Washington Senior Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Washington, Illinois.
- Location
- 1201 Newcastle, Washington, Illinois 61571
- CMS Provider Number
- 145000
- Inspections on file
- 57
- Latest survey
- August 19, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Washington Senior Living during CMS and state inspections, most recent first.
The facility did not educate residents or staff on the grievance process, failed to provide grievance forms, and lacked a clear method for submitting grievances. Multiple residents reported missing personal items but were unaware of how to file a grievance, and staff did not advise them to do so. The Social Services Director and Activities Director were not trained on grievance procedures, and there was no public location for grievance forms or a grievance box.
A resident with severe cognitive impairment and multiple chronic conditions developed unexplained discoloration, swelling, and pain in a lower extremity. The LPN on duty notified hospice and the ADON but did not promptly inform the resident's POA, resulting in the POA learning of the injury from hospice instead of the facility. This delay in notification was contrary to facility policy requiring immediate communication of significant changes in condition to the resident's representative.
Staff engaged in verbal and physical altercations in resident areas, with multiple residents and staff reporting discomfort and unprofessional conduct. The incident, which occurred in a hallway where residents reside, involved two CNAs with prior disciplinary issues and resulted in a failure to provide a respectful and dignified environment for all residents.
Two residents were involved in an altercation where one kicked the other multiple times, resulting in pain and no follow-up assessment or investigation by the facility. Staff failed to communicate the incident to key personnel, and no protective measures or behavioral interventions were implemented, despite ongoing concerns about aggressive behavior. This lack of action and documentation affected all residents in the facility.
Two residents were involved in an altercation where one kicked the other multiple times, resulting in pain and no subsequent assessment or follow-up by nursing staff. The facility did not notify the residents' physicians or representatives, nor did they document the incident or initiate an immediate investigation, contrary to facility policy.
A resident with a history of aggressive behavior physically abused another resident in the dining room after becoming agitated, resulting in the victim experiencing pain in her knees. Despite facility policy requiring immediate protection and follow-up, staff did not assess or follow up with the injured resident after the incident.
Two residents were involved in an altercation where one kicked the other, causing pain to the recipient who had pre-existing knee issues. Although a CNA witnessed and reported the incident to the administrator, there was no immediate investigation or timely report to the State Agency as required by facility policy. The administrator only interviewed one resident and delayed reporting the incident, resulting in a deficiency related to abuse reporting and investigation protocols.
Staff failed to immediately report a resident's allegations of misappropriation of funds and sexual abuse to the administrator and State Agency as required. CNAs did not report the resident's claim of missing money, and the DON delayed reporting the sexual abuse allegation for over 12 hours. The resident was sent to the ED for evaluation, and documentation showed no timely reporting of either incident.
A resident reported to a CNA that a staff member took her money to buy food and did not return with the money or food. The CNA did not report the allegation, and the Administrator confirmed that no investigation was conducted. Review of records showed no evidence that the allegation of misappropriation of funds was investigated.
A CNA performed a mechanical lift transfer of a resident with significant mobility impairments without the required second staff member, resulting in the lift tipping over and the resident needing to be lowered to the floor with assistance from an LPN. Facility policy mandated two-person assistance for all mechanical lift transfers, but this was not followed during the incident.
A resident alleged that an agency CNA ripped off his brief and left him naked in bed. The DON reported the allegation to the administrator, who treated it as a customer service issue and did not notify the State Agency or conduct an abuse investigation, contrary to facility policy.
A resident with incontinence and a stage three pressure ulcer reported that a CNA became upset, forcefully removed the resident's brief, and left the resident naked in bed. The incident was reported to the DON and then to the Administrator, who treated it as a customer service issue rather than a potential abuse allegation, failing to initiate the required abuse investigation as outlined in facility policy.
A facility failed to investigate an abuse allegation involving a resident with Alzheimer's disease, who reported inappropriate touching by a male caregiver. The facility did not suspend or interview the only male CNA employed, despite policy requirements to remove alleged perpetrators from resident contact pending investigation. The administrator admitted to forgetting about the male CNA's employment, and the CNA continued working after the allegation was reported.
The facility failed to maintain daily sanitation during outbreaks of respiratory and gastrointestinal viruses, affecting all 76 residents. Insufficient housekeeping staff led to unclean rooms and inadequate sanitizing, despite the facility's protocols requiring daily cleaning, especially during outbreaks. Residents reported having to clean their own spaces, and the DON acknowledged the ongoing issue with cleanliness.
A cognitively impaired, high fall risk resident was neglected by an LPN who failed to document multiple falls or provide necessary care. The resident was left on a cold floor without a mattress or blankets, despite being care planned to have a mattress beside the bed. The facility's policies on abuse prevention and fall protocol were not followed, resulting in the resident experiencing neglect.
