without the alarm sounding. Staff were unaware of his whereabouts, and there was no evidence of consistent monitoring or thorough communication regarding his elopement risk. The resident was later found wandering in another city and brought to a hospital, highlighting failures in supervision and exit door security.
A resident with a history of stroke and cardiac issues received an Amazon package containing pills that had been opened by an LPN, who believed it was medication due to the packaging. Staff interviews confirmed that packages are supposed to be delivered unopened and that mail should not be opened by staff without resident permission, in accordance with facility policy.
Two residents were involved in an incident of inappropriate touching in the dining room, with one resident touching another's crotch area. The incident was not witnessed by staff but was reported by other residents. The facility's administrator reviewed video footage and confirmed the inappropriate behavior. Despite the facility's abuse prevention policy, the incident was substantiated, highlighting a failure in supervision and prevention measures.
A resident with acute respiratory failure and obesity hypoventilation syndrome was admitted without a baseline care plan or documented vital sign assessments. The facility failed to document oxygen administration levels or obtain necessary physician orders, leading to the resident being sent back to the hospital due to breathing difficulties. Interviews revealed a lack of proper assessment and documentation by the nursing staff.
A resident with Dementia and a high fall risk experienced multiple falls, including one with significant injuries, due to inadequate interventions and supervision. Despite being identified as a high fall risk, the facility's measures were insufficient, leading to repeated unwitnessed falls in the dining room. The resident's care plan noted the risk, but interventions failed to prevent further incidents.
A resident with a history of osteoarthritis, COPD, and osteoporosis sustained injuries due to inadequate training and supervision while using a motorized wheelchair. The resident experienced a fractured toe and a leg laceration requiring sutures. Despite claims of provided education, there was no documentation to support that the resident received proper training on safe wheelchair use. The facility's care plan was developed 26 days after the resident received the wheelchair, with no evidence of subsequent training after the incidents.
A resident with adjustment disorder and spinal stenosis experienced a 17-minute delay in response to a call light request for assistance to get into a wheelchair. Despite being cognitively intact and requiring substantial assistance, the call light was not answered promptly by staff, including a CNA, laundry staff, and an LPN, who were nearby. The facility's policy mandates a response within 3-5 minutes, which was not adhered to, resulting in the deficiency.
A resident with spinal stenosis and adjustment disorder was left without assistance for 17 minutes despite activating the call light. The resident needed help to sit up and get into a wheelchair. Staff members, including a CNA and an LPN, did not respond to the call light, although it was audible at the nurses' station. The resident requires substantial assistance for daily activities, and the facility's policy is to answer call lights within 3-5 minutes.
The facility failed to follow its policy on discarding expired house stock medication in the south wing medication room. Expired Magnesium 500mg and Aspirin Low Dose 81mg were found, and staff confirmed that expired medications should be sent back to the pharmacy or discarded by nursing staff.
The facility failed to supervise smoking breaks for five residents and did not provide privacy bags for urine collection bags for two residents with catheters, compromising their dignity and violating facility policies.
The facility failed to follow its Purposeful Rounding Policy, resulting in delayed responses to a resident's call light and incontinence care needs. Despite multiple grievances and re-education efforts, the issue persisted, indicating non-compliance with the policy.
The facility failed to perform routine checks on a resident with an automatic implantable cardiac defibrillator (AICD). The resident's electronic health records lacked documentation of these checks, and the last recorded check was in July 2023, despite the requirement for checks every 91-95 days remotely and annually in the clinic.
The facility failed to label and date tube feeding bottles before administering them to two residents. Both an LPN and the ADON confirmed that the bottles should have been labeled and dated, as per the facility's policy. The residents involved had diagnoses requiring tube feeding, but the facility did not adhere to its own procedures.
A facility failed to follow its infection control policy by not isolating a resident with a bed bug infestation. Despite the resident reporting bed bugs and staff being aware, no transmission-based precautions were initiated, and staff entered the room without PPE. The facility's infection control policies were not adhered to, leading to a deficiency.
A resident with multiple diagnoses and cognitive intactness requested assistance in re-evaluating his guardianship status, but the facility failed to provide necessary support. This led to the resident feeling imprisoned, calling the police, and experiencing psychosocial harm.
