Twin Willows Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Salem, Illinois.
- Location
- 1600 North Broadway, Salem, Illinois 62881
- CMS Provider Number
- 146070
- Inspections on file
- 15
- Latest survey
- January 16, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Twin Willows Nursing Center during CMS and state inspections, most recent first.
The facility failed to prevent cross-contamination during meal service, as CNAs delivered drinks by the rims of glasses after touching various surfaces without hand hygiene. Drinks were also served uncovered, contrary to proper protocols, affecting all 24 residents.
The facility failed to maintain a clean and accessible environment, with observations of dirt, mildew, and blocked access in shower rooms and hall bathrooms. Housekeeping staff acknowledged persistent cleanliness issues, and the DON was unaware of an environmental cleaning policy. These deficiencies potentially affect all 24 residents.
The facility failed to ensure call lights were within reach for several residents, including those with cognitive impairments and histories of falls. Observations revealed call lights were often placed out of reach, compromising residents' ability to request assistance. Staff interviews confirmed the expectation for call lights to be accessible, yet this was not consistently achieved.
A resident with severe cognitive impairment and significant assistance needs was left to eat without immediate help, leading her to use her fingers to eat. Despite the care plan requiring substantial assistance, staff interviews confirmed the resident's meal tray should not have been placed in front of her without someone available to assist, compromising her dignity.
A facility failed to investigate a bruise of unknown origin on a cognitively impaired resident with progressive supranuclear ophthalmoplegia. The resident had a dark purple bruise on the right buttocks, with no pain or discomfort reported. Despite notifying the POA and doctor, no investigation was conducted, contrary to the facility's policy requiring prompt investigation of such injuries.
A resident with multiple health conditions, including diabetes and obesity, was at risk of developing pressure ulcers. Despite a care plan requiring zinc oxide application to the left hip, there was no documentation of treatment in January. Observations showed confusion among staff about treatment responsibilities, leading to inconsistent care and worsening of the resident's condition.
The facility failed to implement effective fall prevention measures for three residents with cognitive impairments, leading to multiple falls and injuries. Care plans were not consistently updated with new interventions, and call lights were often out of reach, contributing to the risk of falls.
A resident with multiple diagnoses, including Parkinsonism and Alzheimer's, experienced significant weight loss, dropping from 178 to 158 pounds. The facility failed to follow its policy for managing weight loss, as there was no referral to a dietician or implementation of nutritional supplements. The dietary manager did not receive weight loss information, and the LPN confirmed the facility's inaction in addressing the resident's weight loss.
A resident with dementia frequently wandered into other residents' rooms, causing distress, without a care plan addressing this behavior. Staff removed the resident multiple times, but the facility lacked behavior tracking for wandering, as confirmed by the DON.
A resident with a history of incontinence and other medical conditions received improper incontinent care from CNAs who failed to follow infection control protocols. The CNAs did not perform hand hygiene before donning gloves, did not change gloves appropriately, and touched the resident's skin and linens with contaminated gloves. The DON observed the incident and instructed the CNAs, but hand hygiene was still not performed as required by the facility's policy.
A resident with a history of multiple health issues was prescribed a Z-pak for bronchitis without proper diagnostic confirmation, such as a culture or x-ray. The facility's documentation was insufficient, with no notes on respiratory symptoms between late December and early January, and the care plan lacked a section for respiratory concerns. The DON admitted to the absence of necessary follow-up documentation after antibiotic administration, leading to a deficiency in antibiotic stewardship.
The facility failed to post current daily nurse staffing data, affecting all 24 residents. On several occasions, the postings were outdated or incorrect, with one instance showing a future date and another showing a past date. A staff member acknowledged the oversight, indicating it was likely missed. The facility's form confirmed 24 residents were present.
The facility failed to store food according to professional standards after their freezer malfunctioned, affecting all 29 residents. The Director of Nurses moved the food to her house, but could not provide evidence of proper temperature maintenance. The facility's policy requires off-site storage in a Public Health Certified area, which was not followed.
