Vandalia Healthcare & Senior Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Vandalia, Illinois.
- Location
- 1500 West St Louis Avenue, Vandalia, Illinois 62471
- CMS Provider Number
- 145903
- Inspections on file
- 30
- Latest survey
- September 3, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Vandalia Healthcare & Senior Living during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of falls experienced multiple unwitnessed falls, some resulting in injuries. Despite these incidents, the care plan was not updated with new interventions, and staff did not implement additional fall prevention strategies as required by facility policy.
The facility did not maintain adequate nursing staff to meet residents' needs in a timely manner, resulting in delays in care such as toileting and call light response. Multiple staff and residents reported that call lights often went unanswered for extended periods, especially during evening and night shifts, due to insufficient CNA coverage. Administrative staff were aware of the staffing shortages but were not always able to secure additional help, leading to ongoing delays in essential resident care.
The facility did not provide bedtime snacks as required, instead serving them with the evening meal, leaving residents without food options until breakfast. Staff reported that snack availability was reduced due to budget cuts, and the kitchen was locked after supper, preventing access to additional snacks. Observations confirmed that designated snack areas were inadequately stocked, affecting all residents, including those with significant medical needs.
Two residents requiring assistance with toileting experienced significant delays in call light response, with one reporting waits of up to 45 minutes, particularly during evening and overnight shifts. Multiple staff members, including CNAs and LPNs, confirmed that call lights were not always answered promptly due to insufficient staffing, especially during shift changes or when only one CNA was present per unit. Resident Council minutes and the facility ombudsman also documented ongoing concerns about untimely call light responses.
The facility failed to provide consistent showers for three residents requiring assistance, with gaps in documentation and adherence to the shower schedule. Residents with severe cognitive impairment and those needing partial assistance did not receive showers as scheduled, and staff cited staffing issues as a reason for missed showers. The facility's policy requires at least weekly showers, but incomplete records suggest this standard was not met.
The facility failed to maintain a safe and clean environment for residents, with issues such as leaking toilets, missing tiles, and unsecured fixtures affecting five residents. Some residents were unable to use their bathrooms for months, leading to inconvenience and frustration. Staff shortages and a lack of maintenance budget contributed to the deficiencies, with the maintenance man quitting and using his own money for repairs.
The facility failed to maintain safe water temperatures, with readings between 116 and 122.5 degrees Fahrenheit, exceeding the policy of 100-110 degrees. Several residents, including those cognitively impaired, were affected. Maintenance issues, such as a hole in the pipe leading to the hot water heater, contributed to the problem. The DON and Maintenance Assistance/Therapy Assistant were aware of the policy but did not ensure compliance.
The facility failed to provide nutritional supplementation as recommended for three residents, resulting in significant weight loss for one. A resident with multiple medical conditions did not receive extra protein despite recommendations, and expressed dissatisfaction with food quality. Another resident on hospice care did not receive prescribed supplements at lunch due to staff oversight. A third resident did not receive a high calorie/protein supplement as ordered, with staff unaware of the requirement.
The facility failed to maintain a full-time DON and ensure RN coverage for 8 hours daily, affecting 33 residents. The DON worked as a floor nurse due to staffing shortages, neglecting administrative duties, and resigned due to these challenges. The facility's schedule showed several days without RN coverage, confirming the deficiency.
The facility failed to store and serve food safely, affecting all 33 residents. Opened food items lacked dates, and scoops were improperly stored in bins. A dietary staff member handled drinks by the rim after touching various surfaces. The Dietary Manager confirmed these practices were against professional standards.
The facility failed to provide an accessible call system in the shower room and community bathroom, affecting all 33 residents. Observations showed that call light boxes lacked pull cords, making them inaccessible from the toilet or floor. Additionally, shower stalls had no call system. Staff interviews revealed a lack of awareness and policy regarding call light systems.
The facility failed to provide the required 80 square feet per resident bed in multiple occupancy rooms, affecting several residents. Observations revealed that the rooms were certified for double occupancy but did not meet the required space, with measurements ranging from 71.31 to 74.48 square feet per resident. The Administrator acknowledged the issue and confirmed that residents were not informed during admission. Despite the space limitations, adequate space was determined to meet residents' needs, and no concerns were noted in Resident Council Minutes.
A resident with moderate cognitive impairments reported being handled roughly by a CNA during care, without explanation or time to assist, leading to distress and a feeling of being rushed. The facility acknowledged the incident as poor customer service, failing to promote the resident's dignity and independence.