The facility failed to maintain a routine cleaning schedule for the kitchen, with no cleaning check-off sheets for staff. Observations revealed food boxes on the freezer floor, no sanitization logs for the dishwasher, and no temperature logs for the freezer, cooler, or refrigerator. Bread lacked expiration dates, and the kitchen steamer/oven and floors were unclean. The Dietary Manager acknowledged these issues, which could affect all 73 residents, except one who is NPO.
The facility failed to implement procedures to reduce Legionella risk in its water system, affecting 73 residents. The Maintenance Director lacked documentation and knowledge of Legionella procedures, only checking water temperatures weekly. The Infection Preventionist did not manage a Legionella water plan. The facility's policy requires a water management program, risk assessments, and documentation maintenance.
The facility failed to document COVID-19 vaccinations, screening, offering, or education for staff, potentially affecting all 73 residents. The Infection Preventionist was unable to provide documentation or confirm staff vaccination status, admitting to not having screened, educated, or offered the vaccine to staff.
The facility failed to conduct thorough fall investigations for three residents, resulting in incomplete documentation and lack of interventions to prevent future falls. The DON acknowledged missing details due to inadequate charting by agency nurses, who were difficult to contact post-shift. Residents with various medical conditions experienced multiple falls, with investigations lacking root cause analysis and necessary preventive measures.
The facility failed to make survey results from the past five years accessible to residents, as required by regulations. During a resident council meeting, several residents were unaware of their right to review these results. An investigation found no survey results available, and staff were unable to locate the survey binder. This deficiency affects all 73 residents in the facility.
The facility failed to document or provide written notification to residents or their representatives about the reasons for emergent hospital transfers or discharges, as required by their policy. This oversight affects all 73 residents, as it disrupts continuity of care and violates residents' rights. The administrator admitted to the lack of documentation, citing recent changes and an inability to find the necessary paperwork.
The facility did not provide Bed Hold Policy notifications to residents or their representatives during hospital transfers, as required by their policy. The administrator acknowledged the oversight, citing recent changes and missing paperwork, potentially affecting all 73 residents.
The facility failed to post complete nurse staffing information daily, omitting total nursing hours worked and not retaining 18 months of postings. The administrator confirmed the absence of total hours on the form, and the HR Director was unaware of the requirement to include this information. This deficiency potentially affects all 73 residents in the facility.
A facility failed to protect residents from abuse, resulting in two incidents. One resident with a history of aggression injured another by slamming a door on her hand, causing severe injuries. Another incident involved inappropriate touching between residents, but the investigation found insufficient evidence of abuse. The facility's policies on abuse prevention were not effectively implemented.
The facility failed to ensure CNAs completed required in-service training, including dementia management and abuse prevention. The DON could not provide proof of training completion for the past six months, and recent sessions lacked attendance records for all CNAs. This oversight potentially affects all 61 residents, especially those with cognitive impairments.
A resident with dementia, known to wander, was repeatedly injured by another aggressive resident in an LTC facility. Despite the facility's Abuse Prevention Program, no increased supervision or care plan updates were implemented after the first incident, leading to a second injury. Staff acknowledged the challenges in monitoring the resident but failed to take necessary protective measures.
A facility failed to report a resident-to-resident abuse incident where one resident entered another's room, resulting in verbal aggression and physical harm when the door was slammed on the intruding resident's hand. Despite the facility's policy requiring immediate reporting of such incidents, this event was not documented or reported to the State Agency, as confirmed by the corporate administrator.
The facility failed to investigate a potential abuse incident between two residents, where one resident was injured after the other slammed a door on their hand. Despite the facility's policy requiring an investigation, no action was taken by the staff or administration, with the incident being dismissed as typical aggressive behavior by one of the residents.
A facility failed to provide a resident with a copy of the bed hold policy upon their transfer to the hospital. The facility's policies indicate that bed hold and readmission rights should be maintained, but the resident's clinical record lacked documentation of written notice of the bed hold policy. The DON confirmed the omission.
The facility failed to serve food at a palatable temperature, affecting all 68 residents. Food temperatures were not consistently taken or documented, and meals were often served cold, as reported by residents and staff. On the day of the survey, cheese pizza was served at inadequate temperatures without reheating, and unheated carts were used for room trays. The administrator acknowledged the failure to adhere to temperature-taking policies.