Cross-Contamination of Drinking Glasses During Meal Service
Penalty
Summary
The facility failed to prevent cross-contamination of drinking glasses during meal service, affecting all 24 residents. On multiple occasions, a Certified Nurse Aide (CNA) delivered drinks to residents by holding the rims of the glasses, which is where residents drink from. This occurred after the CNA had touched various surfaces, including the kitchen door, drink cart handle, her jeans, and wheelchair handles, without performing any hand hygiene. Additionally, drinks were delivered uncovered from a cart, further increasing the risk of contamination. The Dietary Manager and a dietary staff member acknowledged that drinks should not be handled by the rims and should be covered when transported. Despite this understanding, the drinks were not covered, and the improper handling continued over several days. The lack of adherence to proper food handling protocols was observed and confirmed through interviews with staff, highlighting a systemic issue in the facility's meal service procedures.
Facility Fails to Maintain Clean and Accessible Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and clean environment for its residents, as evidenced by multiple observations of unclean and obstructed areas. In the shower rooms on the 200 and 400 halls, there was a significant accumulation of dirt, mildew, and a black substance along the edges between the floor and walls, as well as missing tiles. Toilets in these areas had visible dirt and black rings, and access to handwashing sinks was blocked by large linen barrels and trash cans. Additionally, a resident's handwashing sink was found to drain extremely slowly, taking nearly nine minutes to empty, which the resident had previously reported to the facility. Housekeeping staff acknowledged the persistent issues with cleanliness, stating that the shower rooms always appear dirty despite cleaning efforts, and that there is no housekeeping staff available in the evenings. The Director of Nursing was unaware of the existence of an environmental cleaning policy, indicating a lack of structured procedures for maintaining cleanliness. These deficiencies have the potential to affect all 24 residents living in the facility, as the shower rooms and hall bathrooms are shared by multiple residents.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach for six out of seven residents reviewed for call lights. This deficiency was observed through multiple instances where residents with varying degrees of cognitive and physical impairments were unable to access their call lights. For example, Resident 19, who has severe cognitive impairment and a history of falls, was found with call lights out of reach on multiple occasions, leading her to express concerns about having to crawl to the bathroom without assistance. Similarly, Resident 5, with moderate cognitive impairment and a history of falls, was observed with call lights under the bed covers and wrapped around a wall light, both out of reach. Resident 21, who has severe cognitive impairment and a history of falls, was also found with call lights on the floor behind a recliner, not accessible to him. These observations indicate a pattern of neglect in ensuring that residents have access to call lights, which are crucial for their safety and ability to request assistance. Additional residents, including Resident 24, who has Parkinsonism and Alzheimer's disease, and Resident 11, with Parkinson's disease, were also found without call lights within reach. Resident 1, who is cognitively intact but has physical limitations, was observed with a call light five feet away on the floor, leading her to express that reaching it would be challenging. Interviews with staff, including the Director of Nursing and Certified Nurse Assistants, confirmed that call lights should be within reach of all residents, yet this standard was not consistently met, as evidenced by the observations and resident statements.
Failure to Assist Resident with Eating Compromises Dignity
Penalty
Summary
The facility failed to promote dignity for a resident with severe cognitive impairment and significant assistance needs during meal times. The resident, diagnosed with unspecified dementia and other conditions, was observed attempting to eat with her fingers after her meal tray was placed in front of her without immediate assistance. Despite the care plan indicating that the resident requires substantial to maximal assistance with eating, the tray was left unattended, leading the resident to use her hands to eat, which compromised her dignity. Staff interviews confirmed that the resident should not have been left to eat without assistance, as she is dependent on staff for eating. The Director of Nursing and a Certified Nurse Assistant both acknowledged that the resident's food should not have been placed in front of her without someone available to assist, highlighting a lapse in following the care plan and ensuring the resident's dignity during meals.
Failure to Investigate Bruise of Unknown Origin
Penalty
Summary
The facility failed to investigate a bruise of unknown origin for a resident diagnosed with progressive supranuclear ophthalmoplegia, who was severely cognitively impaired with a BIMS score of 2. The resident's nurse's note documented a dark purple bruise on the right buttocks, measuring 5.5 cm by 4.5 cm, with no open areas or edema, and the resident denied any pain or discomfort. Despite notifying the power of attorney and the doctor, no new orders were given. The Director of Nursing acknowledged the lack of further information or investigation into the injury, despite it being mentioned in a meeting. The facility's policy mandates that all injuries of unknown source be promptly and thoroughly investigated, which was not adhered to in this case.