A resident expressed dissatisfaction with being woken up too early and taken to the dining room, contrary to their preference to sleep longer. Staff confirmed the resident was typically in the dining room by 6:00 AM, and the facility administrator acknowledged residents should choose their waking times, but was unsure of a policy supporting this.
A facility failed to accurately code an MDS Assessment for a resident who experienced a significant weight loss of 15.61% over six months. The resident's weight log showed a decrease from 132 pounds to 111.4 pounds, but this was not documented on the MDS. The MDS/Care Plan Coordinator confirmed that such weight losses should be coded, as per the facility's policy.
A resident prone to skin tears was observed without the required protective skin sleeves on two occasions. CNAs admitted they were unaware of the sleeves' location, despite the care plan and physician orders mandating their use at all times. The Care Plan Coordinator confirmed the necessity for the resident to wear the sleeves consistently.
A facility failed to position a resident with dysphagia upright during meals, leading to choking episodes, and did not follow professional standards to prevent an open wound in another resident. The resident with dysphagia was fed while reclined, contrary to care plan instructions, resulting in coughing and choking. Another resident, at risk for pressure ulcers, was found with an open wound during incontinence care, with staff failing to apply barrier cream or notify the RN. These deficiencies indicate a need for improved adherence to care plans and professional standards.
A resident with a Stage III pressure ulcer did not receive adequate care as per professional standards. The facility failed to document pressure ulcer assessments and treatments in the resident's medical record. The Director of Nursing indicated that CNAs applied barrier cream, but the wound was not assessed weekly due to the resident being on hospice. Observations showed the ulcer was still open, and the MDS/CP Coordinator confirmed that hospice orders were not properly transcribed or completed.
A resident with multiple diagnoses, including dementia and muscle weakness, was not properly assessed or assisted after being found crawling on the floor and sliding out of a wheelchair. Despite being at high risk for falls, staff failed to notify a nurse or follow care plan interventions, such as offering ambulation with a walker. The facility's fall prevention policy was not followed, as no assessments or fall huddles were conducted after these incidents.
The facility failed to provide proper catheter and incontinence care for two residents. An LPN did not secure a suprapubic catheter as required and used improper hygiene practices. Two CNAs did not change gloves or perform hand hygiene during incontinence care for a resident on Enhanced Barrier Precautions. These actions violated the facility's infection control policies.
A facility failed to limit as-needed psychotropic medication to 14 days for a resident receiving Lorazepam for anxiety. Despite a pharmacy recommendation for a gradual dose reduction, the physician declined without providing a rationale. The facility's policy requires as-needed psychotropic medications to be limited to 14 days unless extended with documented rationale, which was not followed in this case.
The facility failed to follow infection control standards for handling soiled linens, hand hygiene, and precautions for three residents. An LPN did not wear a gown during catheter care for a resident on Enhanced Barrier Precautions, improperly disposing of soiled linens. An RN did not don a gown for a resident on Contact Isolation, using regular trash for soiled dressings. Two CNAs did not change gloves or perform hand hygiene during incontinence care for a resident, handling clean items with contaminated gloves.
A resident with multiple diagnoses, including dementia and Alzheimer's, did not receive an influenza vaccine as per the facility's policy. The resident's medical record showed the last flu vaccination was over a year ago, and there was no documentation of consent or refusal for a more recent vaccine. The facility's policy requires annual flu vaccinations and proper documentation, which was not adhered to in this instance.
A resident reported that a nurse had forgotten to administer her noon dose of Ativan on several occasions. Facility records showed discrepancies in the administration and documentation of the medication, with missing entries on the Controlled Substance Proof of Use sheet and inconsistencies in the Medication Administration Record (MAR). The facility's Medication Administration policy was not consistently followed, leading to a deficiency in care.
A resident reported that an LPN had forgotten to administer her noon dose of Ativan on several occasions. The facility's records showed multiple instances where doses were not signed out at the correct times, and interviews revealed that the LPN had a history of not signing out narcotic medications. Despite previous education on the issue, the problem persisted, leading to a deficiency in maintaining accurate controlled substance records.
Failure to Update Care Plan and Implement New Fall Prevention Interventions
Penalty
Summary
The facility failed to develop and implement new interventions to prevent falls for a resident with severe cognitive impairment and a history of falls. The resident, who was dependent on staff for all transfers and toileting and required assistance with showers, experienced multiple falls, including unwitnessed incidents resulting in bruises and skin tears. Despite these occurrences, the resident's care plan was not updated to include new or revised interventions following each fall event. Progress notes documented several fall incidents, but the care plan did not reflect any newly implemented strategies to address these repeated events. The facility's own policy required staff to identify and implement additional or different interventions if falls recurred, but this was not done. Interviews confirmed that falls should have been addressed in the care plan and that new interventions should have been developed, but these actions were not taken.
