White County Rehab And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Carmi, Illinois.
- Location
- 615 West Webb Street, Carmi, Illinois 62821
- CMS Provider Number
- 146124
- Inspections on file
- 37
- Latest survey
- August 25, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at White County Rehab And Nursing during CMS and state inspections, most recent first.
Multiple residents did not receive timely care, including missed diabetic snacks and delayed bathing assistance, due to insufficient staffing levels. Staff and resident interviews confirmed that with only three or four CNAs on duty, essential care tasks such as snack distribution, showers, and prompt response to call lights were not consistently completed as required by care plans.
Multiple residents with significant medical needs were unable to access hot water for bathing, incontinence care, and hygiene due to a facility-wide hot water system failure. Staff confirmed the absence of hot water in resident areas and had to use alternative methods, such as obtaining hot water from the kitchen, to provide care. The issue persisted for about a week, with maintenance staff identifying a failed water heater element as the cause and no hot water available in resident bathrooms, shower rooms, or the laundry room.
Several residents who were dependent on staff for bathing did not consistently receive showers or bathing assistance as required by their care plans, due to factors such as staff shortages and lack of hot water. Documentation and staff interviews confirmed that scheduled hygiene care was missed for multiple residents with significant physical and cognitive impairments.
Three residents with limited ROM and mobility issues did not receive or have documented restorative care programs, despite care plans and physician orders specifying daily passive and active ROM exercises. Staff interviews confirmed that no structured restorative programs were in place, and ROM activities were only performed incidentally during ADLs. The facility also lacked a reproducible restorative care policy.
Two residents did not receive incontinence care according to facility policy and standards of practice. One was cleaned with dry toilet paper and a wet paper towel instead of approved cleansing products, and another was not properly rinsed or had their buttocks cleaned after incontinence care. In both cases, staff did not follow required procedures for perineal hygiene.
Three residents did not receive prescribed nutritional supplements, such as ice cream or extra protein, as ordered by their physicians and recommended by the dietitian to prevent weight loss. Care plans lacked specific interventions for supplements, and staff failed to provide supplemental items during meal observations, even after dietary recommendations for additional calories due to weight loss.
A resident with stage 4 chronic kidney disease requiring hemodialysis did not have consistent communication and information sharing between the facility and the offsite dialysis center. Documentation in the communication log was incomplete, refusals of dialysis were not always shared with the dialysis provider, and monthly lab results were only obtained when specifically requested by staff, rather than through a routine process.
Two residents with diabetes were not offered bedtime snacks as required, with one resident's care plan specifically calling for diabetic snacks and the other lacking such an intervention. Staff interviews indicated that snacks were not distributed due to insufficient CNA staffing, despite facility policy requiring daily bedtime snacks.
Staff failed to perform hand hygiene between glove changes and after providing incontinence and wound care to three residents, including those with cognitive impairment and incontinence. CNAs and an LPN did not follow the facility's hand washing policy, resulting in lapses in infection control during direct care activities.
A resident was left exposed from the waist down during personal care activities, including perineal and wound care, due to staff failing to pull the privacy curtain and repeatedly opening the door. The resident, who was cognitively intact, expressed feeling exposed and requested to have his pants put on, but the request was denied. The facility's policy on providing privacy during care was not followed.
A resident with multiple health issues, including C-Difficile and an indwelling catheter, did not receive proper perineal, urinary catheter, and wound care. Staff failed to follow infection control policies, such as hand hygiene and using clean materials, leading to inadequate care. Observations included improper handling of soiled materials and inadequate cleaning methods, compromising the resident's care.
A resident with Down syndrome and diabetes was verbally threatened by another resident with mental health disorders during an altercation in the dining room. Despite the incident being reported to the DON and the LPN contacting the threatening resident's physician, an abuse investigation was not initiated immediately, contrary to the facility's policy. The delay in addressing the incident highlights a deficiency in the facility's abuse prevention procedures.
A facility failed to timely investigate a verbal altercation between two cognitively intact residents, one with Down syndrome and diabetes, and the other with major depressive disorder and anxiety. The incident involved threatening comments and was reported to the Administrator in Training, but no investigation was initiated until weeks later. Staff were aware of the altercation and took steps to manage the situation, but the facility did not follow its policy to review such incidents as potential abuse.
