Alden Lincoln Rehab & H C Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 504 West Wellington Avenue, Chicago, Illinois 60657
- CMS Provider Number
- 145126
- Inspections on file
- 24
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Alden Lincoln Rehab & H C Ctr during CMS and state inspections, most recent first.
A resident with multiple comorbidities, prior pelvic and hip fractures, and documented need for partial/moderate assistance and supervision during showers was taken to the shower by a CNA, who then left to answer another call light after instructing the resident to wait. The resident, normally assisted with tasks such as removing socks while staff remained present, attempted to remove a tight sock while alone, lost balance, and fell in the shower room. The RN later found the resident on the floor, and hospital records confirmed multiple new right hip and pelvic fractures from a mechanical fall in the shower. Staff interviews, including those of the CNA, RN, NP, PT, and DON, confirmed that the resident should not have been left unattended in the shower room and that facility expectations and fall management policy required staff to remain with residents needing supervision and assistance during showers.
The facility failed to ensure that scheduled nursing staff were present on their assigned units, leading to delayed medication administration and lack of nurse availability on night shifts. Cognitively intact residents with complex conditions, including diabetes on insulin and chronic heart failure, reported that nurses were sometimes absent at shift start, that only one nurse was covering multiple floors, and that medications such as insulin and pain meds were given late. One resident had to seek out an RN on another floor to obtain pain medication when no nurse was present on his unit, and that RN confirmed the assigned nurse arrived close to midnight. Resident council minutes and concern forms documented repeated complaints about no nurse on night shifts, while leadership acknowledged a pattern of nurses arriving late and confirmed there was no formal staffing policy beyond meeting minimum ratios.
A resident's allegation of sexual abuse was not reported to the state health department within the required two-hour window. The administrator, who is responsible for abuse reporting, received notification from the ombudsman via email, but the initial report was not sent until several hours later. Interviews and documentation confirmed that staff were aware of the reporting requirements and had received relevant training, but the mandated timeline was not met.
A resident with severe cognitive impairment and a history of falls was found on the floor with a head injury after falling in her room. An LPN discovered that a floor mat, intended only for use when residents are in bed, had been left between beds, creating a tripping hazard. Facility policy and staff confirmed that such mats should be removed when residents are ambulating, but this was not done, resulting in the resident's fall.
Staff failed to keep call devices within reach for two residents with cognitive and physical impairments and did not consistently ask what assistance was needed when responding to call lights. An LPN and CNA did not follow facility policy requiring call lights to be accessible and for staff to inquire about residents' needs, despite care plans and job descriptions specifying these requirements.
Two residents with severe dementia and known risks were not provided with timely or adequate care plans addressing their behaviors and fall risks. One resident's repeated behavior of grabbing objects while being transported was not care planned until after a fall occurred, despite staff awareness. Another resident, identified as a high fall risk, was left alone in bed while awake contrary to care plan interventions, and staff did not consistently follow the prescribed measures.
A resident with severe cognitive impairment and a history of falls, known to frequently grab onto objects while being transported in a wheelchair, was not care planned for this behavior. Staff were aware of the behavior but did not implement interventions or update the care plan, leading to the resident grabbing another wheelchair, falling, and sustaining a finger fracture and head contusion.
A resident with severe dementia and contractures was assessed as dependent on all ADLs, yet the care plan inaccurately documented the use of a gait belt for transfers, contradicting the need for a mechanical lift. Staff interviews revealed inconsistencies in understanding the resident's needs, and the care plan was outdated, leading to improper handling of the resident's transfers and mobility. The facility's policy required current care plans, but lack of communication among CNAs and failure to update the care plan contributed to the deficiency.
A resident with severe dementia and dependency on all ADLs sustained a left femur fracture due to the facility's failure to follow the prescribed transfer care plan. Despite being assessed as needing a mechanical lift for transfers, staff inconsistently used a two-person assist, and the resident's care plan contained conflicting instructions. The mechanical lift was not always available, contributing to the incident.
A facility failed to assess a resident's ability to self-administer medications, did not obtain a physician's order, and neglected to create a care plan for self-administration. A resident was found with loose pills and other medications at their bedside without proper documentation or orders. The DON admitted there was no policy for self-administration, and the facility's policy requiring physician orders and assessments was not followed.
