Willows Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Rockford, Illinois.
- Location
- 4054 Albright Lane, Rockford, Illinois 61103
- CMS Provider Number
- 146101
- Inspections on file
- 23
- Latest survey
- January 26, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Willows Health Center during CMS and state inspections, most recent first.
An LPN worked on multiple shifts while their nursing license was under suspension, and the facility did not prevent this, affecting all residents present on those days. Facility records showed that the LPN’s license was suspended according to the state licensing agency, yet timesheets confirmed the LPN worked during the suspension period while the census reflected dozens of residents in the building. Human Resources later stated the LPN had not disclosed the suspension and acknowledged that nurses should not work when their licenses are suspended, consistent with state licensing guidance prohibiting practice during a suspension.
A resident admitted with multiple health conditions and requiring maximum assistance developed a new unstageable pressure ulcer on the left heel after admission. Initial skin checks did not reveal any issues, but the ulcer was discovered by staff about a week later. Although the care plan included ace wraps, skin monitoring, and pressure-relieving interventions, the ulcer developed between weekly skin checks, and daily full inspections of the feet may not have been performed.
The facility failed to ensure a safe environment and adequate supervision for two residents at high risk for accidents. A resident with Alzheimer’s disease, dementia, anxiety, weakness, and a prior hip fracture, care planned as high fall risk and requiring extensive ADL assistance and a mechanical lift, was noted by staff to be extremely restless and repeatedly trying to stand from a wheelchair with a quiet chair alarm. She was left unsupervised at the nurses’ station while staff attended to another resident, during which time she fell, was found on the floor with head bleeding and severe right leg pain, and was later diagnosed with an acute displaced right femoral fracture. Another resident with Parkinson’s disease and dementia, whose hospital SLP plan required 1:1 feeding assistance and prohibited straw use due to aspiration risk, was repeatedly observed with cups of liquid and straws at bedside and on meal trays, while staff acknowledged that hospital transfer and SLP recommendations, including no straws, should have been followed.
Surveyors found that food was not stored or handled in a sanitary manner and that cooking areas were not kept clean. An opened box of French baguettes, including an unwrapped baguette, was stored directly under a condenser/evaporator in the walk-in freezer, with ice build-up on the box, contrary to facility policy requiring covered, labeled, and properly contained food. The exhaust hood over the cooking area had visible dust and debris on the fire suppression lines above the cooking surfaces, despite written procedures and maintenance responsibilities for regular cleaning of such equipment.
The facility failed to provide meaningful, individualized activities to multiple residents with dementia, particularly on weekends. Several residents with Alzheimer’s dementia or other cognitive impairments were observed sitting in wheelchairs or recliners in front of the TV, asleep or simply looking around, with no engagement in the structured activities listed on the memory care activity calendar. Some residents’ care plans documented impaired cognitive function/dementia but contained no activity interventions, while another resident’s plan noted dependence on staff for leisure pursuits but individual visits were not observed. An LPN and several CNAs reported there were no activities on weekends in the dementia unit and that they only tried to talk with residents or help with puzzles or reading in between nursing tasks. Leadership staff confirmed there was no activity staff on weekends, despite a facility policy stating that meaningful, ability-centered activities for residents with cognitive or memory diseases are to be continually available.
A resident had a PRN order for sublingual Ativan for anxiety that was entered without a required stop date, contrary to facility policy and regulatory expectations. The Nurse Manager, who oversees psychotropic meds, reported he was unaware the order lacked a stop date and stated the order was carried out by hospice staff and should have been clarified. He later produced a separate document for the antianxiety order that was not present in the resident’s medical record, despite his statement that all psych meds with stop dates should be reflected there.
A resident with Parkinson’s disease, dementia, and an ADL self-care deficit requiring staff assistance was observed to be confused, very restless, and repeatedly stating the need to use the bathroom while partially out of bed. After the call light was activated, a CNA not assigned to the unit entered 12 minutes later, turned off the call light, and left to find the assigned CNA. An RN appeared briefly at the doorway and left, and two CNAs did not arrive to assist with toileting until about 20 minutes after the call light was activated, despite the resident’s ongoing attempts to get up. Staff later stated that the goal was to answer call lights within 15 minutes, and facility policy required timely response and assistance with bathroom needs and notification of a supervisor if timely response was not possible.