The facility failed to ensure staff wore appropriate PPE when caring for COVID-19 positive residents, as required by CDC guidelines. Multiple staff members entered rooms of COVID-19 positive residents wearing only surgical masks, despite signage indicating the need for N95 respirators, gowns, gloves, and eye protection. The facility's DON and Regional Clinical Director acknowledged that many staff members were unable to pass the Respirator Fit Test due to a loss of taste and smell from previous COVID-19 infections, and the facility had only two PAPRs available, which was insufficient for the number of COVID-19 positive residents.
A resident experienced two seizures after a LTC facility failed to administer prescribed seizure medications due to pharmacy delivery issues. The facility did not notify the resident's medical provider or use a backup pharmacy, and lacked emergency medications like injectable Ativan or Valium. This resulted in significant lapses in medication management and emergency preparedness.
A long-term care facility failed to timely acquire medications for residents, resulting in missed doses and potential health risks. A resident with epilepsy did not receive seizure medications on time, leading to seizures. Another resident missed a Trulicity injection due to delivery issues, and two others experienced delays in receiving Vitamin B12 and phenazopyridine. The facility did not follow its pharmacy policy for handling unavailable medications.
A facility failed to implement and reassess behavior interventions for a resident with inappropriate sexual behaviors, despite having a care plan in place. Staff were not adequately educated on handling such behaviors, and there was a lack of consistent monitoring as required by the care plan. Incidents included inappropriate interactions with other residents and visitors, with no new interventions documented in response.
The facility failed to protect residents from abuse, with two incidents involving inappropriate behavior and physical altercation. In one case, a resident reported an inappropriate sexual interaction between two other residents, which was not witnessed by staff and not substantiated due to lack of credible witnesses. In another case, a CNA witnessed a resident slapping another's arm during an altercation, but the incident was not reported to the administrator. The facility's policy on abuse prevention was not effectively implemented, leading to a deficiency in resident protection.
The facility failed to report allegations of resident-to-resident abuse in a timely manner. In one case, a CNA witnessed a resident slap another but did not report it, assuming the LPN would. In another, a CNA was informed by a resident of alleged inappropriate contact but the RN did not report it, as it was hearsay. The administrator was unaware of both incidents until informed by a surveyor days later.
The facility failed to protect residents from abuse, resulting in two incidents. A resident in a wheelchair was physically assaulted by another resident in the dining room, causing fear and distress. In a separate incident, another resident experienced unwanted physical contact from a non-English speaking resident who entered her room and kissed her. The facility did not investigate these incidents as abuse, instead categorizing one as a wandering event, despite the residents' expressed discomfort and fear.
A cognitively intact resident with a history of Paranoid Schizophrenia and Cerebral Infarction was allegedly kissed twice by another resident during an incident. The facility's administrator classified the event as a wandering incident and did not report it to the State Agency, failing to adhere to the facility's policy on reporting alleged violations.
A resident reported being kissed without consent by another resident, but the facility failed to investigate the incident as sexual abuse. Despite staff awareness and reports, the facility only investigated the event as a wandering incident, neglecting its policy to thoroughly investigate all alleged violations.
A resident's assessment was incomplete due to a language barrier, as the staff could not communicate effectively with the resident who speaks Haitian. The Social Services Director did not use available interpreter services or involve the resident's son, who usually translates, leading to incomplete sections in the MDS. This resulted in an inaccurate assessment of the resident's cognitive patterns, mood, and behavior.
Failure to Provide Sufficient Nursing Staff for Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple instances where residents did not receive required care in a timely manner. Several residents with diabetes did not consistently receive prescribed snacks at night, with both residents and CNAs reporting that staffing shortages prevented the distribution of snacks as ordered in care plans. One resident specifically stated not receiving nightly diabetic snacks, and staff confirmed that on certain shifts, there were not enough CNAs to complete all required tasks, including snack distribution. Additionally, residents dependent on staff for bathing did not consistently receive assistance according to their care plans, which specified showers or baths at least twice weekly. Documentation and interviews revealed gaps of up to nine days between bathing assistance for some residents, and staff attributed these lapses to insufficient staffing levels. Multiple CNAs reported that with only three or four CNAs on duty, they were unable to provide timely showers or meet all residents' needs, resulting in delays and missed care. The Director of Nursing acknowledged that residents should be offered bathing assistance twice a week but was unable to provide evidence that this standard was consistently met. Staff interviews further indicated that call lights were not answered promptly, incontinence care was delayed, and overall resident care was not provided as required due to inadequate staffing. The facility's own staffing policy requires sufficient staff to meet residents' needs based on assessments and care plans, but the documented events and staff statements demonstrate that this standard was not maintained.