Failure to Educate Residents and Staff on Grievance Process and Provide Accessible Grievance Submission
Penalty
Summary
The facility failed to educate residents on what constitutes a grievance, did not provide grievance forms, and lacked a clear and accessible method for residents to submit grievances. Multiple residents reported missing personal clothing items but were unaware of what a grievance was or how to file one. Staff members, including laundry aides, the Housekeeping/Laundry Supervisor, the Social Services Director, and the Activities Director, also demonstrated a lack of knowledge regarding the grievance process and did not advise residents to file grievances. The facility's grievance policy was not effectively communicated or implemented, and there was no visible location for residents to obtain or submit grievance forms. Resident Council meeting minutes and interviews with residents and staff confirmed that residents frequently experienced missing personal items and voiced their concerns to staff, but these concerns were not addressed through a formal grievance process. The Social Services Director, who was supposed to oversee grievances, had not been trained on the process and did not have access to grievance forms. The Administrator confirmed that there was no public location for grievance forms or a grievance box, and staff were instructed to direct all concerns to the Administrator rather than following a formal grievance procedure.
Failure to Promptly Notify Family of Resident Injury
Penalty
Summary
The facility failed to promptly notify a resident's family or legal representative of a significant change in the resident's condition, as required by facility policy. The incident involved a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, diabetes with chronic kidney disease, and generalized anxiety disorder. Staff discovered discoloration, swelling, and pain in the resident's left lower extremity, with no record of a fall. The nurse on duty reported the injury to hospice and the Assistant Director of Nursing but did not notify the resident's Power of Attorney (POA) until several hours later. The facility's policy specifies that the resident's legal representative should be promptly informed of such changes, and documentation should be made in the nurse's notes. The delay in notification was confirmed through interviews and record review. The POA expressed dissatisfaction upon learning of the injury from hospice rather than directly from the facility. The nurse involved stated she was accustomed to a different protocol from another state, where hospice would notify the POA, but was informed by the Director of Nursing that this was not the correct procedure at this facility. The failure to promptly notify the resident's representative of the injury constituted a deficiency in following the facility's established policy for communication regarding changes in resident condition.
Failure to Maintain Resident Dignity Due to Staff Altercation
Penalty
Summary
The facility failed to maintain an environment free from inappropriate staff behavior, specifically failing to provide respect and dignity for residents. Documentation and interviews revealed that certified nursing assistants (CNAs) engaged in verbal arguments in resident areas, with multiple residents and staff reporting that such incidents were observed and created discomfort. Resident council meeting minutes and concern forms documented ongoing issues with staff approach and professionalism, and residents reported feeling uncomfortable due to staff arguing and unprofessional conduct. On a specific occasion, two CNAs were involved in a physical altercation in a hallway where residents reside. Video evidence and staff interviews confirmed that one CNA approached another in an assigned area, leading to a verbal argument that escalated when one CNA pushed the other. The altercation was witnessed by residents and staff, and both CNAs had prior disciplinary records for attendance and conduct issues. The incident occurred in a public area of the facility, directly impacting the environment experienced by residents. The facility's own policies and job descriptions require staff to treat residents and each other with respect and dignity, and to maintain a safe, homelike environment. Despite these requirements, the documented staff conflict and lack of effective intervention prior to the altercation resulted in a failure to uphold residents' rights to a dignified existence and a respectful environment. The deficiency had the potential to affect all residents in the facility.
Failure to Investigate and Protect Residents After Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged abuse incident involving two residents. According to the facility's own Abuse Prevention Program Policy, all reports and allegations of abuse must be promptly and aggressively investigated, with immediate protection for the residents involved. However, after an altercation in the dining room where one resident kicked another multiple times in the knees, the administrator only interviewed the resident who reported being kicked and did not initiate a full investigation or provide an investigation report. No assessment or follow-up was conducted to check for injuries or offer pain management to the resident who was kicked. Multiple staff interviews revealed that the incident was not communicated to key personnel, including the DON, and was not discussed in staff meetings. The CNA who witnessed the altercation reported it to the administrator, but no further action was taken to separate the residents or evaluate the aggressor for behavioral interventions. Other staff and residents described ongoing behavioral issues with the resident who committed the kicking, including frequent yelling and aggressive behavior, but these concerns were not addressed or documented in care planning or meetings. The facility's failure to follow its abuse investigation policy and to protect residents from further potential abuse affected not only the two residents directly involved but also had the potential to impact all 79 residents in the facility. The lack of documentation, communication, and follow-up after the incident demonstrates a breakdown in the facility's systems for identifying, investigating, and responding to abuse allegations as required by policy.