A resident admitted for rehab after brain surgery with a history of subdural hematoma and craniotomy was care planned as at risk for weight loss with a goal to maintain current weight and had a physician order for weekly weights. Facility records showed significant weight loss over several weeks, a missed weekly weight with no documentation of refusal, and no notification to the dietitian despite instructions to report continued weight loss. The dietitian confirmed she was not informed of the ongoing decline and that the resident should have been weighed weekly, while the resident, who was alert and cognitively intact, reported substantial weight loss and decreased appetite following surgery.
Two residents did not receive ordered medications because staff failed to ensure drug availability and timely administration. One resident missed multiple doses of D‑Mannose and Simvastatin when an RN found the medications were not in the pharmacy delivery or stock cart, and documentation showed they were not given due to unavailability. Another resident with Parkinson’s disease did not receive a scheduled bedtime dose of carbidopa‑levodopa, even though it was available in the stock system, and also missed doses of a prescribed statin when it was not obtained from the pharmacy. Staff interviews confirmed that required steps such as using stock medications, requesting STAT delivery, or securing medications from a local pharmacy or family were not consistently followed.
Staff failed to follow infection prevention and control requirements when a resident on contact and droplet precautions for COVID-19 had clearly posted signage and PPE available at the doorway, yet a CNA entered the room with no PPE and an occupational therapist entered without eye protection, contrary to facility policy and the infection preventionist’s expectations. In a separate case, a resident with a PICC line in place after IV antibiotic therapy was not placed on Enhanced Barrier Precautions, with no related orders, signage, or PPE cart outside the room, despite facility policy and the infection preventionist’s statement that residents with indwelling IV access should be on EBP.
Two residents who were eligible for pneumococcal vaccination did not have documentation showing they were offered or received the recommended PCV vaccines according to CDC guidelines. One resident had no pneumococcal vaccine documented despite being over 65 and reporting a prior PPSV23 dose, and another had only a PPSV23 dose recorded with no subsequent PCV dose. The facility’s policy states that recommended vaccines, including PCV20 or PCV15 plus PPSV23, must be offered and administered to eligible residents, and that all immunizations, refusals, and contraindications must be documented, but this was not reflected in these residents’ records.
A nurse administered liquid Ativan, prescribed for one resident, to another resident who did not have a physician's order for this medication form. The act was observed by a CNA, confirmed by video evidence, and not properly documented. This resulted in a medication error, unauthorized administration of a controlled substance, and violation of resident rights and safety standards.
A nurse administered a liquid form of Ativan to a resident without a physician's order, using another resident's medication to manage agitation and anxiety. The medication was not listed on the resident's MAR, and staff interviews confirmed the medication was given without proper authorization, violating facility policy on medication administration.
The facility failed to thoroughly investigate an allegation of narcotic misappropriation involving four residents. An agency LPN, who worked one day, was accused of drug diversion, but the facility did not report the incident to authorities or conduct comprehensive audits and interviews. Discrepancies in narcotic counts were noted, and the LPN exhibited erratic behavior, but the facility did not adhere to its policy for investigating medication discrepancies.
A facility failed to conduct a required narcotic count at shift change, affecting a resident prescribed controlled substances. An RN arrived late and did not perform the count, leading to discrepancies discovered the next morning. An LPN involved exhibited unusual behavior and was escorted out. The facility's policy requires narcotic counts at each shift change, but records showed missing signatures, indicating non-compliance.
A resident with multiple medical conditions, including a history of falls, slid out of bed while reaching for juice, leading to a hospital visit for a suspected bleed. The incident occurred after a CNA left the resident sitting on the bed for over an hour, despite her poor sitting balance. The care plan did not address her sitting balance issues, and staff interviews indicated a lack of active monitoring during the incident.
The facility failed to update infection control policies to include Enhanced Barrier Protection (EBP) and lacked measures to prevent Legionella growth in water systems. Staff were unaware of EBP requirements, leading to inadequate precautions for residents with wounds and catheters. Additionally, there was no water management policy or assessment for Legionella, indicating significant oversight in infection control measures.
The facility failed to maintain resident dignity by serving meals in disposable plastic cups instead of regular dishes to eight residents. The Dietary Manager admitted that the kitchen staff should have transferred the food to small bowls, as using disposable dishes is only appropriate in specific situations like isolation or dish machine malfunctions. This oversight did not align with the facility's policy on resident dignity.
The facility failed to conduct weekly wound assessments for two residents with pressure ulcers, resulting in deficiencies in care. One resident with a stage 2 ulcer did not receive assessments for four weeks, while another with a stage 3 ulcer had incomplete documentation. The DON acknowledged the oversight, citing a lack of a wound program and reliance on hospice and nurse practitioners. The facility's policy requires weekly documentation, which was not consistently followed.