The facility failed to follow dementia care and behavior management policies, immediate assessment and physician notification after a fall, and medication administration policies. A CNA continued care for an aggressive resident with dementia, a nurse delayed sending a resident with head pain to the hospital after a fall, and an LPN prepared medications in advance for multiple residents.
A facility failed to ensure a comprehensive care plan for a resident with dementia who exhibited physically aggressive behavior. The care plan lacked specific causal factors and personalized interventions, leading to an incident where a CNA was reported to be verbally and physically discourteous towards the resident. Staff interviews confirmed the resident's aggressive behavior, but the care plan was not updated to address these behaviors effectively.
Failure to Assess and Manage Pressure Ulcers for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and treat pressure ulcers for two residents with significant risk factors. One resident (R3) was dependent on staff for all care and unable to turn or reposition herself, with diagnoses including hemiplegia, hemiparesis, chronic respiratory failure, obesity, muscle wasting, peripheral vascular disease, and a history of pressure-related wounds. On the day of transfer to the hospital, the CNA observed dark areas on the resident’s buttocks, and the wound care nurse identified a new dark, blister-like sacral wound and noted that the resident was not responding to questions as usual. The NP ordered transfer to the hospital for a wound evaluation due to the new wound onset but did not personally assess the wound that day. The DON and wound care nurse stated that weekend wound care staff do not measure wounds, and the wound care nurse on duty did not measure or document the size of the new sacral wound, and another nurse on shift reported never assessing the wound, relying instead on the wound care nurse. The same resident (R3) had documented Braden scores indicating moderate to mild risk in prior months and a care plan for skin checks and reporting signs of skin breakdown, but there was no Braden score documented on the date of the new wound. The facility’s policy required that at first observation of any skin condition, the nurse describe and document it in the clinical record, notify the family and physician, and have the wound care nurse follow up with staging and measurements. Despite this, staff interviews revealed that floor and weekend wound nurses did not perform measurements, and there is no indication in the report that the new sacral wound was staged or measured before transfer. The NP explained that a wound can become infected with necrotizing fasciitis leading to sepsis and stated that the resident was sent out for a new wound onset; the report notes that this practice resulted in the resident being hospitalized for necrotizing fasciitis of the wound bed. For another resident (R4), surveyor observation during incontinence care revealed two pink open areas with scant drainage on the left and right buttocks. The CNA providing care stated it was the first time caring for this resident and did not know if the open areas were pre-existing, while another CNA indicated that the wound care nurse should know about the wounds and that barrier cream had been ordered. The NP identified the buttock wounds as new and noted excoriation to the scrotal area, ordering hydrocolloid dressings and nystatin with barrier cream. The wound care nurse reported she had not been informed of the open buttock wounds prior to this and then applied hydrocolloid dressings and topical treatments; however, another CNA stated she had informed the wound care nurse of the open buttock areas several times weeks earlier and was told only to apply barrier cream. R4 had diagnoses including hemiplegia, hemiparesis, osteoporosis, lack of coordination, Braden scores indicating moderate to high risk, and a care plan for risk of skin breakdown and a left buttock pressure area requiring weekly systemic skin inspection, staging, and measurement. The facility’s policies required head-to-toe skin assessments on admission and regular skin assessments, as well as prompt documentation and notification of new skin alterations, but staff accounts and surveyor findings show that R4’s buttock wounds were not timely communicated, assessed, staged, or measured in accordance with those policies.
Failure to Supervise High Fall-Risk Resident During Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring during a transfer for a resident with a known history of falls and multiple risk factors. The resident had diagnoses including dementia, Parkinson's disease, edema of both lower extremities, unspecified abnormalities of gait and mobility, and was identified as high risk for falls. The resident’s care plan dated 2/13/2026 indicated the need for a sit-to-stand mechanical lift for transfers due to decreased lower extremity strength and endurance, with interventions to maintain body alignment and ensure safe placement of extremities during transfers. Despite this, on 3/3/2026 a CNA sat the resident on the side of the bed and left to retrieve the mechanical lift, during which time the resident began to slide and was subsequently lowered to the floor. Interviews and record review confirmed that the resident had multiple prior falls, including an unwitnessed fall from bed on 12/21/2025 and a fall on 1/23/2026 when the resident attempted to go to the bathroom independently. On 3/10/2026, the resident reported that he was unable to maintain his balance when left sitting on the side of the bed and slid to the floor. On 3/11/2026, the CNA stated she had left the resident seated at the bedside to get the mechanical lift and returned when he yelled, then lowered him to the floor and sought assistance. On 3/12/2026, the Restorative Nurse/Fall Coordinator stated that the resident was high risk for falls and should not be left alone on the side of the bed, and the DON stated that staff are expected to monitor any high fall-risk resident and never leave them alone on the side of the bed. The facility’s Falls-Clinical Protocol identified history of falls and gait and balance disorders as risk factors for subsequent falls.
