There were 36 recertification surveys completed in the month of August and 41 complaint/incident surveys. August was the second highest month in 2026 for fining likely related to the number of fines that were trebled based on repeat state citations. Here are statistics for the month of August:
Recertifications: Total of 36 with 3 deficiency free surveys (or 8%). 33 providers received deficiencies averaging 5.4 per survey. 9 of the 33 (or 27%) received a fine. The average recertification survey was conducted at 13.3 months, 44 providers are currently over 12 months since their last recertification with the longest being 15 months.
Congratulations to Faith Lutheran Home on their deficiency free recertification survey!
Complaints/Incidents: Total of 41 providers with complaint and/or incident surveys during the month. Only 13 of the 41 (which seems lower than normal) were without deficiencies cited during their complaint/incident survey. 28 providers received deficiencies averaging 2.9 and 8 of the 28 (or 29%) received a fine.
Deficiencies with fines:
Of the 21 total fines issued (among 17 providers) 4 of them were treble fines due to repeated state citations in the previous 12 months. The breakdown of fines includes:
- F689 – 6 deficiencies for $86,750
- F609 – 6 deficiencies for $3,000
- F684 – 4 deficiencies for $27,750
- F600 – 2 deficiencies for $11,500
- 50.7 – 2 state citations for $1,000
- F740 – 1 deficiency for $10,000
- F695 – 1 deficiency for $2,500
- F607 – 1 deficiency for $500
Total state fines is $143,000.
There were 3 immediate jeopardy deficiencies identified during August which include:
F689 related to multiple elopements by the same resident due to the wandergaurd alarm not sounding. The staff failed to implement safety interventions that prevented the resident from eloping.
F689 also related to an elopement when the staff responded to an alarming door at 12:30 a.m., checked immediately outside the door but didn’t see anyone. They failed to do a count of the residents and nearly 2 hours later the resident was located outside by a passer-by who found them lying on the road with their head on the curb. The resident was transported to the ER and noted to have subdural hematoma, extracranial soft tissue swelling and hemorrhage, and right sided nasal bone fracture. The staff were unaware that the resident was missing or injured until the ER notified them that the resident was there and maybe transported to a different hospital due to injuries.
F740 was related to a resident who had a history of suicidal ideations and ongoing thoughts of death. The staff found the resident with a trash bag over their head and were not breathing with a faint pulse. The staff failed to call 911 immediately, instead they called the management staff who directed them to notify 911. The resident passed away with manner of death being suicide.
Harm level deficiency cited during the month:
- F600 cited twice at a “G” level when staff failed to prevent abuse by other residents. Additionally, nursing home staff failed to assess a resident’s capacity to consent to a sexual relationship when the staff had suspicion of a sexual relationship with a male visitor.
- F684 cited four times at a “G” level when staff failed to properly assess and intervene with changes in condition including:
- A resident refused multiple medications on various occasions without any assessment as to a change in behavior. The staff also failed to notify hospice that the resident was refusing medications. They were later transferred to the hospital for the behaviors and were diagnosed with a UTI and dehydration.
- A resident was transported to the ER after family noticed severe pain. The resident did not have any bowel movements for multiple days (exceeding the established bowel protocol). Assessments were not completed and the bowel protocol was not followed. They were diagnosed with severe bowel impaction.
- Two residents with changes in condition including an abnormal UA result and a significant acute change in behaviors had faxes sent to the physician over a holiday weekend without notifying the on-call physician or completing assessments. Both residents were transferred to the ER and diagnosed with sepsis related to a UTI and sepsis related to a gallbladder infection.
- A resident complained of acute rib pain that the staff did not complete an assessment or notify the physician until days later and was transferred to the ER where they were diagnosed with acute rib fractures.
- F689 cited four times at a “G” level for accidents, hazards and supervision related to:
- Staff failure to use a gait belt during a transfer resulting in a fall with injury.