A resident with an indwelling urinary catheter experienced a deficiency in care due to a lack of a catheter secure device and kinked tubing, leading to potential complications. The resident reported not having the secure device for two weeks, and the LPN confirmed the tubing was kinked, necessitating a urine sample. The care plan required a secure device every shift, but documentation showed inconsistencies. The facility's policy did not address secure devices, despite the resident's complex medical history.
LPN Worked While Nursing License Was Suspended
Penalty
Summary
The facility failed to ensure that nursing staff were working with an active nursing license, affecting all 91 residents in the facility. The facility data sheet dated 1/26/26 showed a current census of 91 residents. An undated copy of an LPN’s licensure summary from the state licensing agency showed that this nurse’s license was suspended from 12/15/25 through 12/24/25. Timesheet summaries printed on 1/26/26 showed that this LPN worked on 12/16/25, 12/19/25, and 12/23/25, all during the period of license suspension. Daily census sheets printed on 1/26/26 showed that the facility census was 67 on 12/16/25, 64 on 12/19/25, and 66 on 12/23/25, indicating residents were present while the LPN worked with a suspended license. During an interview on 1/26/26 at 10:20 AM, the Human Resources staff member stated that the LPN did not inform the facility of the temporary suspension and acknowledged that nurses should not work while their licenses are suspended. The state licensing agency’s frequently asked questions indicated that suspended licensees are prohibited from practice during the suspension term and may be subject to certain terms and conditions. No additional resident-specific medical histories or conditions were documented in relation to this deficiency.
Failure to Prevent New Pressure Ulcer in Resident
Penalty
Summary
A deficiency occurred when a resident, admitted with multiple diagnoses including a pathological fracture, congestive heart failure, atrial fibrillation, and osteoporosis, developed a new pressure ulcer on her left heel after admission. Upon admission, the resident was noted to have a surgical wound to her left hip but no other skin issues, and was assessed as cognitively intact but requiring maximum assistance with transfers and bed mobility. The initial skin check performed by an LPN and the nurse manager did not reveal any open areas or redness on the resident's heels. However, approximately one week later, staff alerted the LPN to a pressure ulcer on the resident's left heel, which was found to be unstageable with black tissue present. The facility's care plan for the resident included interventions such as applying ace wraps to both lower extremities, keeping the skin clean and lubricated, monitoring bony prominences for redness, using pillows to avoid direct contact with bony prominences, and utilizing pressure-relieving devices. Despite these interventions, the pressure ulcer developed. The LPN and DON indicated that skin checks were performed weekly, and suggested that the ulcer may have developed between checks. It was also noted that daily full inspections of the feet may not have been performed, especially since the resident's legs were wrapped with ace wraps per physician orders. The facility's policy required systematic assessment, identification of risk factors, and early interventions, but the new pressure ulcer was not identified until it had progressed.
Failure to Supervise High-Risk Resident and Follow Aspiration Precautions
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision for residents at risk for accidents, including falls and aspiration. One resident (R1) had diagnoses of Alzheimer’s disease, dementia, anxiety disorder, weakness, and a prior right femoral neck fracture, and her active care plan identified cognitive impairment, extensive ADL assistance needs, use of a mechanical lift for transfers, and high fall risk, with interventions including prompt response to assistance requests and use of bed and chair alarms. On the day of the incident, multiple notes documented that R1 was extremely restless, anxious, and repeatedly attempting to stand from her wheelchair, with staff keeping her at the nurses’ station or taking her room to room to keep her in sight, and that her chair alarm was described as “not very loud.” Despite these known risks and behaviors, R1 was left unsupervised at the nurses’ station when a CNA took another resident to the bathroom and asked another CNA to watch R1; that CNA left the area, and R1 was subsequently found on the floor in the hallway by staff and another resident, bleeding from the back of her head and unable to move her right leg. The RN responding to the incident stated that the nurse assigned to the unit was on lunch break and she did not know where the other unit staff were at the time of the fall. Hospital records following the incident documented that R1 complained of severe right hip and knee pain, with imaging confirming an acute, moderately displaced right femoral fracture requiring surgical intervention. The facility also failed to follow speech therapy and hospital transfer recommendations for another resident (R46) at risk for aspiration. R46, admitted with Parkinson’s disease and dementia, had hospital speech pathology and dysphagia treatment plan documents specifying that he required 1:1 feeding assistance, should not use straws due to aspiration risk, and should continue SLP services and swallowing monitoring. Observations over multiple days showed R46 in his room and at meals with Styrofoam cups containing liquids and straws in them, both on his bedside table and on his meal trays, despite these written precautions. The DON and Director of Therapy acknowledged that staff were expected to follow hospital transfer recommendations and that, until evaluated by the facility speech therapist, the no-straw precaution should have been maintained, and the facility speech therapist later confirmed that his evaluation also recommended no straws for R46’s safety.