Failure to Provide Hot Water for Resident Care and Hygiene
Penalty
Summary
The facility failed to provide hot water for resident use in multiple areas, affecting at least five residents who were reviewed for hot water access. Residents with various medical conditions, including cerebral palsy, morbid obesity, diabetes, chronic kidney disease, COPD, Crohn's disease, heart failure, and Huntington's Disease, reported not having hot water available for bathing, incontinence care, and personal hygiene. Several residents, all of whom were cognitively intact, stated they had not been able to shower for about a week due to the lack of hot water, and staff confirmed the absence of hot water in resident bathrooms, shower rooms, and the laundry room. Observations and interviews revealed that staff had to use alternative methods, such as obtaining hot water from the kitchen, to provide resident care. Certified Nursing Assistants (CNAs) reported washing hands in cold water in resident bathrooms and then re-washing in areas with hot water, as well as using basins of hot water from the kitchen for resident care. The Maintenance Director confirmed that the hot water had not been working since a specific date, and temperature checks in various rooms showed water temperatures well below the facility's policy for comfortable resident use. The breakdown of the hot water system was traced to a tripped breaker and a failed element in the hot water heater, with the necessary replacement part ordered but not yet delivered. Facility records showed that prior to the failure, water temperatures were within the required range. However, after the breakdown, no further temperature checks were conducted by maintenance, and the lack of hot water persisted throughout the facility, impacting resident care and daily living activities.
Failure to Provide Scheduled Bathing Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide showers for residents who required assistance with activities of daily living (ADLs), specifically bathing, for four out of five residents reviewed. Documentation and interviews revealed that residents with significant physical and cognitive impairments, including those with cerebral palsy, morbid obesity, diabetes, amputations, chronic pain, osteoarthritis, visual loss, and dementia, did not consistently receive bathing assistance as outlined in their care plans. These care plans specified that residents were to be assisted with showers or baths at least twice a week and as necessary, yet records showed gaps of up to nine days without bathing assistance for some residents. Multiple residents reported not receiving showers as scheduled, citing reasons such as staff shortages and lack of hot water. Staff interviews corroborated these accounts, with several CNAs stating that when staffing levels were low, they were unable to provide showers to all residents as required. One resident specifically refused showers due to the absence of hot water, and staff confirmed that on certain days, no residents received showers, with only minimal hygiene care provided instead. The Director of Nursing acknowledged that there was no reproducible evidence that the affected residents were offered bathing assistance during the identified periods. The facility's own policy required that showers, baths, or bed baths be offered per regulation and resident preference, but this was not consistently followed. The deficiency was identified through a combination of record review, resident interviews, and staff statements, all indicating a failure to meet the established standard of care for resident hygiene.
Failure to Provide and Document Restorative ROM Programs
Penalty
Summary
The facility failed to provide appropriate restorative care programs for three residents with limited range of motion (ROM) and mobility issues. Each resident had documented care plans or physician orders indicating the need for daily passive and active ROM exercises to maintain or improve their mobility. However, interviews with Certified Nursing Assistants (CNAs), the Director of Nursing (DON), and the Director of Rehab revealed that there were no specific or documented restorative programs in place. Instead, staff reported that any ROM activities were only performed incidentally during activities of daily living (ADLs), rather than as part of a structured restorative program. The facility also lacked a reproducible policy for restorative care. The residents involved had significant medical histories, including cerebral palsy, morbid obesity, diabetes, chronic pain syndrome, repeated falls, muscle weakness, multiple sclerosis, and dependence on a wheelchair. Assessments and care plans documented their cognitive status and functional limitations, with explicit interventions for daily ROM exercises. Despite these documented needs, there was no evidence of restorative care being administered or documented in the seven days prior to the survey, as confirmed by both staff interviews and resident statements.
Failure to Provide Proper Incontinence Care and Hygiene
Penalty
Summary
The facility failed to provide incontinence care according to current standards of practice for two residents. One resident with diagnoses including cerebral palsy, morbid obesity, diabetes, and urinary incontinence was found lying in bed with a strong odor of urine. The resident's incontinence brief was wet, and care was provided using dry toilet paper and a wet paper towel to clean feces from the buttocks, rather than using appropriate cleansing products as per facility policy. The resident was left to finish a bowel movement on a depend pad, and the care provided did not follow the expected procedure for perineal hygiene. Another resident with functional urinary incontinence and a moderate cognitive deficit was found with a saturated incontinence brief. The CNA used a shampoo/body soap directly on a wet washcloth to clean the groin area, but did not rinse the area as required when the product is applied directly to the body. The buttocks were not washed, rinsed, or dried, and the CNA exited the room without performing hand hygiene. The facility's policy requires cleansing all affected areas with appropriate products and rinsing when necessary, which was not followed in these instances.