Failure to Prevent Worsening of Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary services consistent with professional standards to prevent the worsening of pressure ulcers for a resident identified as R4. R4 was admitted with diagnoses including Type 2 diabetes mellitus, morbid obesity, and venous insufficiency, and was at risk of developing pressure ulcers. Despite having a care plan that included the application of zinc oxide to the left hip three times a day and as needed, there was no documentation of this treatment being administered throughout January. Observations revealed that the treatment was not consistently performed by the nursing staff, and there was confusion among staff regarding who was responsible for applying the treatment. On January 14, 2025, a registered nurse (V12) was observed not performing the treatment, mistakenly believing that CNAs were responsible for it. The Director of Nursing (V2) clarified that the nursing staff should apply all treatments. When the treatment was eventually performed, the left hip area was observed to have open and scabbed areas, indicating a lack of consistent care. The Director of Nursing acknowledged the lack of documentation and expressed uncertainty about the specific treatment being administered, highlighting a failure in communication and adherence to the prescribed care plan.
Inadequate Fall Prevention and Supervision
Penalty
Summary
The facility failed to implement effective and appropriate interventions to prevent falls for three residents, R5, R19, and R21, who were reviewed for falls. R5, who has moderate cognitive impairment and a history of falls, experienced multiple falls resulting in injuries such as bruises and hematomas. Despite these incidents, the care plan was not consistently updated with new interventions. Observations revealed that R5's call light was often out of reach, and the alarm pad was not used correctly, contributing to the risk of falls. R21, with severe cognitive impairment, also experienced several falls, some resulting in injuries. The care plan for R21 included interventions such as visual checks and reminders to use the call light, but these were not effectively implemented. Observations showed that R21's call light was frequently out of reach, and there was a lack of documentation regarding physician notification after falls, indicating inadequate follow-up and intervention. R19, who has severe cognitive impairment and a history of falls, experienced falls resulting in injuries such as lacerations and hematomas. The care plan included interventions like visual checks and ensuring the call light was within reach, but these were not consistently followed. Observations indicated that R19's call light was often inaccessible, and there was a lack of timely assistance, contributing to the risk of falls. The facility's failure to update care plans and implement effective interventions for these residents highlights deficiencies in fall prevention and supervision.
Failure to Address Resident's Weight Loss
Penalty
Summary
The facility failed to adhere to its policy for managing weight loss in a resident, identified as R24, who was part of a sample of 23 residents. R24, who has diagnoses including Parkinsonism, anemia, Alzheimer's disease, and cerebral infarction, was noted to have a potential for excessive weight loss due to cognitive issues and being a picky eater. Despite documented interventions in R24's care plan, such as monitoring meal intake and offering food substitutes, the facility did not implement these measures effectively. R24 experienced significant weight loss, dropping from 178 pounds to 158 pounds over a few months, which exceeded the facility's threshold for notifying a physician and dietician. However, there was no evidence of a referral to a registered dietician or the provision of nutritional supplements to address the weight loss. The facility's documentation was inconsistent, with different weights recorded on various forms, and the correct weights were not communicated to the dietary manager. The dietary manager, V15, stated that she did not receive information about residents' weight loss or calculate weight loss, relying on nursing staff to provide this information. V16, an LPN, confirmed that the facility did not follow through with R24's weight loss management, including failing to notify the registered dietician or implement supplements. The facility's policy required notifying the physician and dietary supervisor of significant weight changes, but this was not done, contributing to the deficiency in care for R24.
Failure to Address Wandering Behavior in Dementia Resident
Penalty
Summary
The facility failed to provide necessary person-centered care and services for a resident diagnosed with dementia, specifically in addressing wandering behavior. The resident, identified as R14, was admitted with diagnoses including dementia without behavioral disturbance and altered mental status. The Minimum Data Set for R14 indicated that no brief interview of mental status was performed due to the resident being rarely or never understood. Despite these conditions, R14's current care plan did not address the issue of wandering into other residents' rooms. Multiple incidents were observed where R14 entered other residents' rooms, causing distress to those residents. On several occasions, residents were heard calling for help to have R14 removed from their rooms. Staff members, including a Certified Nurse Aide and Housekeeping personnel, were involved in removing R14 from these rooms. The Director of Nursing confirmed that there was no behavior tracking for R14's wandering, and the care plan provided to the surveyor was the entirety of R14's care plan, which lacked any problem areas related to wandering.