Improper Food Storage and Unsanitary Kitchen Conditions
Penalty
Summary
Surveyors identified a deficiency related to food storage and kitchen sanitation affecting all 35 residents in the facility. During a kitchen tour, an opened box of French baguettes was observed stored directly below the condenser/evaporator in the walk-in freezer, with an unwrapped baguette protruding from the top of the box. The outside of the box had visible ice build-up. The facility’s own Production, Purchasing, Storage Policy required that unused portions and open packages be covered, labeled, and dated, and that bulk materials be stored in NSF-approved containers with tight-fitting lids or in food-grade plastic bags, which was not followed in this instance. In addition to improper food storage, the cooking area was not maintained in a clean and sanitary condition. The exhaust hood above the cooking area had a build-up of dust and debris on the fire suppression lines located directly over the cooking surfaces. The facility’s Sanitation and Infection Prevention/Control Policy stated that written procedures were available for daily and weekly cleaning of all areas and equipment in the department, and that the Maintenance Department was scheduled to clean equipment requiring special training and equipment, such as refrigeration coils and exhaust hoods. Staff interviews confirmed that food in the freezer should be stored securely in sealed bags or containers with lids and that an outside company is responsible for cleaning the exhaust hood, indicating that the observed conditions were inconsistent with facility policies and expected practices.
Failure to Provide Meaningful Activities for Dementia Residents on Weekends
Penalty
Summary
The deficiency involves the facility’s failure to provide meaningful, individualized activities to several residents with dementia, despite having a written activities policy and a posted activity calendar. Four residents with dementia were observed over the course of a weekend with no engagement in the scheduled activities. One resident with Alzheimer’s dementia, a former engineer, was observed sitting in a wheelchair in front of the TV, later asleep, and his son reported there were no ongoing activities on Saturdays or Sundays and that he wanted his father to be engaged. This resident’s activity care plan documented impaired cognitive function/dementia but contained no activity interventions. Another resident with dementia, anxiety, and mood disorders was observed wheeling herself around the activity and dining rooms, being repeatedly redirected by an LPN, and later sitting in a wheelchair facing the TV stating there was nothing to do; her activity care plan also documented impaired cognitive function/dementia but had no activity interventions. A third resident with Alzheimer’s dementia was observed asleep in a wheelchair in front of the TV and later awake and looking around with no ongoing activities, despite a care plan stating the resident was dependent on staff for leisure pursuits and that Life Enrichment would provide individual visits and monitor participation. A fourth resident with dementia was observed sitting in a recliner and later at an activity table just looking around, again with no activities occurring, and had no activity care plan in the record. The Memory Care Activity Calendar listed multiple structured activities throughout the day, including positive affirmation, 1:1 reminisce, short stories, games, music and movement, and sensory exploration, but none of these were provided. Nursing staff, including an LPN and several CNAs, reported there were no activities on weekends in the dementia unit, that they tried to talk with residents or sit them by the TV in between nursing tasks, and that they had their own duties such as toileting, transferring, and feeding. The Life Enrichment Director and the Director of Memory Wellness both acknowledged that residents in the dementia unit need activities for engagement and that there was no activity staff on weekends, even though the facility’s activities policy states that meaningful, ability-centered activities for residents with cognitive or memory diseases are to be continually available.
PRN Psychotropic Medication Order Lacked Required Stop Date
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a PRN psychotropic medication order included a required stop date for one resident receiving an antianxiety medication. Record review showed that the resident’s physician order sheet, dated 11/5/25, contained an order for Ativan 0.25 ml sublingual every 2 hours as needed for anxiety, with no stop date indicated. During interview, the Nurse Manager stated he was responsible for ensuring psychotropic medications had appropriate diagnoses and stop dates and acknowledged he was not aware that this antianxiety order lacked a stop date, noting that the order was carried out by hospice staff and should have been clarified. He further stated he did not know why the order was entered into the electronic chart without a stop date and later produced a separate document for the antianxiety order that was not reflected in the resident’s medical record, despite his assertion that all ordered medications, including psychotropics with stop dates, should appear there. The facility’s psychotropic medication policy, dated 8/25, documents that psychotropic medications are to be used, evaluated, and monitored in accordance with state and federal guidelines.