Failure to Notify Physicians and Representatives After Resident-to-Resident Abuse
Penalty
Summary
The facility failed to notify the physicians and representatives of two residents involved in an abuse incident, as required by policy and regulation. An altercation occurred in the dining room where one resident, who was alert, oriented, and serving as Resident Council President, was kicked multiple times in the knees by another resident using a wheelchair. The affected resident reported pain in the knees for several days following the incident and stated that no nursing staff assessed or followed up regarding the injury. There was no documentation in either resident's medical records, care plans, or nursing notes regarding the incident or any notifications to their physicians or representatives. Interviews with facility staff, including the Administrator and DON, revealed that no investigation was initiated immediately after the incident, and the event was not reported to the local State Agency until several days later. The Administrator acknowledged not investigating or reporting the incident initially, and the DON was unaware of the event, indicating a lack of communication and follow-up. The facility's policies require prompt investigation and notification in cases of abuse, but these procedures were not followed in this instance.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with a history of dementia, aggressive behavior, and other psychiatric and mobility issues (R2) physically abused another resident (R1) in the dining room. R2, whose care plan noted a risk for psychosocial problems, physical aggression, and behavioral outbursts, became agitated when attempting to maneuver his wheelchair through a crowded area. After R1 suggested an alternative route, R2 began yelling and kicked R1 several times in the knees, causing pain due to R1's pre-existing knee problems. Staff were alerted by the commotion and separated the residents, but the incident was not followed up with an assessment of R1's injuries or further communication with R1 regarding the event. The facility's Abuse Prevention Program Policy requires immediate protection of residents involved in abuse, prompt investigation, and ongoing monitoring of residents with increased vulnerability. Despite these policies, R1 reported that no one followed up to check on her or her injuries after the incident, and there was no documentation of an assessment or intervention for R1 post-incident. The event was reported to the state agency, but the lack of immediate and appropriate response to R1's needs following the altercation constituted a failure to protect the resident from abuse as required by facility policy.
Failure to Timely Report and Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the local State Agency for two of four residents reviewed for abuse. According to the facility's Abuse Prevention Program Policy, all allegations or suspicions of abuse must be immediately reported to the administrator and the State Agency, and a thorough investigation must be conducted and documented. In this incident, one resident reported being kicked several times on the knees by another resident during an altercation in the dining room, which caused pain due to pre-existing knee problems. The altercation was witnessed by a CNA, who separated the residents and reported the incident to the administrator. Despite being informed of the incident, the administrator did not conduct a full investigation or report the event to the State Agency as required by policy. Only the resident who reported being kicked was interviewed, and no further follow-up or assessment of injuries was performed. The initial report to the State Agency was delayed, occurring several days after the incident rather than immediately as mandated. This failure to promptly report and investigate the abuse allegation resulted in noncompliance with both facility policy and regulatory requirements.
Failure to Immediately Report Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to immediately report allegations of misappropriation of funds and sexual abuse involving a resident to the State Agency and the facility administrator, as required by policy. Certified Nursing Assistants (CNAs) were informed by a resident that a staff member had taken money to purchase food but did not return with the food or the money. Both CNAs did not report this allegation to the administrator or a nurse. Additionally, the resident later reported to an LPN that the administrator had engaged in inappropriate sexual behavior. The LPN immediately notified the administrator and the Director of Nursing (DON) of the allegation. Despite the facility's policy requiring immediate reporting of such allegations, the DON did not report the sexual abuse allegation to the State Agency until over 12 hours after being informed. There was also no evidence that the misappropriation of funds allegation was reported to the administrator or the State Agency. The resident was sent to the emergency department for evaluation following the sexual abuse allegation. Documentation review confirmed the lack of timely reporting for both incidents.
Failure to Investigate Alleged Misappropriation of Resident Funds
Penalty
Summary
The facility failed to investigate an allegation of abuse involving one resident who reported to a CNA that a staff member took her money to purchase food but did not return with either the money or the food. The resident was unable to identify or describe the staff member involved. The CNA did not report the allegation to a nurse or the Administrator. Upon interview, the Administrator confirmed that no investigation had been conducted regarding the resident's allegation of misappropriation of funds. Review of the facility's Abuse Prevention Program policy and the resident's electronic medical record showed no documentation or evidence that the allegation was investigated.