Failure to Provide Prescribed Nutritional Supplements to Prevent Weight Loss
Penalty
Summary
The facility failed to ensure that residents received nutritional supplementation as recommended by the dietitian and ordered by the physician, resulting in three residents not receiving prescribed supplements to prevent weight loss. For one resident with muscle wasting and severe cognitive impairment, the care plan did not include interventions related to nutritional supplements or weight loss, despite a physician order for ice cream twice daily as a supplement. Observations showed that this resident was not served ice cream with meals until prompted by surveyors, and was not provided a second helping of ice cream when an ice cream sandwich was served as dessert, contrary to the dietitian's recommendations for supplemental calories. Another resident with diabetes, heart disease, and moderate cognitive deficit also had a physician order for ice cream twice daily as a supplement, following a period of weight loss. The care plan did not specify which supplements were to be provided. Observations revealed that this resident was not served ice cream with meals as ordered, and did not receive a second helping of ice cream when an ice cream sandwich was served as dessert. The dietary manager and dietitian confirmed that the residents should have received both the dessert and the supplemental ice cream, as the supplement was intended to provide additional calories due to weight loss. A third resident with chronic kidney disease and dietary restrictions was not provided the required extra ounce of protein per meal as ordered. When the resident refused the main meal, the substitute meal provided (chicken noodle soup and a peanut butter sandwich) was not equivalent in protein content to the prescribed supplement. The facility's policy stated that nutritional supplements should be incorporated into care plans and provided as needed, but this was not consistently implemented for the residents reviewed.
Failure to Maintain Consistent Communication with Dialysis Center
Penalty
Summary
The facility failed to maintain effective communication and collaboration with an offsite dialysis center for a resident with chronic kidney disease, stage 4, who required hemodialysis. The resident's care plan included specific interventions related to dialysis, such as monitoring labs and encouraging attendance at scheduled treatments. However, the facility's process for sharing information with the dialysis center was inconsistent, as evidenced by incomplete documentation in the communication log sent with the resident to dialysis appointments. When the resident refused dialysis, this was only recorded in the facility's progress notes and not communicated in the binder shared with the dialysis center. Additionally, the facility did not routinely receive monthly laboratory results from the dialysis clinic unless specifically requested. The registered dietitian reported a lack of direct communication with the dialysis unit and did not receive lab results unless nursing staff intervened. The director of nursing confirmed that obtaining the resident's lab work required a special request to the dialysis clinic, indicating that regular, systematic communication and information sharing between the facility and the dialysis provider was lacking.
Failure to Provide Bedtime Snacks Due to Staffing Shortages
Penalty
Summary
The facility failed to ensure that bedtime snacks were offered to two residents who were reviewed for snacks. One resident, who had a diagnosis of diabetes and a moderate cognitive deficit, was care planned to receive diabetic snacks between meals and at bedtime per diet orders. This resident reported not receiving snacks at night, despite being diabetic and supposed to have a nightly snack. The other resident, with multiple diagnoses including diabetes and who was cognitively intact, also reported not receiving a snack the previous night. This resident's care plan did not include an intervention related to diabetic snacks. Interviews with several CNAs revealed that snacks were not passed on the evening in question due to staffing shortages, with staff stating they did not have the manpower or time to distribute snacks as usual. The facility's policy stated that bedtime snacks should be offered daily and that dietary staff would deliver supplements to each nursing station for distribution. The DON stated there had been no complaints related to snacks not being offered.
Failure to Perform Hand Hygiene Between Glove Changes During Resident Care
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed according to current standards for three residents during care activities. In one instance, a CNA provided incontinence care to a resident with cerebral palsy, morbid obesity, diabetes, and urinary incontinence, but did not perform hand hygiene between glove changes while cleaning the resident after a bowel movement. In another case, a CNA assisted a resident with functional urinary incontinence and moderate cognitive deficit with incontinence care, but failed to perform hand hygiene after removing soiled gloves and before donning clean gloves, and also exited the room without performing hand hygiene. Additionally, the CNA did not properly wash, rinse, or dry the resident’s buttocks after care. A third incident involved an LPN administering wound care to a resident with muscle wasting and severe cognitive impairment. The LPN changed gloves between treating different areas but did not perform hand hygiene after doffing gloves and before donning a new pair. The facility’s own hand washing policy requires hand hygiene before and after resident care and after glove removal, but these procedures were not followed during the observed care activities.