Failure to Provide Timely Toileting Assistance for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide timely toileting assistance to a resident who was dependent on staff for ADLs. The resident had Parkinson’s disease, dementia, and an ADL self-care deficit due to weakness, requiring staff assistance. On the observed date and time, the resident was found confused, very restless, with his legs partially off the bed, repeatedly stating he needed to stand up and use the bathroom. The surveyor immediately activated the call light and remained with the resident, encouraging him to stay in bed and wait for help. A CNA who was not assigned to the unit entered the room 12 minutes after the call light was activated, turned off the call light, and left to find the assigned CNA. Four minutes later, an RN appeared at the doorway, stated that CNAs were coming, and then left, while the resident continued attempting to get up to use the bathroom. Two CNAs finally entered the room 20 and 22 minutes after the call light was activated to assist the resident to the bathroom, with one CNA stating the resident required two staff for transfers. After toileting, a CNA stated that the goal was to answer call lights within 15 minutes, but that it depended on unit acuity and what was going on. The facility’s Call Light System policy required staff to respond and assist a resident to the bathroom in a timely manner and to notify a supervisor if unable to respond timely due to workload or an emergency.
Failure to Monitor and Report Ongoing Weight Loss and Obtain Ordered Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to adequately monitor and respond to a resident’s weight loss and to follow its own policy for obtaining weekly weights after admission. The resident had been hospitalized for a subdural hematoma and underwent a craniotomy before being admitted to the facility for rehabilitation. The admission care plan identified the resident as being at risk for weight loss with a goal to maintain current weight. A physician’s order directed that the resident be weighed weekly, every Tuesday, and the facility’s policy required weekly weights for the first four weeks after admission. The weight records showed documented weights of 179 lbs on admission, 170.4 lbs one week later, and 167.4 lbs two weeks after that, but no weight was documented on the intervening Tuesday, and there was no documentation that the resident refused to be weighed. The records showed a 6.5% weight loss from admission to the later date. The dietitian assessed the resident shortly after admission and again after the initial significant weight loss, attributing the early loss to fluid shifts and resolving edema from hospitalization and IV fluids, and directed staff to continue monitoring weights and to notify her of any continued weight loss. Despite further documented weight loss between the second and third recorded weights, there was no evidence that staff notified the dietitian of this continued decline. During interview and record review, the dietitian confirmed that the resident should have been weighed weekly, that she had not been informed of the ongoing weight loss, and that she would have reassessed the resident if notified. The resident, who was alert and cognitively intact, reported having lost a lot of weight since surgery, described a decreased appetite after surgery that had only recently begun to improve, and stated he had been weighed a couple of times in the facility and had not refused to be weighed.
Failure to Ensure Availability and Administration of Ordered Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure ordered medications were available and administered as prescribed for two residents. One resident was admitted with physician orders for D‑Mannose 500 mg, four capsules by mouth three times daily, and Simvastatin 40 mg once daily. Over several days following admission, the resident received no doses of D‑Mannose and missed doses of Simvastatin on two days. During a morning medication pass, an RN stated that the D‑Mannose was not available because it had not been received from the pharmacy and was not in the stock medication cart, and also confirmed that Simvastatin had not been available on prior days. The MAR and progress notes documented that these medications were not given because they were unavailable or awaiting pharmacy delivery, despite facility policy requiring use of stock medications and STAT pharmacy delivery when medications are not on hand. Another resident was admitted with hospital discharge orders for carbidopa‑levodopa to be given multiple times daily for Parkinson’s disease and Pravastatin for cholesterol control. The MAR showed that the resident did not receive an evening dose of carbidopa‑levodopa on the day of admission and did not receive Pravastatin on the first two days. The DON reported that the nurse on duty confirmed the resident’s wife brought in and gave one dose of carbidopa‑levodopa, but the nurse did not administer the bedtime dose, even though carbidopa‑levodopa was available in the facility’s stock medication cart. The DON also stated that Pravastatin should have been obtained from the pharmacy and administered but was not. A nurse later confirmed with the pharmacy that carbidopa‑levodopa was available in the stock system while Pravastatin was not, and explained that if medications were not available in the stat safe or stock, they should contact the NP for a stat order and obtain the medication from a local pharmacy or through the family.