Failure to Ensure Two-Person Assist During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) performed a mechanical lift transfer of a resident without the required assistance of a second staff member, contrary to facility policy. The resident, who had diagnoses including Multiple Sclerosis, muscle wasting and atrophy, encephalopathy, and neuromuscular dysfunction of the bladder, was dependent for transfers and required a two-person assist for mechanical lift use. During the transfer, the CNA attempted to maneuver the resident into a high back reclining wheelchair alone, resulting in a change in the resident's center of gravity and causing the mechanical lift to tip over. The CNA called for help, and an LPN responded to assist in safely lowering the resident to the floor. The resident was cognitively intact but had significant functional impairments, including limited use of one upper extremity and both lower extremities, and was at risk for falls due to deconditioning and Multiple Sclerosis. The facility's policies clearly stated that two staff members were required for all mechanical lift transfers. Interviews and documentation confirmed that the transfer was performed by a single CNA, in violation of these policies, which directly led to the incident where the resident and CNA became pinned against a dresser and required assistance to resolve the situation.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report a potential allegation of abuse to the State Agency for one resident. According to the facility's Abuse Prevention Training Program, employees are required to report any allegation of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property immediately to the administrator, who must then report it to the State Agency after the resident has been assessed and the alleged perpetrator removed. Documentation shows that a resident reported feeling that some staff rushed through care and had a poor attitude, specifically identifying an agency CNA. The grievance form did not contain further information, and the staff member was removed from the schedule. The DON stated she was notified that the resident alleged an agency CNA ripped his brief off and left him naked in bed, and she reported this to the administrator. The administrator acknowledged being made aware of the allegation but treated it as a customer service issue rather than a potential abuse case, and did not notify the State Agency or conduct an abuse investigation. The administrator confirmed that this incident was not included in the facility's abuse investigations for the past three months.
Failure to Investigate Potential Abuse Allegation
Penalty
Summary
The facility failed to identify and investigate a potential allegation of abuse involving a resident with incontinence, ADL self-care deficiency, and a stage three pressure ulcer. The resident reported that a CNA became upset after being asked to change his brief, ripped the brief off, and left him naked in bed without replacing it. The resident stated he informed another CNA about the incident, who then reported it to the DON. The DON relayed the information to the Administrator, who did not treat the incident as a potential abuse allegation but instead handled it as a customer service issue and completed a grievance form. The facility's abuse prevention protocol requires that all alleged occurrences of abuse be investigated promptly, including interviewing all involved parties and reviewing relevant records. However, the Administrator did not initiate an abuse investigation or document whether the grievance was confirmed. The incident was not included in the facility's list of reported abuse allegations, and there was no evidence that the required investigative steps were followed as outlined in the facility's policy.
Failure to Investigate and Protect Resident in Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an alleged abuse incident involving a resident with Alzheimer's disease, who reported being inappropriately touched by a male caregiver. The facility's policy requires the removal of any alleged perpetrators from resident contact pending an investigation, but this was not followed. The resident, who is not cognitively intact and requires maximum assistance with bathing, described the alleged perpetrator as a blonde male caregiver of average height. However, the facility does not employ any male CNAs fitting this description, and the male nurse present at the facility did not match the description and did not provide direct care to the resident. Despite the facility's policy, the male CNA, who was the only male CNA employed and did not match the description given by the resident, was not suspended or interviewed during the investigation. The administrator admitted to forgetting about the male CNA's employment and confirmed that the CNA continued to work after the allegation was reported. The failure to remove the male CNA from resident contact and to conduct a thorough investigation constitutes a deficiency in the facility's handling of the abuse allegation.
Inadequate Housekeeping During Viral Outbreaks
Penalty
Summary
The facility failed to maintain daily sanitation of the facility and resident rooms during outbreaks of respiratory and gastrointestinal viruses, affecting all 76 residents. Between late January and early February, 23 residents exhibited symptoms of nausea, vomiting, and diarrhea, with two diagnosed with Norovirus. Additionally, nine residents showed respiratory symptoms, with six testing positive for Influenza A and five for RSV. The housekeeping staff was insufficient, with only one housekeeper present during the day and another in the evening, making it impossible to perform enhanced sanitizing during the outbreak. The Housekeeping Manager, V8, was occupied with room changes and unable to complete regular cleaning tasks. Residents reported that their rooms were not cleaned daily, with some having to clean their own spaces due to the lack of housekeeping services. The Director of Nursing, V2, acknowledged the ongoing issue with housekeeping and the lack of cleanliness, emphasizing the importance of sanitizing high-touch surfaces during the outbreak. The facility's Infection Prevention and Control Manual and housekeeping procedures outlined the need for daily cleaning and sanitizing, especially during outbreaks, but these protocols were not followed due to staffing shortages.