Failure to Maintain Sufficient Nursing Staff for Timely Resident Care
Penalty
Summary
The facility failed to maintain sufficient nursing staff to meet the needs of all residents in a timely manner, as evidenced by multiple interviews and record reviews. The census at the time was 37 residents, with several requiring substantial or maximal assistance for activities of daily living (ADLs), including toileting and incontinence care. One resident with significant medical conditions, including respiratory failure, heart failure, and morbid obesity, reported waiting up to 45 minutes for assistance after activating the call light, particularly during evening and overnight shifts. This resident also stated that CNA hours had been reduced on his unit, leading to frequent delays in receiving help, especially when left on the toilet. Staff interviews corroborated these delays, with CNAs and LPNs reporting that call lights often went unanswered for extended periods due to insufficient staffing. Staff described situations where only one CNA was available per unit or for the entire building, making it difficult to provide timely care, especially for residents requiring two-person assistance. Staff also reported that when short-staffed, essential care such as toileting, incontinence care, showers, and vital signs were delayed. The ombudsman and other residents confirmed ongoing concerns about untimely responses to call lights, particularly during evening and night shifts. Administrative staff acknowledged awareness of staffing shortages but indicated that efforts to fill shifts were sometimes unsuccessful, and administrative personnel did not always come in to assist when notified of shortages. The facility's own policy requires sufficient licensed and unlicensed nursing staff on each shift to meet residents' needs, but interviews and documentation revealed that this standard was not consistently met. The deficiency affected the ability to provide timely and adequate care to all residents, as reported by both staff and residents.
Failure to Provide Bedtime Snacks in Accordance with Resident Needs and Facility Policy
Penalty
Summary
The facility failed to ensure that residents were provided with a bedtime snack in accordance with their needs, preferences, and requests. Interviews with residents and staff revealed that snacks, which were supposed to be served at bedtime, were instead being distributed with the evening meal at 4:30 PM. Many residents consumed these snacks with their supper, leaving them without food options until breakfast the next morning. Staff reported that the kitchen was locked after supper, and they did not have access to additional snacks to offer residents later in the evening or at night. Multiple staff members, including CNAs and LPNs, stated that the reduction in snack availability was due to budget cuts following a change in facility ownership. Staff also indicated that they sometimes purchased snacks with their own money to provide for residents, as the facility no longer stocked the kitchenette or linen closet with adequate snack options. Observations by the surveyor confirmed that the areas designated for snacks were inadequately stocked, with only minimal items such as a can of peanut butter, a box of oatmeal, and a few pudding cups available, and no bread or other items to make sandwiches. Residents affected by this deficiency included individuals with significant medical histories, such as diabetes, heart failure, and chronic respiratory conditions, who may have specific dietary needs. Despite the facility's policy requiring an evening snack to be offered and documented for each resident, the practice of serving snacks with supper and the lack of accessible snacks throughout the night did not meet the stated policy or regulatory requirements. Staff interviews and direct observation confirmed that the deficiency was facility-wide and had the potential to affect all 37 residents.
Delayed Call Light Response Due to Insufficient Staffing
Penalty
Summary
The facility failed to ensure that call lights were answered in a timely manner for two residents who required assistance with activities of daily living, specifically toileting. One resident, who was cognitively intact and required substantial to maximal assistance for toileting due to multiple medical conditions including respiratory failure, heart failure, and morbid obesity, reported waiting up to 45 minutes for assistance after activating the call light in the early morning hours. This resident stated that delays were most pronounced during evening and overnight shifts and that he was frequently left on the toilet for extended periods. Staff interviews confirmed that call lights were not always answered promptly, particularly during shift changes or when staffing levels were low, with one CNA noting that the average response time could be fifteen minutes or longer depending on circumstances. Another resident, also cognitively intact and requiring supervision or assistance for toilet hygiene, reported rarely using the call light and instead seeking staff directly for help. However, when the call light was used, the resident stated it was generally answered in a timely manner. Despite this, the facility's ombudsman and multiple CNAs corroborated ongoing concerns about delayed call light responses, especially during times of reduced staffing. Resident Council meeting minutes further documented repeated complaints about untimely call light responses over several months. Staff interviews consistently indicated that insufficient staffing contributed to delays in responding to residents' needs, particularly for toileting and other personal care tasks. Several CNAs and nurses acknowledged that they were unable to meet residents' needs promptly, especially when only one CNA was available per unit or during busy periods. The facility's policy required immediate response to call lights, but this standard was not consistently met, as evidenced by both resident and staff reports as well as facility documentation.