Failure to Use Required PPE for COVID-19 Isolation and Enhanced Barrier Precautions for PICC Line
Penalty
Summary
The deficiency involves failures in implementing required infection prevention and control measures for residents on transmission-based precautions and those requiring Enhanced Barrier Precautions (EBP). One resident with a documented COVID-19 infection was ordered to be on contact and droplet precautions, with signage posted outside the room specifying the need for gowns, gloves, face shields or goggles, and masks, and a bin of PPE available at the doorway. Despite this, a CNA was observed entering the resident’s room without any PPE to turn off the call light, and an occupational therapist later entered the same room without donning a face shield. The infection control nurse confirmed that no staff should enter the COVID-19 isolation room without all required PPE and that eyeglasses alone are not acceptable in place of a face shield. A second deficiency involved a resident admitted with sepsis and bacteremia who had a PICC line in the left arm for IV antibiotic administration. Although IV antibiotics were completed, the PICC line remained in place, and there was no physician order or documentation placing the resident on EBP related to the indwelling device. The facility’s isolation list did not show the resident on EBP or any isolation precautions, and repeated observations showed the resident in bed with the PICC line in place, but without any EBP signage on or around the door and without an isolation cart or PPE available near the room. The infection preventionist stated that residents with a PICC line or any type of IV access should be on EBP, and the facility’s EBP policy required signage and readily available gowns and gloves for residents with indwelling medical devices.
Failure to Offer Recommended Pneumococcal Vaccines per CDC Guidelines
Penalty
Summary
The deficiency involves the facility’s failure to ensure that eligible residents were offered pneumococcal vaccination in accordance with CDC recommendations and the facility’s own immunization policy. For one resident (R23), the face sheet showed admission to the facility and age over 65, and the Immunizations Report showed no pneumococcal vaccine on record. A progress note documented that this resident reported having received a Pneumococcal 23 (PPSV23) vaccination after age 65, but no additional documentation of any pneumococcal vaccine was available in the record. For another resident (R36), the face sheet showed admission and age over 65, and the Immunizations Report documented a PPSV23 vaccine administered on 12/8/21, with no other pneumococcal vaccines recorded and no further documentation provided. During an interview, the Administrator in training stated that the unit clerk is responsible for tracking residents’ immunization status and determining when they are due for specific immunizations, and that the facility follows CDC recommendations for pneumococcal and other vaccines. The CDC Adult Immunization Schedule cited in the report specifies that adults aged 65 years or older who have previously received only PPSV23 should receive one dose of PCV15, PCV20, or PCV21 at least one year after the last PPSV23 dose. The facility’s written Immunization Policy and Procedure, revised in 9/2025, states that the facility shall offer and administer recommended vaccines to all eligible residents, document all immunizations, refusals, and contraindications, comply with CDC requirements, and provide PCV20 or sequential PCV15 plus PPSV23 per CDC guidelines upon admission and as needed based on immunization history. Despite these policies and guidelines, the records for R23 and R36 did not show that the appropriate pneumococcal vaccines were offered or administered in line with CDC recommendations.
Unauthorized Administration of Controlled Substance and Misappropriation of Medication
Penalty
Summary
A nurse administered a liquid medication, specifically Ativan (Lorazepam Oral Concentrate), to a resident who did not have a physician's order for this form of the medication. The resident's medication administration record (eMAR) showed only an order for Ativan tablets, not the liquid form, at the time of administration. The incident was observed by a CNA, who reported that the nurse stated she was giving an 'extra dose' and asked the CNA not to witness the act. Video evidence confirmed the nurse gave the resident a liquid medication with a distinctive white stopper, which matched another resident's prescribed Ativan. The nurse did not document the administration of this medication to the resident and instead recorded a dose for the resident who was actually prescribed the liquid Ativan. The facility's investigation determined that the nurse gave a controlled substance to a resident without a valid order and used medication prescribed for another resident. This was classified as a medication error, unauthorized administration of a controlled substance, and a violation of resident rights and safety standards. Staff interviews confirmed that such actions are outside the scope of nursing practice and violate facility policy, which prohibits the use of a resident's possessions, including medications, without proper authorization.