Neglect of High Fall Risk Resident
Penalty
Summary
The facility failed to prevent neglect of a cognitively impaired, high fall risk resident, resulting in the resident lying on a cold, hard floor for an undetermined amount of time. The resident, who was admitted with multiple diagnoses including dementia, agitation, and orthostatic hypotension, was found cold and shivering with chattering teeth in the early hours of the morning. The care plan for the resident included keeping the bed in a low position with a mattress on the floor, but this intervention was not followed. The Licensed Practical Nurse (LPN) on duty, identified as V5, was aware of the resident's falls throughout the night but failed to document the incidents or notify the Director of Nursing, the doctor, or the family. The LPN did not conduct necessary assessments or follow the facility's fall protocol, which includes immediate assessment, neurological checks, and risk management fall assessments. The resident was left on the floor without a mattress or blankets, despite the hallway being cooler than usual due to heating issues in the facility. The facility's policies on abuse prevention and fall clinical protocol were not adhered to, as the LPN allowed the resident to remain on the floor without adequate care or documentation. The Director of Nursing confirmed that the resident's care plan did not include instructions to allow the resident to lay on the floor, and the LPN's actions were deemed neglectful. The facility's failure to provide necessary care and services to the resident resulted in neglect, as defined by their own policies.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to maintain a routine cleaning schedule for the kitchen, which included the absence of cleaning check-off sheets for staff. During a kitchen tour, it was observed that multiple boxes of food were stacked on the floor in the freezer, and there were no sanitization logs available for the dishwasher. Additionally, there were no temperature logs for the freezer, cooler, or refrigerator. Eight loaves of bread were found on storage racks without any delivery or expiration dates. The kitchen steamer/oven had a build-up of a black sticky substance, and the kitchen floors were dirty with brown streaks and debris. The Dietary Manager, who has been in the position since July 2024, acknowledged the lack of a cleaning schedule and check-off sheets for staff. She admitted that the freezer food delivered the previous night had not been put away and was unsure of the location of the dishwasher sanitization logs and temperature logs for the cooler or freezer. The facility's food storage policy from 2020 requires food to be stored off the floor, labeled with expiration dates, and kept at appropriate temperatures, but these standards were not met. All 73 residents, except one who is NPO, receive food from the dining room, indicating that these deficiencies could potentially affect all residents in the facility.
Failure to Implement Legionella Risk Reduction Procedures
Penalty
Summary
The facility failed to implement a procedure to reduce the risk of Legionella in its water system, potentially affecting all 73 residents. During a survey, the Maintenance Director was unable to provide documentation or information on Legionella procedures, water system management, or risk assessment. The Maintenance Director admitted to not flushing pipes for Legionella or having a water management plan, only checking water temperatures weekly since February 2024. The Infection Preventionist also stated that they do not manage a Legionella Disease water plan and noted no residents had contracted Legionella. The facility's undated Water Management Program policy outlines the need for procedures to reduce Legionella risk, requiring the Maintenance Director to maintain documentation of the water system and conduct risk assessments, with the Infection Preventionist maintaining related documentation.
Failure to Document COVID-19 Vaccination Efforts
Penalty
Summary
The facility failed to maintain documentation of COVID-19 vaccinations, screening, offering, or education for staff, which has the potential to affect all 73 residents living in the facility. The facility's COVID-19 Vaccine policy, effective January 4, 2021, requires the Infection Control Coordinator to maintain surveillance data on COVID-19 vaccine coverage and make it available to staff as part of educational efforts. However, during a survey conducted from December 18 to December 20, 2024, the Infection Preventionist (IP) was unable to provide any documentation regarding staff COVID-19 vaccinations, screening, offering, or education. The IP admitted to not knowing which staff members were fully vaccinated and stated that they had not screened, educated, or offered the COVID-19 vaccination to staff.
Inadequate Fall Investigations and Documentation
Penalty
Summary
The facility failed to conduct thorough fall investigations for three residents, R15, R48, and R49, as observed during a survey. The Director of Nursing (DON) acknowledged that the details of falls were often missing from the computer system due to inadequate documentation by agency nurses, who comprised about 85% of the nursing staff. The Administrator confirmed that these agency nurses were not diligent in charting and were difficult to contact after their shifts, which contributed to the lack of comprehensive fall investigations. Resident R15 experienced multiple falls, including unwitnessed falls from her chair and bed. The investigations for these incidents lacked root cause analysis, progress notes, and interviews with the resident or staff. Additionally, there were no documented interventions to prevent further falls. R15, who has a history of cerebral infarction and other medical conditions, stated that she does not attempt to get up by herself and requires assistance. Resident R48, diagnosed with vascular dementia and other cognitive impairments, had several witnessed and unwitnessed falls. The investigations for these falls were incomplete, missing root cause analysis, witness statements, and interventions to prevent future incidents. Similarly, Resident R49, who has difficulty walking and other health issues, experienced unwitnessed falls with investigations lacking in fall interventions and staff education on safe transfers. The facility's fall policy requires thorough documentation and analysis of falls, which was not adhered to in these cases.