Failure to Provide Privacy During Resident Care
Penalty
Summary
The facility failed to ensure privacy for a resident during personal care activities, including perineal, urinary catheter, and wound care. The resident, who was cognitively intact and had a history of enterocolitis, skin infection, and hemiplegia, was left exposed from the waist down multiple times during care. Certified Nursing Assistants (CNAs) and a Licensed Practical Nurse (LPN) were involved in the care process, during which the privacy curtain was not pulled, and the door was opened several times, leaving the resident exposed. The incident occurred over approximately one hour, during which the resident expressed feeling exposed and requested to have his pants put on, but the request was denied. The Director of Nursing later confirmed that the expectation was for staff to provide privacy during care. The facility's policy on perineal and incontinence care, which includes providing privacy, was not followed, leading to the deficiency.
Inadequate Infection Control Practices During Resident Care
Penalty
Summary
The facility failed to provide proper perineal, urinary catheter, and wound care for a resident, identified as R1, who was admitted with diagnoses including enterocolitis due to clostridium difficile, local infection of the skin and subcutaneous tissue, flaccid hemiplegia, and cerebral infarction. R1 was cognitively intact and dependent on staff for toileting hygiene and transfers. The care plan for R1 included interventions for infection control due to C-Difficile and the presence of an indwelling urinary catheter, emphasizing good hand hygiene and enhanced barrier precautions. On the day of observation, two CNAs, V4 and V5, assisted R1 from a wheelchair to a bed using a mechanical lift. During this process, V5 removed R1's soiled pants and placed the urinary catheter collection bag on the fitted sheet. V5 used a disposable under pad sprayed with peri wash to clean feces from R1's body, employing a wipe and wad method, which left feces on the urinary catheter tubing. V5 changed gloves without performing hand hygiene and continued cleaning R1 with the same method. V5 also handled the peri wash bottle with soiled gloves and did not prevent traction on the urinary catheter tubing, causing it to move in and out of the urethra. Later, an LPN, V8, entered the room to perform wound care, placing supplies on an uncleaned bedside table and a feces-soiled cloth pad. V8 and V4 continued to handle supplies and assist R1 without proper hand hygiene. Additional CNAs, V6 and V7, entered the room, and V7 attempted to put the urinary catheter collection bag through a pant leg without realizing the privacy cover was soiled with feces. Throughout the process, staff failed to follow the facility's infection control policies, including proper hand hygiene, use of clean materials for each area cleansed, and maintaining a clean environment for wound care.
Failure to Prevent Verbal Abuse Between Residents
Penalty
Summary
The facility failed to ensure that residents were free from verbal abuse, as evidenced by an incident involving two residents, R1 and R2. R2, who has Down syndrome and diabetes, and R1, who has major depressive disorder, anxiety, and delusional disorders, were involved in a verbal altercation. R1, who is cognitively intact, threatened R2 with physical harm during an argument in the dining room. The incident was documented by an LPN, who reported that R1 was yelling and using abusive language towards R2. Despite the altercation being reported to the Director of Nursing (DON) and the LPN contacting R1's physician, an abuse investigation was not initiated immediately as per the facility's policy. The facility's policy requires that any resident-to-resident altercation be reviewed as a potential abuse situation. However, the Administrator in Training, who was informed of the incident by R2, did not start an abuse investigation. The facility's policy emphasizes the residents' right to be free from abuse, including verbal aggression. The failure to initiate an investigation promptly after the incident on 12/20/2024, and the delay in documenting the event until 1/7/2025, highlights a deficiency in the facility's adherence to its abuse prevention and response procedures.
Failure to Timely Investigate Resident Altercation
Penalty
Summary
The facility failed to timely initiate an investigation for an abuse allegation involving two residents, R1 and R2. R2, who has Down syndrome and diabetes, reported a verbal altercation with R1, who has major depressive disorder, generalized anxiety disorder, and delusional disorders. Both residents were cognitively intact at the time of the incident. The altercation occurred in the dining room, where R1 reportedly made threatening comments to R2. R2 reported the incident to the Administrator in Training (V5), but no investigation was initiated at that time. The incident was documented in the facility's progress notes, and staff members, including a Licensed Practical Nurse (V9), were aware of the altercation. V9 contacted the Director of Nursing (V2) and took steps to separate the residents and contact R1's physician. R1 was eventually sent to a local hospital for evaluation. Despite these actions, the facility did not follow its policy to review resident-to-resident altercations as potential abuse situations, and an investigation was not initiated until several weeks later, on January 7, 2025.