Failure to Prevent and Monitor Stage 3 Sacral Pressure Ulcer
Penalty
Summary
This facility failed to provide necessary care and services to prevent the recurrence and worsening of a stage 3 sacral pressure ulcer for one resident. The resident was readmitted to the facility after hospitalization and initially had no pressure ulcers identified, but was noted to have moisture-associated skin damage (MASD). Shortly after readmission, a wound was identified on the sacrum, and wound care orders were initiated. However, there were gaps in wound care treatment orders and inconsistent documentation of wound care administration, with several dates lacking evidence that wound care was provided as ordered. Additionally, weekly wound assessments and measurements were not consistently performed or documented, and there was a period when the wound care physician did not monitor the wound. The resident's wound worsened over time, increasing in size and developing slough, indicating a decline in condition. Interviews with staff revealed that the previous wound care nurse had not been fulfilling job responsibilities, and the new wound care nurse had only recently assumed the position. The facility's documentation showed lapses in both assessment and treatment, including missing wound care documentation on multiple dates and a lack of wound management records after a certain point. These failures contributed to the recurrence and deterioration of the resident's stage 3 sacral pressure ulcer.
Failure to Maintain Effective Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and/or maintain an effective training program for all new and existing staff members. This deficiency was identified based on the lack of evidence that staff received adequate training as required by regulations. The report notes that the training program was either not in place, not properly implemented, or not maintained for both new hires and current employees. No additional details regarding specific residents, staff members, or incidents were provided in the report.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents occurring. Specific actions or inactions leading to this deficiency include the lack of proper oversight and the presence of hazards in the area, as directly observed by surveyors.
Failure to Supervise Cognitively Impaired Resident and Monitor Exit Doors
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and monitoring for a cognitively impaired resident with a history of elopement. The resident, who had a BIMS score of 5 indicating severe cognitive impairment and required supervision with ambulation, was able to exit the facility through a locked dining room door without the door alarm sounding. The resident then accessed the patio/courtyard, exited through a gate, and did not return. Multiple staff members, including the DON, Assistant Administrator, and Activity Aides, reported not hearing any door alarms during the time the resident left, and surveillance footage confirmed the resident's exit without staff intervention or alarm activation. The resident had been admitted from an assisted living facility due to safety concerns related to wandering and medication management. Despite documentation of the resident's cognitive impairment and need for supervision, there was no evidence that staff had obtained a thorough history from the resident's family or the previous facility regarding elopement risk. Staff interviews revealed a lack of awareness of the resident's whereabouts, and there was no clear documentation of consistent monitoring or supervision, especially after the scheduled smoking time when the resident was last seen. The facility's policy required staff to know the whereabouts of assigned residents and to ensure that exit doors were secured and alarmed, but these procedures were not effectively implemented. The incident resulted in the resident being missing for an extended period, during which he was found wandering in another city and subsequently brought to a hospital. The failure to secure the exit doors, ensure alarm functionality, and provide adequate supervision for a resident with known cognitive impairment and elopement risk directly led to the deficiency. The facility's lack of effective communication, assessment, and monitoring contributed to the resident's unsupervised exit and subsequent absence.
Failure to Deliver Resident Package Unopened
Penalty
Summary
Facility staff failed to follow their policy regarding resident rights by not ensuring that a resident's package was delivered unopened. The incident involved a male resident with a history of partial paralysis due to stroke, hypertensive heart disease, and a cardiac implant. The resident reported that a nurse delivered an Amazon package containing cod liver oil pills to him after it had already been opened. The nurse admitted to opening the package, stating she believed it was medication for the resident, as it was in a brown package similar to those typically used for medication deliveries. The nurse apologized to the resident, explaining her mistake. Interviews with facility staff revealed that packages are generally delivered unopened to residents, and it is not appropriate for staff to open residents' mail or packages. Staff acknowledged that medication and Amazon packages can look similar, but emphasized that all packages should be checked for proper labeling before being opened. The facility's policy clearly states that staff should never open a resident's mail unless the resident allows it, which was not followed in this instance.