Inconsistent Shower Provision for Residents Requiring Assistance
Penalty
Summary
The facility failed to ensure that residents requiring assistance received showers as scheduled, affecting three residents (R2, R3, and R5) out of a sample of 21. R2, who has severe cognitive impairment and is dependent on assistance for bathing, did not receive showers consistently according to the facility's schedule. The documentation showed gaps in shower provision, with no records of refusals or additional showers beyond those documented. Similarly, R3, also with severe cognitive impairment and dependent on assistance, experienced inconsistencies in receiving scheduled showers, with records indicating bed baths instead of showers on some occasions. R5, who is cognitively intact but requires partial assistance for bathing, reported receiving fewer showers than previously scheduled. The resident expressed a preference for two showers per week, which was not consistently provided. The care plan for R5 lacked specific details on the level of assistance required and the frequency of showers, contributing to the inconsistency in care. Interviews with CNAs revealed challenges in adhering to the shower schedule due to staffing issues, resulting in missed showers that were not always rescheduled. The facility's policy mandates at least weekly showers for all residents, but the lack of complete documentation and adherence to the schedule suggests a failure to meet this standard. The administrator and regional nurse acknowledged the absence of shower sheets for the affected residents, indicating that showers may not have been completed as required. This deficiency highlights a gap in the facility's ability to provide consistent and adequate hygiene care for its residents.
Facility Maintenance and Housekeeping Deficiencies
Penalty
Summary
The facility failed to maintain resident rooms and equipment in a state of good repair, affecting five residents. Observations revealed issues such as leaking toilets, missing tiles, and unsecured fixtures. For instance, one resident's bathroom had a leaking and crooked toilet with tiles fallen from the wall, while another resident's toilet was not secure to the floor and could be easily moved. Additionally, some rooms had window sills with dust, dirt, debris, and cobwebs. Residents reported being aware of these issues, with some expressing frustration over the inconvenience caused by non-functional bathrooms. Two residents had been unable to use their bathroom for several months, requiring them to use a shared bathroom down the hall, which sometimes resulted in waiting times. Staff interviews indicated that the maintenance man responsible for repairs had quit, leaving some repairs incomplete, and that he had been using his own money for parts due to a lack of budget. The Director of Nursing and other staff members were not fully aware of the extent of the issues, with some only learning about them during the survey. The facility's policy emphasizes the importance of maintaining a safe and clean environment, but the lack of routine maintenance and housekeeping staff shortages contributed to the deficiencies. The maintenance assistant was unaware of work orders for some repairs, and the housekeeping staff was understaffed, further exacerbating the situation.
Unsafe Water Temperatures in Facility
Penalty
Summary
The facility failed to maintain safe water temperatures for 14 residents, as observed during a survey. The water temperatures in various locations within the facility were recorded using a calibrated digital metal stemmed thermometer. The temperatures ranged from 116 to 122.5 degrees Fahrenheit, exceeding the facility's policy of maintaining water temperatures between 100 and 110 degrees Fahrenheit. The Director of Nursing (DON) and the Maintenance Assistance/Therapy Assistant were involved in monitoring the water temperatures, but discrepancies were noted between their recorded temperatures and those observed during the survey. Several residents, including those who were cognitively impaired and ambulatory, were affected by the high water temperatures. One resident reported that the water was too hot but had not been burned. Another resident mentioned that a bathroom had been closed for several months, causing inconvenience. The DON acknowledged that a wandering cognitively impaired resident could have accessed the shower rooms or bathrooms, potentially leading to safety concerns. The facility had experienced maintenance issues, including a hole in the pipe leading to the hot water heater, which was believed to cause the water heater to overheat. The facility's maintenance staff had been reduced, with the Maintenance Assistance/Therapy Assistant temporarily filling in. The DON and the Maintenance Assistance/Therapy Assistant were aware of the water temperature policy but failed to ensure compliance, resulting in unsafe conditions for the residents.
Failure to Provide Nutritional Supplementation
Penalty
Summary
The facility failed to provide nutritional supplementation as recommended for three residents, leading to significant weight loss for one of them. Resident R3, who had multiple medical conditions including acute kidney failure and diabetes, experienced a 21.8% weight loss over four months. Despite recommendations from the Registered Dietician (RD) for additional protein due to weight loss and skin breakdown, R3 did not receive the extra protein with meals. The dietary manager and staff were unaware of the need for extra protein, and R3's dietary card did not reflect this requirement. Additionally, R3 expressed dissatisfaction with the food quality and reported that some meals were not suitable for his dietary needs. Resident R15, who has severe cognitive impairment and is on hospice care, did not receive the prescribed nutritional supplement at lunch on two consecutive days. The dietary aide admitted to forgetting to serve the supplements due to being nervous and overwhelmed. The dietary manager acknowledged the oversight and stated that R15 often does not consume the supplement, but no corrective action was documented to ensure future compliance with dietary orders. Resident R4, who is on a regular diet with pureed texture and pudding thick liquids, did not receive the high calorie/high protein supplement as ordered during lunch. The CNA and cook were unaware that R4 was supposed to receive the supplement twice a day. The RD confirmed the order for BID supplementation due to R4's history of weight loss, but the facility failed to consistently provide the necessary nutritional support.