Unauthorized Administration of Ativan Without Physician Order
Penalty
Summary
A medication error occurred when a nurse administered a liquid form of Ativan to a resident who did not have a physician's order for this medication or formulation. The resident, who had a history of atherosclerotic heart disease, insomnia, spinal stenosis, dementia with psychotic disturbance, panic disorder, restlessness, agitation, and mood disorder, was observed to be anxious and agitated. The nurse gave the resident a liquid medication from a dropper, which was later confirmed through video review to be Ativan belonging to another resident. The medication administration record for the resident did not include any oral liquid medications, and there was no valid order for liquid Ativan at the time of administration. Staff interviews confirmed that the nurse gave the medication without a physician's order and used another resident's medication. The incident was reported by a CNA who witnessed the event and was corroborated by other staff, including the DON and RNs, who emphasized that medications should not be borrowed or administered without proper orders. The facility's policy requires strict adherence to the five rights of medication administration, including verifying the right resident, medication, dose, route, and time, and administering medications only from packaging labeled for the individual resident. This policy was not followed in this incident.
Failure to Investigate Alleged Misappropriation of Narcotics
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of misappropriation of narcotic medications involving four residents in certified beds. The incident occurred when an agency LPN, who worked only one day at the facility, was accused of drug diversion. The Director of Nursing (DON) and the Administrator did not report the allegation to the state agency or the police, citing a lack of proof and fear of legal repercussions. The facility did not perform audits on units other than the sheltered care unit, where the LPN was assigned, and failed to interview all staff involved, including the maintenance man who escorted the LPN out of the facility. The incident began when discrepancies in the narcotic count were noticed by a Registered Nurse (RN) who worked the night shift on Christmas Eve. The RN did not count the narcotics upon arrival, assuming it was done by someone else. The next morning, the count was off, and the RN attempted to involve the agency LPN, who was acting erratically and did not cooperate. Another RN noticed discrepancies in the narcotic cards and called the LPN to verify the count. The LPN was described as rushed and exhibiting unusual behavior, such as trying to access the medication refrigerator under the pretense of getting lunch. The facility's policy requires that all discrepancies, suspected loss, or diversion of medications be reported to the Administrator, DON, and Consultant Pharmacist, and an investigation be conducted. However, the facility did not adhere to this policy, as evidenced by the lack of comprehensive interviews and audits. Additionally, the facility's pharmacy consultant confirmed there was no test available to verify if morphine or lorazepam liquids were tampered with, and the facility did not provide records of medication cart and drug audits. The failure to follow established protocols and conduct a thorough investigation into the alleged misappropriation of narcotic medications resulted in a deficiency finding.
Failure to Conduct Narcotic Count at Shift Change
Penalty
Summary
The facility failed to ensure a narcotic count was completed upon nursing shift change, specifically affecting a resident who was prescribed controlled substances, including lorazepam and morphine. The incident involved a registered nurse (RN) who arrived late for her shift on Christmas Eve and did not perform the required narcotic count, assuming it had been done by someone else. The following morning, discrepancies in the narcotic count were discovered by another RN, who attempted to address the issue with an agency licensed practical nurse (LPN) who had been on duty. The LPN was reportedly rushed and exhibited unusual behavior, such as attempting to access the medication refrigerator for personal reasons, which led to her being escorted out of the facility. The Director of Nursing (DON) confirmed that narcotic counts should be conducted at every shift change, and the facility's policy mandates that all Schedule II-V controlled medications be counted by two nurses at each shift change. The Controlled Substance Shift to Shift Count Record for December 2024 showed missing signatures for the morning and evening shifts on December 25, 2024, indicating that the required counts were not completed. This failure to adhere to established procedures for narcotic counts resulted in a deficiency in the facility's pharmaceutical services.
Resident Fall Due to Inadequate Supervision and Positioning
Penalty
Summary
The facility failed to ensure a resident was positioned safely in bed, leading to a fall incident. The resident, who was on blood thinner medication, attempted to reach for cranberry juice and slid out of bed, resulting in a hospital visit for a suspected subarachnoid bleed. The incident occurred when a CNA from an agency left the resident sitting on the side of the bed for over an hour, despite the resident's poor sitting balance and tendency to lean forward and fall asleep. The resident's care plan did not adequately address her sitting balance issues or the need for supervision while sitting. The resident, identified as having multiple medical conditions including atrial fibrillation, type 2 diabetes, and a history of falling, was found on the floor by staff. The CNA had placed a tray table in front of the resident, which she pushed away after eating, leading to her sliding off the bed. The resident's care plan indicated she required assistance with mobility and transfers, but it did not specify her poor sitting balance or the need for additional supervision when sitting up. Staff interviews revealed that the CNA was not actively monitoring the resident, and the nurse on duty was at the end of the hall during the incident. The facility's fall prevention policy required staff training on fall prevention, but the incident suggests a lapse in adherence to these protocols. The Director of Nursing acknowledged that the resident should not have been sitting on the side of the bed, as she was unable to do so safely on her own.