Failure to Prevent Resident-to-Resident Inappropriate Touching
Penalty
Summary
The facility failed to prevent an incident of inappropriate touching between two residents, R3 and R4, in the dining room. R3, who has a cognitive pattern score of 5 out of 15 indicating impairment, was touched in the crotch area by R4, whose cognitive pattern score is intact at 15 out of 15. R4's care plan notes a loss of social skills and symptoms of socially inappropriate behavior. The incident occurred when no staff were present in the dining room, and it was reported by other residents. A Licensed Practical Nurse (LPN) was informed of the incident by residents and reported it, although she did not witness it herself. The nurse's station does not have a view of the dining room where the incident took place. The facility's administrator was informed of the incident after arriving at the facility and took steps to report it to the police. Video footage confirmed that R4 touched R3 inappropriately, and the police report corroborated this observation. Despite the facility's abuse prevention policy, which aims to create a resident-sensitive and secure environment, the incident was substantiated, indicating a failure in supervision and prevention measures. Staff witness statements confirmed that no staff observed the incident, and it was only brought to attention by other residents.
Failure to Develop Baseline Care Plan for Resident with Respiratory Needs
Penalty
Summary
The facility failed to develop a baseline plan of care for a resident diagnosed with acute respiratory failure, obesity hypoventilation syndrome, and shortness of breath, who required a BiPAP machine when sleeping. Upon admission, the resident's face sheet indicated these diagnoses, and the respiratory progress note detailed the resident's condition, including the use of a BiPAP machine during hospitalization. However, the Director of Nursing (V8) acknowledged that there was no baseline care plan in place, and vital sign assessments were not documented upon the resident's readmission. The Director of Nursing stated that the nurse should have assessed and documented the resident's condition, notified the physician, reviewed medications, and obtained necessary orders. Despite these expectations, the nurse did not document vital signs or assess the resident's oxygen levels upon readmission. The resident was sent back to the hospital due to breathing difficulties shortly after readmission, and there was no documentation of the oxygen levels administered via the BiPAP machine. Interviews with the nursing staff revealed a lack of documentation and assessment of the resident's vital signs and oxygen levels. The LPNs involved did not recall the specifics of the oxygen administration or the resident's vital signs, and one LPN stated that vital signs could be assessed at the end of the shift. The facility also failed to present a baseline care plan or orders for oxygen administration during the survey, indicating a significant oversight in the resident's care management.
Inadequate Fall Prevention for High-Risk Resident
Penalty
Summary
The facility failed to develop an effective plan with interventions to prevent or reduce the risk of falling for a resident diagnosed with Dementia, wandering behaviors, and identified as a high fall risk with balance problems while standing. This deficiency affected a resident who experienced eight falls, seven of which were unwitnessed. One of these falls resulted in significant injuries, including right periorbital soft tissue swelling and a right scalp hematoma with contusion of the face and scalp. The resident, diagnosed with Dementia and requiring assistance with personal care, was noted to have wandering behaviors and balance problems. Despite being identified as a high fall risk, the facility's interventions were inadequate. The resident experienced multiple falls in the dining room, often unwitnessed, and was found on the floor on several occasions. The falls were attributed to various factors, including the resident's shuffling gait, attempts to self-toilet, and inappropriate footwear. The facility's documentation and staff interviews revealed a lack of consistent and effective interventions to address the resident's fall risk. The resident's care plan noted the risk of falling due to Dementia, weakness, and a history of falls, but the interventions implemented were insufficient to prevent further incidents. The facility's failure to provide adequate supervision and appropriate interventions resulted in repeated falls and injuries for the resident.