Infection Control Breach During Incontinent Care
Penalty
Summary
The facility failed to adhere to proper infection control techniques during the provision of incontinent care for a resident, identified as R4, who was observed to be totally incontinent of bowel and bladder. R4's medical history includes Type 2 diabetes mellitus, morbid obesity, venous insufficiency, muscle weakness, and a need for assistance with personal care. During an observation, a CNA, identified as V10, did not perform hand hygiene before donning gloves and proceeded to clean R4's buttocks and rectum area, which had a moderate amount of stool. After removing the soiled gloves, V10 failed to perform hand hygiene before putting on a new pair of gloves and continued to clean R4's groin area. Additionally, V10 did not remove gloves when touching R4's skin and clothing, and along with other CNAs, touched R4's bed linens with contaminated gloves. The Director of Nursing (DON), identified as V2, was present during the incident and instructed the CNAs to remove their gloves when touching linens. However, the CNAs did not perform hand hygiene after removing their gloves. Interviews with the DON and other CNAs confirmed that the staff should have changed gloves and performed hand hygiene after cleaning stool and before continuing care. The facility's handwashing policy, which aligns with CDC guidelines, emphasizes the importance of handwashing before and after situations likely to cause microbial contamination, including contact with body fluids, even when gloves are worn.
Deficiency in Antibiotic Stewardship for Resident with Bronchitis
Penalty
Summary
The facility failed to adhere to standards of practice for antibiotic use for a resident diagnosed with bronchitis. The resident, who had a history of anxiety disorder, cerebral infarction, chronic kidney disease, gastroesophageal reflux disease, and adult failure to thrive, was prescribed a Z-pak antibiotic on January 8, 2025, without a documented culture or x-ray to confirm the diagnosis. The resident's nurse's notes did not document any symptoms of respiratory distress or infection between December 23, 2024, and January 8, 2025, when the antibiotic was ordered. The care plan also lacked a section addressing respiratory problems or concerns. The Director of Nursing acknowledged that the resident had symptoms of clear phlegm as early as November 10, 2024, but no further documentation was made until the antibiotic was prescribed. The resident was observed coughing and spitting clear phlegm into tissues, but no diagnostic tests were conducted to justify the antibiotic use. The facility's infection control log noted the infection as nosocomial, yet there was no follow-up documentation for 72 hours after the antibiotic administration, as required. This lack of documentation and diagnostic confirmation led to the deficiency in antibiotic stewardship practices.
Failure to Post Current Nurse Staffing Data
Penalty
Summary
The facility failed to post daily nurse staffing data for both licensed and unlicensed staff responsible for resident care, which has the potential to affect all 24 residents residing at the facility. On multiple occasions, the staff postings were either outdated or incorrect. On January 13, 2024, the staff posting displayed a future date of February 26, 2024, with a census of 32 residents. On January 14, 2025, the posting was updated to reflect the correct date and a census of 24 residents. However, on January 15 and 16, 2025, the postings still showed the date as January 14, 2025. During an interview on January 15, 2025, a staff member acknowledged that the daily staff posting was not current and suggested it was likely missed that day. The Long-Term Care Facility Application for Medicare and Medicaid form 671, dated January 14, 2025, confirmed there were 24 residents living in the facility.
Improper Off-Site Food Storage Due to Freezer Malfunction
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, which has the potential to affect all 29 residents currently residing at the facility. The deficiency was identified when the facility's freezer malfunctioned, and the Director of Nurses (V2) moved all the food off-premises to a dedicated freezer at her house. However, V2 was unable to provide reproducible evidence that the temperature of the freezer/food was maintained per current standards of practice. The Cook (V4) and Dietary Aid/Cook (V5) confirmed that the freezer had been non-functional for about two weeks, and V2 was responsible for transporting the food daily from her house to the facility. The Dietary Manager (V6) and Maintenance Director (V3) corroborated the situation, stating that the freezer had been repaired temporarily but failed again. They mentioned that a part had been ordered to fix the freezer, expected to arrive soon. The facility's Food Storage policy from 2009 requires that freezers maintain a temperature that ensures products remain frozen, and an addendum added to the policy on 7/8/24 specifies that food stored off-site must be transferred to a Public Health Certified area. This policy was not followed, as the food was stored at V2's house, which does not meet the specified requirements.
Latest citations in Illinois
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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