Survey Results Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that survey results from the past five years were readily accessible to residents, as required by the State Long-Term Care Ombudsman Program and the facility's own policies. During a resident council meeting, several residents expressed that they were unaware of their right to review the facility's survey results and did not know where these results were located within the facility. This indicates a lack of communication and transparency regarding the availability of important regulatory documents. Further investigation revealed that no survey results were available in the facility for residents to review. The administrator and receptionist were unable to locate the survey binder, despite searching in multiple areas, including the front lobby and resident television area. This deficiency affects all 73 residents currently residing in the facility, as documented in the facility's Long-Term Care Facility Application for Medicare and Medicaid CMS 671 Form.
Failure to Notify Residents of Hospital Transfers
Penalty
Summary
The facility failed to document in the residents' Electronic Medical Records or provide written notification to the residents or their representatives regarding the reason for emergent hospital transfers or discharges. This deficiency was identified during an interview and record review, where it was revealed that the facility did not adhere to its own Transfer and Discharge Policy. The policy mandates that residents and their representatives receive appropriate notice of an impending transfer or discharge, including the reason for the transfer, the effective date, and the location to which the resident will be transferred. However, the facility's administrator admitted that no such documentation or notifications were provided. The deficiency has the potential to affect all 73 residents residing in the facility, as the lack of documentation and notification could disrupt continuity of care and violate residents' rights. The facility's administrator acknowledged the issue, citing recent changes at the facility and an inability to locate the necessary paperwork or written notifications. This oversight indicates a systemic failure to comply with established policies designed to ensure residents and their representatives are informed and prepared for transfers or discharges.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide a copy of the Bed Hold Policy notification to residents or their representatives during emergent hospital transfers or discharges. This deficiency was identified through interviews and record reviews, revealing that the facility's Bed Hold Policy, which should be given at admission and upon each transfer, was not provided. The policy states that residents will be readmitted to the first available bed in a semi-private room after hospitalization. Additionally, the facility's Transfer and Discharge Policy and Notice of a Transfer or Discharge Policy require informing residents of their bed hold rights during temporary transfers. However, the administrator admitted that no such notifications were given, citing recent changes and missing paperwork. This oversight potentially affects all 73 residents residing in the facility.
Failure to Post Complete Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the nurse staffing information was posted daily with the required details, including the total nursing hours worked. This deficiency was observed on multiple occasions, where the nurse staffing posting at the receptionist desk did not include the total hours for CNAs, LPNs, or RNs. The administrator confirmed that the form used for nurse staffing did not document the total hours worked by the nursing staff. Additionally, the facility was unable to provide 18 months of nurse staffing postings as required, with only four months available and several specific dates missing. The HR Director, who was responsible for completing the nurse staffing posting after the former administrator left, admitted to not knowing the specific information that needed to be included on the form, including the requirement to total the hours. The postings were not updated to reflect the actual number of nursing staff or the hours worked. This oversight has the potential to affect all 73 residents residing in the facility, as accurate staffing information is crucial for ensuring adequate care and compliance with regulatory requirements.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in two significant incidents involving residents with cognitive impairments. In the first incident, a resident with a history of aggression and cognitive communication deficit physically abused another resident by slamming a door on her hand, causing severe injuries that required hospitalization and surgical intervention. This resident had a documented history of aggressive behaviors, including physical and verbal aggression, yet the facility did not implement effective measures to prevent further incidents or protect other residents. In the second incident, a resident with moderate cognitive impairment was reported to have inappropriately touched another resident with advanced dementia in the dining room. The staff member who witnessed the incident reported it to the nurse, and the residents were separated. However, the investigation concluded with insufficient evidence to substantiate abuse due to the lack of intent and physical or mental distress, despite the staff member's account of the inappropriate contact. Both incidents highlight the facility's failure to adequately monitor and manage residents with known behavioral issues, resulting in harm and potential harm to other residents. The facility's policies on abuse prevention and resident rights were not effectively implemented, leading to these deficiencies.
Deficiency in CNA In-Service Training Compliance
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) completed the required in-service training, which is essential for maintaining their competence. The facility's assessment mandates that CNAs receive at least 12 hours of training annually, including dementia management and abuse prevention. However, the Director of Nursing (DON) was unable to provide proof of completed trainings for the past six months, indicating a lapse in compliance with these requirements. The facility's job description for CNAs also emphasizes the importance of attending in-service training programs, yet the DON admitted that the electronic training records were not up to date. The deficiency was further highlighted by the fact that recent in-service sessions did not have attendance records for all 32 CNAs employed at the facility. This lack of documentation suggests that not all CNAs participated in the mandatory training sessions held on specific dates. The facility currently houses 61 residents, all of whom could potentially be affected by this oversight in training, particularly those with cognitive impairments who require specialized care.