Inadequate Training and Supervision for Motorized Wheelchair Use
Penalty
Summary
The facility failed to provide adequate training and supervision for a resident using a motorized wheelchair, resulting in multiple accidents. The resident, who has a medical history of osteoarthritis, COPD, osteoporosis, and a history of pathological fractures, sustained a fractured toe and a laceration requiring sutures due to improper use of the wheelchair. The resident reported that her toes were broken when a door hit her foot, and she hit her leg on the bed while trying to maneuver the wheelchair. Interviews and record reviews revealed that the resident did not receive proper education on the safe use of the motorized wheelchair. The resident was observed having difficulty using the wheelchair controls and was assisted by a certified nursing aide. Despite claims from the Director of Nursing and the Director of Rehab that education was provided, there was no documentation to support that the resident received training on the safe use of the wheelchair or on preventing injuries. The facility's care plan policy requires an individualized comprehensive care plan for each resident, which includes measurable objectives and timetables to meet the resident's needs. However, the care plan for the resident was developed 26 days after receiving the motorized wheelchair, and there was no evidence of education or training provided to the resident after the incidents. The facility failed to present any documentation of education or training provided to the resident to minimize injuries when using the motorized wheelchair.
Delayed Response to Call Light Request
Penalty
Summary
The facility failed to respond promptly to a resident's call light request, resulting in a delay of 17 minutes. The resident, who has diagnoses including adjustment disorder with mixed anxiety and depression mood, and spinal stenosis, was cognitively intact with a score of 15 on a cognitive assessment. On the day of the observation, the resident activated the call light at 1:40 PM and was found by the surveyor at 1:48 PM still waiting for assistance to get into his wheelchair. The resident had been on the call light for at least 10 minutes, and it was not answered until 1:57 PM. During this time, a CNA, a laundry staff member, and an LPN were observed in the vicinity but did not respond to the call light. The resident's care plan indicated that he required substantial to maximal assistance for various activities of daily living, including sitting up, and his call light should be kept within reach at all times. The facility's call light policy, dated 5/17/24, stated that call lights should be answered promptly, within 3-5 minutes, by any staff member who hears them. Interviews with staff, including the Director of Nursing, confirmed that all disciplines are expected to respond to call lights promptly. Despite these policies and procedures, the resident's call light was not answered in a timely manner, leading to the identified deficiency.
Failure to Provide Timely Assistance to Resident
Penalty
Summary
The facility failed to provide timely assistance to a resident, identified as R7, who required help with activities of daily living. R7, who has diagnoses including adjustment disorder with mixed anxiety and depression mood, and spinal stenosis, was observed with a call light on for 17 minutes without receiving assistance. During this time, R7 was attempting to sit up and get into a wheelchair but was unable to do so independently. Despite the call light being activated, staff members, including a CNA and a laundry staff member, were observed walking near R7's room without responding to the call light. Additionally, an LPN was present at the nurses' station where the call light beep was audible but did not respond. R7's cognitive assessment indicates that he is cognitively intact, with a score of 15, and requires substantial to maximal assistance for various activities, including sitting up. Interviews with staff, including a CNA and the Director of Nursing, confirmed that R7 needs assistance with all activities of daily living and that call lights should be answered within 3-5 minutes. The failure to respond promptly to R7's call light, as outlined in his care plan, resulted in a delay in providing necessary assistance.
Failure to Discard Expired Medications
Penalty
Summary
The facility failed to follow its policy on discarding expired house stock medication in the south wing medication room. During an observation, a can of Magnesium 500mg and Aspirin Low Dose 81mg were found with expiration dates of 3/2024. An LPN confirmed that expired medication should be sent back to the pharmacy. The Assistant Director of Nursing stated that expired house stock medications are to be discarded by nursing staff, who are responsible for removing expired medications. The facility's policy mandates that all expired medications be removed from the active supply and destroyed in the facility.
Failure to Supervise Smoking Breaks and Provide Privacy Bags for Catheters
Penalty
Summary
The facility failed to follow their smoking policy by not providing supervision for smokers during the 5:00 PM and 7:00 PM smoking breaks. This failure affected five residents who reported missing their smoke breaks due to the activity aide leaving early. The Assistant Administrator and other staff members were unaware of the missed smoke breaks, and it was noted that the activity aide should have notified the administrator to assign another staff member for supervision. The facility's smoking policy requires that residents who pose a hazard with smoking materials must be supervised by a staff member from any department, but this was not adhered to in this instance. Additionally, the facility failed to provide privacy bags for urine collection bags for two residents with catheters. Observations revealed that the urine collection bags were left uncovered and visible from the hallway, compromising the residents' dignity. Both the Licensed Practical Nurse and the Assistant Director of Nursing confirmed that urine collection bags should be covered to maintain dignity. The care plans for these residents indicated the need for privacy bags, but this was not implemented. The facility's policies on resident rights and dignity were not followed, leading to these deficiencies. The smoking policy and the quality of life policy both emphasize the importance of supervision and maintaining dignity, but the facility did not comply with these standards, resulting in the reported issues.