Inadequate PPE Usage in COVID-19 Positive Resident Care
Penalty
Summary
The facility failed to ensure that staff donned Personal Protective Equipment (PPE) in accordance with CDC recommendations for infection control practices, which has the potential to affect all 54 residents residing in the facility. Multiple instances were observed where staff entered rooms of COVID-19 positive residents without wearing the required PPE, such as N95 respirators, gowns, gloves, and eye protection. For example, two Certified Nurse Assistants (CNAs) were seen entering a COVID-19 positive resident's room wearing only surgical masks, despite the presence of signage indicating the need for additional PPE. The report highlights several cases where staff either failed to wear the appropriate PPE or were not fit tested for N95 masks. One CNA mentioned that she failed the fit test because she could not smell the solution used during the test, while another CNA stated she had never been fit tested despite working at the facility for two years. Additionally, a housekeeper was observed in a COVID-19 positive resident's room wearing only a surgical mask, and a transportation aide was seen transporting a COVID-19 positive resident without the required PPE. The facility's Director of Nursing (DON) and Regional Clinical Director acknowledged the issue, noting that many staff members were unable to pass the Respirator Fit Test due to a loss of taste and smell from previous COVID-19 infections. The facility had only two Powered Air Purifying Respirators (PAPRs) available, which was insufficient for the number of COVID-19 positive residents. The facility's policy and CDC guidelines require the use of N95 respirators or PAPRs, gowns, gloves, and eye protection when caring for COVID-19 positive residents, but these were not consistently adhered to by the staff.
Failure to Administer Seizure Medications Leads to Resident Seizures
Penalty
Summary
The facility failed to obtain and administer scheduled seizure medications for a resident, resulting in the resident experiencing two seizures. Upon admission, the resident did not receive their prescribed anti-seizure medications, including Vimpat, Keppra, and Trileptal, due to the facility's inability to secure these medications from the pharmacy. The resident, who had a history of seizures and was severely cognitively impaired, missed multiple doses of these critical medications, leading to two seizures on the same day. The facility's staff, including the Director of Nursing and a Licensed Practical Nurse, were unaware of the medication delivery status and failed to notify the resident's medical provider about the unavailability of the medications. The facility's pharmacy did not deliver the medications until after the resident had already missed several doses, and there was no evidence of the facility contacting the pharmacy for a STAT delivery or using a backup pharmacy. Additionally, the facility lacked emergency medications such as injectable Ativan or Valium, which could have been used to manage prolonged seizures. The facility's policies for handling unavailable medications were not followed, and there was a lack of communication between the facility, the pharmacy, and the resident's medical provider. The failure to administer the prescribed seizure medications and the absence of emergency medications in stock contributed to the resident's seizures, highlighting significant lapses in medication management and emergency preparedness.
Removal Plan
- The provider was notified of the resident's seizure history and order for PRN medication received.
- Review of residents with seizure disorder and last seizure date completed.
- Care Plans have been reviewed and reflect current seizure/epilepsy standards.
- Licensed Nursing staff educated on: A. What to do if a medication is not available. B. Pharmacy process for ordering medication and checking on order status using the pharmacy portal, phone, and messaging system. C. How to use the emergency stock medication. D. Updated Seizure policy. E. New admission clarification for need for PRN medication. F. Physician notification when medication not available. G. Delivery needs for any significant medication with any new admit.
- Review of emergency stock medication inventory by facility Physician/Medical Director.
- Facility to ensure review of admission to include review of potential residents with a history of seizure/other dx that could have a significant impact without medication prior to admission and if applicable, ask provider if any medications are not available, what substitutions can be made based on availability of medication in the emergency stock medication or if medication can be placed on hold.
- Facility to ensure continued compliance, Preadmission screen/admission question to provider if PRN antiseizure medication/medication that could have a significant impact without its administration is needed for new admission and then present to the QAPI for review. Audits will continue based on the recommendations of the QAPI on review of the admission audit findings.