- A staff member transferred a resident by themselves when they required assistance of 2 staff which resulted in a fall and fractured tibia and fibula. Also a resident was found with an electrical cord wrapped around their neck attempting to commit suicide when the staff member left the resident alone to get the nurse instead of staying with the resident to ensure they were safe.
- Staff used a stand-pivot transfer instead of a mechanical lift as required in their care plan which resulted in a fractured humerus. Also a resident eloped as they knew the code to leave the building which the nursing home corrected prior to the survey.
- Staff used a “bear hug” technique instead of stand-pivot transfer to move the resident from the bed to the chair which resulted in an acute rib fracture. The resident was transferred to the hospital due to a fever and chest pain.
- F695 cited one time at a “G” level when staff mistakenly filled a CPAP with distilled vinegar instead of distilled water causing the resident a headache, burning to their eyes, and altered taste.
Top cited deficiencies:
The top 5 cited deficiencies for the month include F880 – cited 19 times, F689 – cited 15 times, F812 – cited 13 times, F656 – cited 10 times, and F658 – cited 10 times. Examples of noncompliance include:
F880:
- Hand hygiene wasn’t completed appropriately during care.
- Enhanced barrier precautions weren’t followed.
- Gloves were placed in the staff member’s scrub pocket.
- Catheter bag was touching the floor.
- Used an oral medication syringe after it fell on the floor.
- A staff members dog was allowed in the dining room during meals and the dog was urinating and defecating in the building.
- Didn’t use a barrier when necessary.
- Staff didn’t change the side of the wipe or get a new wipe between swipes during perineal care.
- Didn’t disinfect the glucometer between residents.
F689:
- During a transfer a mechanical lift sling hook hit the resident in the face causing a bruise.
- Wheelchair brakes weren’t locked during a transfer.
- Resident’s weren’t supervised when they were outside allowing them to leave the campus without staff knowledge.
- A carpet was wet and there wasn’t a wet floor sign.
- Staff failed to use shoes or gripper socks during a transfer.
- Wheelchair pedals weren’t used when a resident was pushed in the chair.
- Smoking materials weren’t secured
- Staff didn’t assess the resident after a fall, complete an investigation into the fall, root cause analysis or implement new interventions.
F812:
- Beard/hair nets weren’t used.
- Thermometer wasn’t cleaned prior to using or between food items.
- Staff didn’t change gloves appropriately
- Hand hygiene wasn’t completed when necessary.
- Didn’t run cold water on thawing meet in the 3 compartment sink.
- Kitchen and equipment cleanliness
- Food temperatures weren’t checked prior to serving.
- Items weren’t labeled or dated.
F656:
- Staff failed to implement fall interventions identified on the care plan.
- The care plan didn’t include the following items:
- Target behaviors for psychotropic medications
- Nonpharmacological interventions for psychotropic medications
- Urinary catheter use
- Need for toileting assistance
- Discontinued shunt use when dialysis began using a port
- Smoking
- Behavioral concerns related to electric scooter use
- UTI with antibiotic use
- Antidepressants
- Diuretics
- Insulin
- Focuses for incontinence, nutritional status, dehydration, psychotropic drug use, schizophrenia diagnosis, medication side effects, and the level 2.
- Suicidal risk and interventions
F658:
- The physician’s order indicated to keep oxygen saturation levels above 90% but staff only monitored the oxygen saturation levels a few times.
- A PICC line wasn’t flushed prior to using the antibiotic.
- Didn’t follow physician orders (for various items) such as incorrect doses or directions on the order.
- Didn’t monitor the heart rate prior to administering a medication that directed staff to “hold if heart rate was less than”
- Didn’t obtain results following laboratory tests.
- Medications were omitted due to being not available
- Staff didn’t have the resident rinse their mouth following administration of an inhaler.
- Following administration of insulin, the staff didn’t keep the pen in the skin for the directed amount of time.