Failure to Follow Purposeful Rounding Policy
Penalty
Summary
The facility failed to follow its Purposeful Rounding Policy by not rounding on residents regularly to meet their needs. This deficiency was highlighted by the experience of a resident who reported that it took three hours for a CNA to respond to his call light. Interviews with the Assistant Administrator and Assistant Director of Nursing revealed that they were unaware of any concerns regarding delayed call light responses or incontinence care. Both stated that staff should answer call lights within two minutes and round every two hours. However, the resident's grievance and complaint forms documented multiple instances of delayed ADL care and call light responses, indicating a pattern of non-compliance with the rounding policy. The resident, who is alert and able to use his call light, had previously expressed concerns about delayed incontinence care. Multiple grievance forms from different dates documented similar issues, including overnight CNAs not changing the resident and not performing patient care. These forms also showed that staff had been re-educated on the importance of prompt call light responses and ADL care, but the recurring nature of the complaints suggests that the facility's corrective actions were not effective in resolving the issue. The failure to adhere to the rounding policy and promptly respond to call lights directly impacted the resident's care and well-being.
Failure to Perform Routine Cardiac Defibrillator Checks
Penalty
Summary
The facility failed to perform routine checks on a resident with an automatic implantable cardiac defibrillator (AICD). During a record review, it was found that the resident's electronic health records did not contain any documentation of cardiac defibrillator checks. The Assistant Director of Nursing (V4) confirmed that they were still waiting for the vendor to provide the defibrillator check documentation. An interview with the Cardiac Defibrillator Specialist (V21) revealed that the last check on the resident's cardiac defibrillator was conducted in July 2023, and it should be checked every 91-95 days remotely and annually in the clinic. The resident was last checked in the clinic in February 2023. Further review of the resident's general orders and progress notes indicated that there were orders for pacemaker checks on multiple dates, and the presence of the AICD was noted in the nursing and nurse practitioner progress notes. The facility's policy on the care of residents with implanted cardiac devices stated that pacemaker checks should be performed as ordered. However, the facility did not adhere to this policy, leading to a lapse in the routine checks for the resident's cardiac defibrillator.
Failure to Label and Date Tube Feeding Bottles
Penalty
Summary
The facility failed to label and date tube feeding bottles before administering them to residents, as observed in two cases. On multiple occasions, Resident 24 and Resident 169 were found with ongoing tube feedings that were neither labeled nor dated. Licensed Practical Nurse (LPN) V20 confirmed during interviews that the tube feeding bottles should have been labeled and dated before administration. The Assistant Director of Nursing (ADON) V4 also stated that it is the facility's policy to label and date all tube feeding bottles before use. Resident 24 had a diagnosis of gastrostomy status and severe protein-calorie malnutrition, with a tube feeding order starting from February 13, 2024. Similarly, Resident 169 had a diagnosis of encounter for attention to gastrostomy and dysphagia following a cerebral infarction, with a tube feeding order starting from April 12, 2024. The facility's policy on gastric tube feeding, revised in May 2017, mandates that all bags, bottles, syringes, and tubing must be timed and dated to determine the discard date. This policy was not followed in the observed cases, leading to the deficiency noted in the report.
Failure to Follow Infection Control Policy for Bed Bug Infestation
Penalty
Summary
The facility failed to follow its infection control policy by not initiating isolation protocols for a resident with a bed bug infestation. On 04/23/2024, the resident was observed in bed without any transmission-based precautions, sharing the room with another resident. Despite the resident reporting bed bugs on 04/21/2024, no isolation or contact precautions were initiated, and staff were observed entering the room without PPE. The Assistant Director of Nursing/Infection Preventionist was unaware of the infestation until informed by the surveyor on 04/23/2024. The Licensed Practical Nurse and Housekeeping Manager were aware of the bed bug issue since 04/21/2024, but no immediate action was taken to isolate the resident or inform the infection control team. The pest control company was scheduled to treat the room on 04/23/2024, but the resident remained in the infested room without proper precautions. The facility's policy on bed bug management, which includes isolating the resident and using contact precautions, was not followed. Interviews with various staff members, including the Administrator and Housekeeping Manager, confirmed that the facility's infection control policies were not adhered to. The resident's medical history includes multiple conditions such as polyneuropathy, hemiplegia, and major depressive disorder. Despite the presence of bed bugs being reported and observed by multiple staff members, the necessary steps to prevent the spread of infestation were not taken, leading to a deficiency in infection control practices.