Medication Acquisition Failures in LTC Facility
Penalty
Summary
The facility failed to implement procedures for the timely acquisition of medications for several residents, leading to missed doses and potential health risks. Resident 1, who was admitted with a history of epilepsy, did not receive their prescribed seizure medications, Keppra, Trileptal, and Vimpat, on time due to delays in delivery from the pharmacy. The medications were ordered late in the evening, and the facility did not have a process in place to obtain them from a backup pharmacy or request a stat delivery. This resulted in Resident 1 experiencing seizures during the first week of admission. The documentation errors by the nursing staff further complicated the situation, as incorrect administration records were noted. Resident 7, who was admitted with type 2 diabetes mellitus, did not receive their scheduled Trulicity injection due to a failure in the delivery process. The Director of Nursing (DON) did not follow the facility's pharmacy policy to request a stat delivery or obtain the medication from a backup pharmacy. Instead, the DON opted to hold the medication until the next day after consulting with the resident's medical provider. This delay in medication administration was not in line with the facility's established procedures for handling unavailable medications during a med pass. Residents 5 and 4 also experienced issues with medication availability. Resident 5 did not receive their Vitamin B12 tablets due to a lack of clarity on whether the medication was automatically refilled or needed manual reordering. Similarly, Resident 4 missed a dose of phenazopyridine because the medication was not ordered from a backup pharmacy or requested for stat delivery. The facility's pharmacy policy outlines steps to prevent such occurrences, but these were not followed, leading to the deficiencies noted in the report.
Failure to Implement and Reassess Behavioral Interventions for Resident
Penalty
Summary
The facility failed to implement and reassess behavior interventions for a resident with inappropriate sexual behaviors. The resident, who has diagnoses including metabolic encephalopathy, epilepsy, and cerebral infarction, was documented as rarely or never understood. Despite having a care plan that included monitoring behaviors and implementing interventions, the facility did not update the care plan with new interventions after incidents of inappropriate sexual behavior occurred. These incidents included the resident following another resident into a room and kissing them, as well as an alleged incident of mutual inappropriate touching with another resident. Staff interviews revealed a lack of awareness and education regarding the resident's inappropriate behaviors. Several staff members, including CNAs and an LPN, reported not having received education on how to handle such behaviors or what constitutes sexually inappropriate behavior. There were also reports of the resident attempting to inappropriately touch a visitor's granddaughter and a housekeeper, with the latter reporting two separate incidents to the administrator. However, there was no evidence of new interventions being implemented in response to these incidents. Observations indicated that the facility did not consistently perform 15-minute checks on the resident as required by the care plan. Staff were unsure of the resident's whereabouts, and there was no documentation of the checks being completed. The facility's policy requires the care planning team to develop individualized comprehensive care plans, but the lack of updated interventions and consistent monitoring suggests a failure to adhere to this policy, contributing to the deficiency in providing necessary behavioral health care and services.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from resident-to-resident abuse, as evidenced by two incidents involving inappropriate behavior and physical altercation. In the first incident, an alleged inappropriate sexual interaction occurred between two residents, R4 and R1, as reported by another resident, R5. Despite R5's severe cognitive impairment, he provided a detailed account of the incident, which was not witnessed by staff. The facility's investigation did not substantiate the allegation due to the lack of credible witnesses and the inability to interview the involved residents, who were both marked as rarely or never understood. In the second incident, a physical altercation occurred between R4 and R2. A CNA witnessed R4 attempting to move R2, resulting in R4 allegedly slapping R2's arm. The incident was not reported to the administrator by the witnessing CNA or the LPN who intervened, as both assumed the other would report it. The facility's investigation concluded that R4 did not intentionally harm R2, and the allegation of abuse was not substantiated. Both residents involved were marked as not interviewable, and no injuries were observed. The facility's policy on resident rights to freedom from abuse, neglect, and exploitation was not effectively implemented, as staff failed to report and adequately address the incidents. The policy requires staff to monitor and report behaviors that may provoke reactions, including physically and sexually aggressive behaviors. The facility's failure to ensure proper reporting and investigation of these incidents highlights a deficiency in protecting residents from abuse.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report allegations of resident-to-resident abuse in a timely manner to the administrator and the State Agency for three residents. In the first incident, a Certified Nursing Assistant (CNA) witnessed a resident, R4, slap another resident, R2, in the dining room. The CNA did not report the incident to the administrator, assuming that the Licensed Practical Nurse (LPN) present would do so. However, the LPN also failed to report the incident, believing it was the CNA's responsibility. As a result, the administrator was not informed of the incident until two days later when the surveyor inquired about it. In the second incident, a CNA was informed by another resident that R4 had allegedly touched and kissed resident R1. The CNA moved R1 to the nurse's station and reported the allegation to a Registered Nurse (RN). The RN, however, did not report the incident to the administrator, as it was based on hearsay and not directly witnessed by staff. Consequently, the administrator was again unaware of the incident until informed by the surveyor four days later. Both incidents were not reported in accordance with the facility's policy, which requires immediate notification of the administrator for any allegations of abuse.