Deficiency in Nursing Leadership and Coverage
Penalty
Summary
The facility failed to maintain a full-time Director of Nursing (DON) and ensure Registered Nurse (RN) coverage for 8 consecutive hours a day, seven days a week, potentially affecting all 33 residents. Observations and interviews revealed that the DON was working as a floor nurse, passing medications, and not performing DON duties for the past two months due to staffing shortages. The DON reported working 12-hour shifts, three days a week on the floor, and had recently resigned from the position due to the inability to fulfill DON responsibilities. The facility's assessment indicated the need for a full-time DON and additional RNs if the DON had other responsibilities, which was not adhered to. Further investigation showed that on multiple occasions, the DON and the Assistant Director of Nursing (ADON) were working as floor nurses instead of fulfilling their administrative roles. The facility's schedule for June 2024 documented several days without any RN hours worked, confirming the lack of adequate RN coverage. The administrator acknowledged the staffing issues and the DON's floor duties, which contributed to the deficiency in meeting regulatory requirements for nursing coverage and leadership.
Food Storage and Handling Deficiencies
Penalty
Summary
The facility failed to store and serve food in a safe and sanitary manner, which has the potential to affect all 33 residents residing at the facility. During an initial tour of the kitchen, surveyors observed several opened food items, including containers of thickened juice, bags of cereal, dried milk, liquid eggs, and lunchmeat ham, all without dates on them. Additionally, scoops were found inside the sugar bin and coffee container, laying directly on top of the contents. During lunch service, a dietary staff member was observed touching various surfaces and then transferring residents' drinks by the rim, which is against professional standards. The Dietary Manager acknowledged that opened items in the kitchen should be dated, and scoops should not be left in bins or containers. The manager also confirmed that staff should not transfer glasses by the rims but rather by the middle or bottom of the glass.
Inaccessible Call System in Bathrooms and Shower Rooms
Penalty
Summary
The facility failed to provide an accessible call system for residents in the shower room and community bathroom, affecting all 33 residents. Observations on multiple occasions revealed that the hall bathrooms and shower rooms on E-Hall, D-Hall, and A-Hall had call light boxes on the wall, but no pull cords were attached to the toggle switches. This made the call lights near the toilets inaccessible from the toilet or the floor. Additionally, the shower stalls in these areas did not contain any call system. Interviews with staff members indicated a lack of awareness and policy regarding the call light systems. The maintenance staff acknowledged the absence of pull cords and expressed uncertainty about the duration of this issue. The administrator also confirmed the lack of accessible call lights and stated that there was no existing policy on call light systems. The deficiency was identified through observations, interviews, and record reviews, highlighting a significant oversight in ensuring resident safety and accessibility.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident bed in multiple occupancy rooms, affecting four residents in the sample of 27. Observations and measurements conducted on August 1, 2024, revealed that the rooms occupied by these residents were certified for double occupancy but did not meet the required space per resident. Specifically, the rooms measured between 71.31 and 74.48 square feet per resident bed, which is below the mandated 80 square feet. The rooms contained various furniture and equipment, such as beds, bedside tables, dressers, and medical supplies, which further limited the available space for residents to move around. During the survey, the Administrator acknowledged that several rooms in the facility did not meet the required space per resident bed and confirmed that residents were not informed of this during admission. Although the facility's Daily Midnight Census sheet indicated that none of the rooms currently had more than one resident, the Administrator noted that this could change at any time. Despite the space limitations, observations and measurements during the survey determined that adequate space exists to meet the medical and personal needs of the residents living in these waivered rooms. Additionally, Resident Council Minutes from the past six months showed no concerns related to the size of the rooms included in the waiver.