Failure to Assist Resident in Re-evaluating Guardianship Status
Penalty
Summary
The facility failed to honor a resident's request to obtain assistance in re-evaluating his guardianship status, which affected his ability to leave the facility and maintain his highest practical well-being. The resident, a cognitively intact male with multiple diagnoses including hemiplegia, CHF, seizures, HTN, and CAD, expressed his desire to have his guardianship status re-evaluated. Despite his repeated requests to the Social Service Director, no assistance was provided to him until after a surveyor's interview. This lack of action resulted in the resident feeling imprisoned and calling the police due to his inability to leave the facility and having his phone taken away by his guardian. The resident was initially assigned a temporary guardian while in a medically induced coma, which later became permanent. The resident expressed dissatisfaction with his guardian and requested assistance from the facility to dispute the guardianship. However, the Social Service Director only provided contact information for legal aid and the ombudsman after the surveyor's interview, and there was no prior documentation of assistance. The facility's failure to respond to the resident's grievances and provide necessary social services led to psychosocial harm for the resident.
Failure to Follow Dementia Care, Fall Protocol, and Medication Administration Policies
Penalty
Summary
The facility failed to follow its policy and procedures for dementia care and behavior management. A certified nursing assistant (CNA) continued to provide care to a resident with dementia who became physically aggressive, instead of discontinuing care and reapproaching later. The resident, who has a history of physical aggression and pseudobulbar affect, was reported to have been pushed and struck by the CNA, although the CNA denied these actions. The facility's dementia care policy emphasizes the need to identify triggers and use behavior management techniques, which were not followed in this instance, leading to the escalation of the resident's aggressive behavior. The facility also failed to follow its policy for immediate assessment and physician notification after a resident experienced head pain following an unwitnessed fall. The resident, who has multiple diagnoses including rheumatoid arthritis and cerebral infarction, fell while attempting to get out of bed and hit her head. The CNA on duty reported the fall to the nurse, but the nurse did not immediately send the resident to the hospital for evaluation, as required by the facility's fall protocol. The nurse on duty at the time of the fall did not complete the necessary fall report and left the responsibility to another nurse who arrived later. Additionally, the facility did not adhere to its Medication Administration Policy. An LPN was observed preparing medications in advance for several residents at the same time, a practice that is against professional nursing standards and the facility's policy. The LPN admitted to this practice, stating it was done to ensure timely medication administration, despite knowing it was incorrect. The facility's policy requires medications to be administered as prescribed and not set up in advance, which was not followed in this case.
Failure to Implement Comprehensive Care Plan for Resident with Aggressive Behavior
Penalty
Summary
The facility failed to follow their policy and procedures for dementia/behavior care planning by not ensuring a care plan for a resident who exhibits physically aggressive behavior towards staff included comprehensive personalized interventions for behaviors. This deficiency was identified for a resident with a history of Dementia without Behavioral Disturbance, Chronic Diastolic Heart Failure, Stage 3 Chronic Kidney Disease, COPD, and Syncope/Collapse. The resident's care plan did not include specific causal factors or potential triggers for her physically aggressive behavior and lacked personalized interventions to address these behaviors. The resident's progress notes and interviews with staff indicated that she often exhibited physically aggressive behavior, such as hitting, biting, and swinging at caregivers, especially during care activities. Despite these documented behaviors, the care plan only included general interventions and did not provide specific strategies tailored to the resident's needs. Staff interviews revealed that the resident's aggressive behavior was known, but the care plan was not updated to reflect personalized interventions to manage these behaviors effectively. An incident on 11/05/2023 highlighted the deficiency when a family member of another resident reported witnessing a CNA being verbally discourteous and physically aggressive towards the resident. The police were notified, and although no injuries were observed, the incident underscored the need for a more comprehensive and personalized care plan. The facility's Director of Nursing acknowledged that the care plan could include more personalized interventions, and the facility's Dementia Care Policy emphasized the importance of individualized care plans to manage dementia-related behaviors effectively.
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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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