Failure to Protect Residents from Abuse and Unwanted Contact
Penalty
Summary
The facility failed to protect residents from abuse, resulting in two incidents involving residents R10 and R12. In the first incident, R10, who is cognitively intact and uses a wheelchair, was attacked by another resident, R1, in the dining room. R1, who also has a BIMS score indicating cognitive intactness, became agitated and physically assaulted R10 by hitting him on the head multiple times. This attack was witnessed by several staff members and other residents. Despite the presence of staff, it took several of them to separate R1 from R10. The incident left R10 feeling fearful and unsafe in the facility. In the second incident, R12, who is also cognitively intact, was subjected to unwanted physical contact by another resident, R8. R8, who does not speak English, entered R12's room, sat on her bed, and kissed her twice on the lips. R12 and her roommate, R6, reported the incident to staff, but R8 continued to enter their room on multiple occasions. The facility's response was to redirect R8 back to his room, but there was no investigation into the incident as abuse. Instead, it was categorized as a wandering event, despite R12 expressing discomfort and fear about R8's actions. The facility's failure to adequately address these incidents of abuse and unwanted contact highlights a deficiency in ensuring the safety and well-being of its residents. The lack of a thorough investigation and appropriate categorization of the incidents as abuse demonstrates a significant oversight in the facility's duty to protect residents from harm. The facility's abuse policy states that residents have the right to be free from abuse, yet the actions taken in these cases did not align with this policy.
Failure to Report Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the State Agency involving a resident, R12, who was allegedly kissed twice by another resident, R8, during an incident. R12, who is cognitively intact with a BIMS score of 15, has a medical history including Paranoid Schizophrenia and Cerebral Infarction. The incident occurred when R8 followed R12 to their room, sat on R12's rollator, and later returned to sit on R12's bed, where the alleged kissing occurred. R6, another resident, witnessed the event and called for staff assistance. The facility's administrator, V1, acknowledged that no investigation for abuse was conducted, and the incident was classified as a wandering event rather than resident-to-resident sexual abuse. Despite the facility's policy requiring reporting of alleged violations within required timeframes, V1 confirmed that the incident was not reported to the State Agency. The facility's policy on residents' rights to freedom from abuse, neglect, and exploitation was not adhered to in this case.
Failure to Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to identify and investigate an allegation of sexual abuse involving a resident, R12, who was reportedly kissed by another resident, R8, without consent. R12, who is cognitively intact, reported that R8 entered her room, closed the curtain, sat on her bed, and kissed her twice on the lips. This incident was witnessed by another resident, R6, who also reported the event to staff members, including CNAs V10 and V12. Despite these reports, the facility did not conduct a thorough investigation into the alleged sexual abuse. The facility's administrator, V1, acknowledged that an investigation was not conducted for the alleged abuse but rather for a wandering incident involving R8. The administrator had documented interviews with R6 and R12 but did not pursue further investigation into the sexual abuse claims. The facility's policy requires that all alleged violations be thoroughly investigated, but this was not adhered to in this case. Staff members, including CNAs and an LPN, were aware of the incident and reported it to their supervisors. However, the facility did not take appropriate steps to investigate the allegations or protect the residents from further potential abuse. The lack of a comprehensive investigation and failure to recognize the incident as potential sexual abuse constitutes a deficiency in the facility's response to resident safety and rights.
Language Barrier Leads to Incomplete Resident Assessment
Penalty
Summary
The facility failed to accurately assess a resident, identified as R8, due to a language barrier. R8's Minimum Data Set (MDS) was incomplete, with sections C, D, and E containing only dashes, except for a few entries. The MDS Coordinator, V21, stated that she does not complete these sections, which are handled by the Social Services Director, V3. V3 admitted that she could not obtain answers from R8 during the assessment because they could not understand each other, as R8 speaks Haitian. Despite this communication barrier, V3 did not seek assistance from R8's son, who usually translates, nor did she use any healthcare hotline numbers for interpreter services. Instead, she attempted to use a picture board on her phone, which R8 did not engage with. V3 also mentioned that she had to select an option in the section regarding hallucinations and delusions because the MDS program required it to be completed. The Resident Assessment Instrument (RAI) manual emphasizes the importance of overcoming language barriers to prevent issues such as social isolation and inaccurate assessments. The facility's failure to provide an interpreter or alternative communication methods resulted in an incomplete and potentially inaccurate assessment of R8's cognitive patterns, mood, and behavior, as required by the RAI manual.
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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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