Infection Control Deficiencies in EBP and Water Management
Penalty
Summary
The facility failed to ensure their infection control policies and procedures were reviewed annually and updated to include Enhanced Barrier Protection (EBP). The Infection Preventionist (V3) was unaware of the requirements for EBP and stated that there was no need for postings or signs on residents' doors to indicate the enhanced barrier precautions. This lack of awareness extended to other staff members, such as a Licensed Practical Nurse (V6), who noted that residents with catheters and open wounds should be on EBP but acknowledged that this was not in place at the facility. The facility's policies, including those for Covid-19, antimicrobial stewardship, and flu and pneumovax, were outdated and did not include EBP procedures. The facility also failed to have measures in place to prevent the growth of Legionella in the water systems. The Maintenance Supervisor (V4) admitted that there had been no assessment of the water systems, no diagram of the water systems, and no monitoring protocols or policies for Legionella. The Administrator (V1) confirmed the absence of a water management policy and assessment for Legionella, indicating a significant oversight in the facility's infection control measures. Specific residents, such as R10 and R17, were not placed on EBP despite having conditions that warranted such precautions. R10 had multiple wounds and required daily dressing changes, yet staff did not wear gowns or follow EBP protocols. Similarly, R17, who had a pressure ulcer and other medical conditions, did not have any EBP signs or PPE available at the doorway, and staff only used gloves during care. The lack of EBP policies and procedures contributed to these deficiencies, as staff were not informed or trained on the necessary precautions for residents with specific medical needs.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
The facility failed to treat eight residents with dignity during a meal service. On the specified date, these residents were served their noon meal with water, fruit cups, pasta salad, and cucumber tomato salads in disposable plastic cups instead of regular dishes. The Dietary Manager acknowledged that the kitchen staff should have transferred the food from the plastic cups to small bowls available in the facility, as using disposable dishes is only appropriate when a resident is on isolation or if there is a malfunction with the dish machine. This oversight was identified as a dignity concern, as it did not align with the facility's policy that emphasizes maintaining resident dignity by using normal dishes.
Deficiencies in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to complete weekly wound assessments for two residents with pressure ulcers, leading to deficiencies in their care. Resident R17, who has a stage 2 pressure ulcer, did not receive weekly wound assessments for a period of four weeks. The Director of Nursing (DON) acknowledged the oversight, mistakenly believing that hospice was responsible for the assessments. The facility's policy requires weekly documentation of wound status, including size, color, drainage, and odor, which was not adhered to in this case. Resident R10, admitted with a stage 3 pressure ulcer, also did not receive complete weekly skin assessments for his pressure injuries. Observations revealed that R10 had multiple wounds, including on his buttock and coccyx, but the documentation was incomplete and not up to date. The DON admitted that there was no wound nurse in the building and that the nurse practitioner only reviewed wounds upon request. The nurse manager stated that the facility lacked a wound program, and the nurses were responsible for measuring and documenting wounds weekly. The facility's failure to conduct and document weekly wound assessments for both residents R17 and R10 highlights a significant gap in their wound care management. The lack of a dedicated wound program and reliance on hospice and nurse practitioners without proper oversight contributed to the deficiencies. The facility's policy mandates weekly wound assessments, which were not consistently performed, leading to inadequate monitoring and documentation of the residents' pressure ulcers.
Failure to Ensure Proper Catheter Care for a Resident
Penalty
Summary
The facility failed to ensure proper catheter care for a resident, leading to a deficiency. The resident, who had an indwelling urinary catheter, was observed with a kinked catheter tubing and without a catheter secure device in place. The resident reported that the secure device had not been used for two weeks, suggesting a possible shortage of these devices. The resident also mentioned that the catheter was leaking at the time of observation. The Licensed Practical Nurse (LPN) acknowledged that the tubing was kinked and stated that this was the reason for collecting a urine sample. The LPN also noted that the tubing often became kinked when the resident moved or sat, indicating a need for closer monitoring. The resident's care plan and physician orders required the use of a catheter secure device every shift to prevent tension on the urinary meatus and potential infection. However, documentation showed inconsistencies in the application of the secure device, with records indicating it was in place only on specific dates. The facility's catheter care policy emphasized maintaining unobstructed urine flow but did not address the use of catheter secure devices. The resident had multiple diagnoses, including Parkinson's disease and mechanical complications of the urinary catheter, which could contribute to the complexity of care required.
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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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