Failure to Promote Resident Dignity and Independence
Penalty
Summary
The facility failed to promote resident independence and dignity by not explaining a task prior to beginning care and not allowing the resident time to perform the task independently. This incident involved a resident with moderate cognitive impairments who reported that a CNA was rough during care, pushing the resident over hard and fast without explanation. The resident expressed distress, yelling out during the incident, which was overheard by another resident across the hall. The resident felt rushed and manhandled, indicating a lack of communication and respect for the resident's ability to assist in their own care. Further investigation revealed that the CNA involved did not pause to allow the resident to voice concerns and continued with the task despite the resident's request for more time to assist. The facility's administrator confirmed that the CNA admitted to being rough and not explaining the care process to the resident. Although the facility did not classify the incident as abuse, it was acknowledged as poor customer service, highlighting a deficiency in promoting resident rights to dignity and self-determination.
Failure to Honor Resident's Sleeping Preferences
Penalty
Summary
The facility failed to honor a resident's preferences regarding their sleeping and waking schedule, which is a violation of the resident's right to self-determination. The resident, identified as R16, expressed dissatisfaction with being woken up too early, sometimes as early as 4:30 AM, and being taken to the dining room where they would sit with nothing to do until breakfast was served around 8:00 AM. This routine was not in alignment with R16's preference to sleep longer, as stated by the resident during interviews. Multiple staff members, including a Licensed Practical Nurse (LPN), dietary staff, and Certified Nurse Aides (CNAs), confirmed that R16 was typically in the dining room by the time they arrived for their shifts at 6:00 AM. The facility administrator acknowledged that residents should be able to get up at their preferred times, but was unsure if there was a specific policy in place to support this. The report highlights a lack of adherence to resident choice, as R16's expressed preferences were not being respected, leading to the identified deficiency.
Failure to Accurately Code MDS for Significant Weight Loss
Penalty
Summary
The facility failed to accurately code a Minimum Data Set (MDS) Assessment for one resident, identified as R4, out of 12 residents reviewed for assessment accuracy in a sample of 27. R4's weight log documented a significant weight loss from 132 pounds on December 21, 2023, to 111.4 pounds on June 1, 2024, which calculates to a 15.61% weight loss over six months. However, this significant weight loss was not documented on R4's MDS dated [DATE]. On July 31, 2024, the MDS/Care Plan Coordinator, identified as V13, confirmed that significant weight losses should be coded on the MDS. The facility's Comprehensive Assessment/MDS Policy, dated November 1, 2017, states that the facility should ensure MDS accuracy and follow the RAI Manual instructions for amending assessments if inaccuracies are found.
Failure to Follow Physician Orders for Skin Protection
Penalty
Summary
The facility failed to adhere to physician orders for a resident identified as R6, who was prone to skin tears and required protective skin sleeves at all times. Observations on two consecutive days revealed that R6 was seated in a reclining wheeled chair without the prescribed protective skin sleeves. Interviews with Certified Nursing Assistants (CNAs) V15 and V16 confirmed that R6 was supposed to wear the sleeves at all times, but they were not in place because the CNAs did not know their location. The resident's care plan, last updated a few days prior, also documented the necessity for arm sleeve protectors to be worn at all times. This was further corroborated by V13, the Minimum Data Set/Care Plan Coordinator, who confirmed the requirement for R6 to wear the arm sleeve protectors consistently.
Failure to Follow Care Plans and Professional Standards
Penalty
Summary
The facility failed to position a resident with dysphagia in an upright position during meals, as per the physician's orders and care plan, which led to choking episodes. The resident, who requires a pureed diet with pudding thick liquids and staff assistance for feeding, was observed being fed while reclined in a wheelchair at angles of approximately 60 and 45 degrees on two separate occasions. During these meals, the resident experienced coughing and choking, with one instance resulting in the resident's face turning red. Staff members confirmed that the resident was not positioned correctly, and the care plan's instructions for feeding were not followed. Additionally, the facility did not adhere to professional standards to prevent the development of an open wound for another resident. This resident, who is at moderate risk for pressure ulcers and has a history of skin impairments, was found with an open and bleeding area on the right buttock during incontinence care. The Certified Nursing Assistants providing care did not dry the resident after cleaning, failed to apply barrier cream, and did not change gloves before placing a new incontinent brief. The Registered Nurse was not informed of the open wound, and the treatment plan was not adjusted despite the wound being open and bleeding. These deficiencies highlight a lack of adherence to prescribed care plans and professional standards, resulting in potential harm to residents. The failure to follow swallowing precautions and proper skin care protocols demonstrates a need for improved staff training and communication to ensure resident safety and well-being.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary services consistent with professional standards of practice to prevent the worsening of pressure ulcers for a resident identified as R4. R4 had a Stage III pressure ulcer on the lower right buttock, as documented in the facility's Quality Assurance Weekly Skin Eval Documentation List. Despite being at high risk for pressure ulcers, R4's medical record did not contain any pressure ulcer assessments, and the care plan was not adequately followed. The Director of Nursing stated that the resident's treatment consisted only of a barrier cream applied by CNAs, and the wound was not being assessed or measured weekly because the resident was on hospice care. Observations revealed that the pressure ulcer was still open, and the facility's records, including the Treatment Administration Record and Physician Order Sheets for June and July 2024, did not document any pressure ulcer treatment orders. The MDS/CP Coordinator confirmed that the hospice order was not transcribed or signed out as completed, and emphasized that nurses should be responsible for completing treatments and assessing the wound. The facility's policy required proper treatment and documentation of pressure areas, which was not adhered to in this case.