Failure to Protect Resident from Repeated Abuse
Penalty
Summary
The facility failed to implement its Abuse Prevention Program effectively, resulting in repeated physical abuse of a resident. The program's policy, dated 10/2022, mandates the protection of residents from abuse and requires immediate evaluation and separation of residents involved in incidents. However, the facility did not take adequate steps to prevent further abuse after an initial incident where a resident's hands were caught in a door by another resident, leading to injuries. The resident who was injured, identified as R4, has dementia and is known to wander into other residents' rooms. Despite this behavior, the facility did not increase supervision or update care plans to protect R4 after the first incident. Staff members, including CNAs and nurses, acknowledged the difficulty in keeping R4 safe due to her wandering tendencies but did not implement any new interventions to prevent further incidents. The resident who caused the injury, identified as R3, has a history of aggressive behavior and was considered a threat to others. Despite this, no measures were taken to separate R3 from R4 or to provide increased supervision. The facility's inaction led to a second incident where R4's hand was again caught in a door by R3, resulting in fractures. The Director of Nursing confirmed that no interventions were put in place to protect R4 after the first incident, highlighting a significant lapse in the facility's abuse prevention efforts.
Failure to Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to report an allegation of resident-to-resident verbal and physical abuse involving two residents. According to the facility's Abuse Prevention Program policy, employees are required to report any incident, allegation, or suspicion of potential abuse immediately to the administrator or a designated individual. However, an incident occurred where one resident entered another resident's room, leading to verbal aggression and physical harm when the door was slammed on the intruding resident's hand, causing immediate bleeding. This incident was not documented in the facility's list of State Agency Reportables, indicating a failure to report the event as required. The incident involved a resident who frequently exhibited restlessness and agitation, with a history of attempting to harm staff and other residents. The resident showed no remorse for injuring others, as noted in a progress note by the facility's nurse practitioner. Despite the severity of the incident, which included physical injury and potential abuse, the corporate administrator confirmed that the incident should have been reported but was not. This oversight highlights a significant deficiency in the facility's adherence to its abuse prevention and reporting policies.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate a potential allegation of resident-to-resident verbal and physical abuse involving two residents. The incident occurred when one resident entered another resident's room, leading to the second resident becoming agitated and verbally abusive. During the altercation, the second resident slammed the door, causing injury to the first resident's hand. Despite the immediate physical harm observed, the facility did not conduct an investigation into the incident as required by their Abuse Prevention Program policy. The report highlights that the facility's staff, including the Registered Nurse and the Director of Nursing, did not take appropriate action following the incident. The Corporate Administrator confirmed that no investigation was conducted, and the Director of Nursing admitted to not investigating the incident, attributing the behavior to the aggressive tendencies of the resident involved. The lack of investigation was further compounded by the previous administrator's decision not to address the incident, despite it being reported.
Failure to Provide Bed Hold Policy to Resident
Penalty
Summary
The facility failed to provide a copy of the bed hold policy to a resident who was transferred to the hospital. The facility's undated Bed Hold Policy states that if a resident pays to hold their bed, the facility guarantees the availability of a bed upon their return, although it does not assure the same room and bed. The Transfer and Discharge Policy, dated March 2014, specifies that relocation rights, including bed hold and readmission rights, will be maintained in all transfers. However, the clinical record of a resident who was transferred to the hospital did not contain documentation of written notice of the facility's bed hold policy. The Director of Nursing confirmed that the bed hold policy was not provided to the resident.
Facility Fails to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to serve food at a palatable and appetizing temperature, affecting all 68 residents. The facility's policy requires food temperatures to be taken and documented before serving, with corrective actions for foods not at the correct temperature. However, the facility's logs showed that food temperatures were not taken for 29 meals, and a second temperature was not taken before serving for 44 meals. Residents and staff reported that food was often served cold, and the facility's food committee and resident council minutes documented complaints about long wait times and cold food. On the day of the survey, a cook was observed serving cheese pizza from a flat baking sheet without using a steam table or heating element. The pizza was not reheated to the required temperature before being served, with one slice measuring 108 degrees F. Another resident's pizza was served at 78 degrees F without reheating. Staff interviews confirmed that meals were often served cold, with unheated carts used for room trays and food not placed in steam table pans. Residents expressed dissatisfaction with the cold food, describing it as tasteless and hard. Staff members, including CNAs and an RN, corroborated these complaints, noting that residents frequently complained about cold meals. The facility administrator acknowledged that dietary staff were not consistently taking food temperatures as required by policy, and the pizza should have been reheated to 140 degrees F before serving.
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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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