Failure to Assess and Implement Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to adequately assess and implement interventions for a resident, identified as R28, who was at high risk for falls. R28, who has multiple diagnoses including unspecified dementia, vascular dementia, and muscle weakness, was observed crawling on the floor and sliding out of his wheelchair on multiple occasions. Despite these incidents, nursing staff did not assess R28 after these events, nor did they implement the interventions outlined in his care plan, such as offering ambulation with a walker and staff assistance. On one occasion, R28 was found crawling on the floor with a pillow, and a CNA attempted to assist him back into his wheelchair without notifying a nurse or conducting an assessment. The personal alarm intended to alert staff was not functioning properly, as it was found disconnected and lying in R28's bed. Staff members were aware of R28's behavior of crawling on the floor but did not consistently follow the protocol of notifying a nurse or treating the situation as a fall if it was unwitnessed. Additionally, R28 was observed in the dining room attempting to slide out of his wheelchair without any staff present to assist him. When alerted, staff members helped R28 back into his wheelchair but again failed to assess him or offer ambulation assistance as per his care plan. The facility's policy on fall prevention was not adhered to, as staff did not conduct fall huddles or assess the resident immediately after these incidents, which are critical steps in minimizing injuries related to falls.
Deficiencies in Catheter and Incontinence Care
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident with a suprapubic catheter, as observed during a survey. The resident's care plan required the catheter to be secured to prevent tension, but it was not secured during the observation. The LPN providing care used an unclean over bed table, did not follow proper hand hygiene, and used personal scissors from their pocket to cut tape for the dressing. The LPN also failed to clean the catheter insertion site correctly, using the same washcloth area multiple times, which could lead to cross-contamination. Another deficiency was noted in the care of a resident requiring incontinence care. Two CNAs failed to change gloves or perform hand hygiene after cleaning the resident, who had a history of ESBL in urine and was on Enhanced Barrier Precautions. The CNAs did not dry the resident's skin after washing, and they handled clean items with contaminated gloves. This improper practice was against the facility's policy, which requires changing gloves and washing hands when moving from contaminated to clean tasks. The facility's policies on perineal cleansing and infection control were not followed, as evidenced by the actions of the staff. The policies require thorough drying of the skin, changing gloves, and performing hand hygiene after resident contact. The failure to adhere to these procedures was confirmed by the staff involved, who acknowledged the need for proper glove changing and hand hygiene during incontinence care.
Failure to Limit As-Needed Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that as-needed psychotropic medications were limited to 14 days for a resident reviewed for unnecessary medications. The resident, identified as R4, was receiving Lorazepam, a benzodiazepine, at a dosage of 0.5 mg twice a day and 1 mg every four hours as needed for anxiety. A pharmacy consultation report dated January 10, 2024, recommended assessing the resident's medication dosage and considering a gradual dose reduction if clinically appropriate. However, on February 14, 2024, the physician declined this recommendation without documenting a resident-specific rationale for not attempting a gradual dose reduction. The facility's policy states that as-needed psychotropic medications should not be given for an excessive duration and are limited to 14 days unless a physician documents a rationale for extending the use. Despite this policy, the resident's July 2024 Physician Order Sheet documented an order for Lorazepam as needed for anxiety, which should have been discontinued after 14 days. The Minimum Data Set/Care Plan Coordinator confirmed that the as-needed Lorazepam should have been discontinued after 14 days, indicating a failure to adhere to the facility's policy on the duration of psychotropic medication use.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to infection control standards and practices, particularly in the handling of soiled linens, hand hygiene, Enhanced Barrier Precautions (EBP), and Contact Isolation Precautions. This deficiency was observed in the care of three residents. For Resident 6, who had a suprapubic catheter and was on EBP, a Licensed Practical Nurse (LPN) failed to wear a gown while providing catheter care, despite signage indicating the need for gloves and a gown. The LPN also improperly disposed of soiled washcloths by throwing them on the floor, and later picked them up with bare hands, indicating a lack of adherence to proper infection control protocols. Resident 13, who was on Contact Isolation Precautions due to a positive ESBL of a left foot wound, received wound care from a Registered Nurse (RN) who did not don a gown before entering the room, despite the presence of EBP signage and available PPE. The RN placed soiled dressings in a regular trash can instead of a designated red barrel for isolation waste, demonstrating a failure to follow proper disposal procedures for infectious materials. For Resident 32, who was on EBP due to a gastrostomy tube and risk of pressure ulcers, two Certified Nurse Assistants (CNAs) failed to change gloves or perform hand hygiene during incontinence care. They continued to handle clean items and the resident's gown with contaminated gloves, which is against the facility's infection control policy. These actions reflect a significant lapse in maintaining hygiene standards and preventing cross-contamination during resident care.
Failure to Administer Influenza Vaccine
Penalty
Summary
The facility failed to adhere to its Influenza Immunization Policy by not offering or providing an influenza vaccine to one of the residents reviewed for immunizations. The resident, identified as R21, had a care plan documenting an admission date and diagnoses including frontotemporal neurocognitive disorder, dementia, Alzheimer's disease, major depressive disorder, anxiety disorder, and muscle weakness. The resident's physician order sheet included an active order dated 11/27/23 for an annual flu vaccine with consent unless contraindicated. However, the resident's current medical record only documented an influenza vaccination date of 10/20/22, with no further information on subsequent vaccinations or refusals. During the survey, the facility's administrator, V1, provided a list of current immunizations for all residents, which confirmed that R21's most recent influenza vaccination was on 10/20/22. A registered nurse, V22, was unable to find additional information regarding R21's influenza vaccination or any documentation of refusal or consent. The facility's policy requires obtaining permission or consent for the vaccine and offering the influenza immunization annually from September 1st through March 31st. The policy also mandates documentation of the immunization on the resident's medication administration record and immunization record, which was not followed in this case.
Failure to Administer and Document Anti-Anxiety Medication
Penalty
Summary
The facility failed to follow physician's orders to administer anti-anxiety medication as prescribed for one resident (R4). R4, who has a history of cerebral infarction, Alzheimer's disease, and other significant health conditions, reported that a male nurse (V7) had forgotten to give her the noon dose of Ativan on several occasions. R4 mentioned this issue to an outside provider, which led to a call to the facility's administration. The facility's records showed discrepancies in the administration and documentation of the medication, with missing entries on the Controlled Substance Proof of Use sheet and inconsistencies in the Medication Administration Record (MAR). On one occasion, the Director of Nursing (V2) admitted to possibly forgetting to administer the morning dose of Ativan to R4 before she left for an outside appointment. Another nurse (V8) reported that when she took over the shift from V7, the documentation was in disarray, and she mistakenly signed off on the MAR for the 8:00 PM dose of Ativan, believing it had already been administered by V7. V8 did not verify this against the controlled substance proof of use sheet, leading to further discrepancies. The facility's Medication Administration policy requires that any medication not administered be documented with the reason for omission, but this was not consistently followed. The failure to properly administer and document the anti-anxiety medication as ordered resulted in a deficiency in the care provided to R4, as evidenced by the inconsistencies and omissions in the medication records and the resident's own reports of missed doses.
Failure to Maintain Accurate Controlled Substance Records
Penalty
Summary
The facility failed to ensure that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for one resident. The resident, who was admitted with multiple diagnoses including Alzheimer's disease, anxiety, and depression, reported that a male nurse, V7, had forgotten to give her noon medication, Ativan, on several occasions. The resident expressed concerns that the medication was not in her medication cup as claimed by V7, leading to doubts about whether she received her prescribed doses. This issue was brought to the attention of the facility's administration by an outside provider after the resident reported the missed doses during a visit. The Medication Administration Record and Controlled Substance Proof of Use sheets for the resident documented several instances where doses of Ativan were not signed out at the correct times. Specifically, doses on 02/20/24, 02/21/24, 03/19/24, and 03/23/24 were not signed out until later dates, indicating a failure to maintain accurate records. Despite the facility's policy requiring narcotic counts at the beginning and end of each shift, the records showed that these counts were not consistently performed or documented correctly. Interviews with the Director of Nursing and several LPNs revealed that V7 had a history of not signing out narcotic medications and that this issue had been previously addressed with him. However, the problem persisted, with other nurses often correcting the records later. The facility's Controlled Substance Policy mandates immediate reporting of discrepancies to the Director of Nursing, but the ongoing issues with V7's record-keeping were not adequately resolved, leading to the deficiency noted in the report.
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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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