A resident with Alzheimer's and dementia experienced a fall resulting in serious injury due to the facility's failure to follow the care plan and monitor changes in her condition. Despite exhibiting unusual behavior and a forward-leaning gait, staff did not adequately intervene or communicate these changes to medical personnel, leading to a fall and hospitalization for subdural hemorrhages.
The facility failed to accurately complete Fall Assessments for two residents, leading to potential safety risks. One resident was found on the floor and diagnosed with fractures, while another was diagnosed with bilateral subdural hematoma after a fall. In both cases, a critical question about the history of falls was left unanswered in their assessments. The facility's policies emphasize the importance of accurate assessments, but these were not adhered to, indicating a lapse in protocol.
The facility failed to adhere to respiratory care equipment protocols, affecting several residents. A resident's nebulizer tubing was not changed weekly as required, and three residents had nasal cannulas without date labels. Additionally, a humidifier bottle was not dated. The facility's policies require regular changes and labeling to prevent infection, but staff did not consistently follow these guidelines, leading to potential risks for the residents.
The facility failed to label opened multi-dose vials, including a house stock vial of Tuberculin and a resident's Travoprost eye drops, as required by policy. An LPN and an RN were unaware of the need to label these medications with open dates, which is crucial for maintaining their efficacy. A resident with severe cognitive impairment was affected by this oversight.
A resident in a wheelchair was unable to reach their call light, which was wrapped around a dresser drawer behind them. The resident, who has a history of falls and requires assistance, expressed that they had to yell for staff when the call light was not accessible. The DON confirmed the inaccessibility and secured the call light to the resident's gown. The resident's care plan and facility policy both require the call light to be within reach, but this was not adhered to, resulting in a deficiency.
A facility failed to follow infection control practices for a resident with an indwelling catheter. Equipment used for bladder irrigation, including a piston syringe and saline solution, was not discarded after use, contrary to policy. The resident, with a diagnosis requiring catheter use, had severely impaired mental status. The LPN and DON confirmed the equipment should have been discarded to prevent infection.
A CNA in an LTC facility failed to perform hand hygiene after cleaning a spill and before handling food for a resident. Additionally, the CNA did not wear the required PPE while providing care to a resident on Enhanced Barrier Precautions due to a chronic wound. Both residents involved were cognitively intact and had significant medical histories, highlighting the importance of adhering to infection control protocols.
A facility failed to implement a dietician's enteral feeding recommendation for a resident with severe dementia and malnutrition, leading to significant weight loss and elevated BUN levels. The MAR showed multiple instances where enteral feeding and flushing were not documented as administered, and the Nurse Practitioner was not informed that the recommendation was not carried out.
The facility failed to post Enhanced Barrier Precaution (EBP) signage and provide accessible PPE outside a resident's room. Staff did not wear proper PPE during high-contact care activities for a resident with multiple diagnoses, including severe dementia and diabetes. The Director of Nursing confirmed the resident should have been under EBP, and the facility's policy mandates the use of gowns and gloves for such residents.
The facility failed to properly assess, monitor, and document a resident's lower leg and feet condition, leading to the resident being transferred to the hospital with dry gangrene. Staff inconsistencies in applying and documenting the prescribed treatment, along with missed care plan updates, contributed to this deficiency.
Failure to Supervise Resident During Shower Resulting in Fall and Multiple Fractures
Penalty
Summary
The deficiency involves the facility’s failure to provide required supervision during a shower, resulting in a resident’s fall and injury. The resident was admitted with multiple medical conditions, including multiple pelvic fractures, chronic diastolic heart failure, diabetes mellitus, atrial fibrillation, muscle weakness, polyosteoarthritis, major depressive disorder, malignant neoplasm of the prostate, and the presence of a cardiac defibrillator. Assessment data showed the resident was cognitively intact and required partial/moderate assistance for showers, meaning staff were expected to provide less than half the effort but still lift, hold, or support the resident’s trunk or limbs as needed. The resident’s care plan and physician orders documented pain and mobility limitations related to a right hip fracture, non‑weight‑bearing or toe‑touch weight‑bearing restrictions, poor balance, and the need for staff assistance with dressing and mobility. On the day of the incident, the resident reported that he was in the shower room attempting to take a shower and was unable to remove a tight sock. He stated that the CNA who accompanied him to the shower left the shower room, telling him she would be back, and that he then leaned over and fell to the floor. The resident stated that he normally received help in the shower and that staff usually stayed with him in case he needed assistance, including with removing his socks. He reported that when he fell, no one was in the shower room with him. Facility documentation from the RN’s progress note indicated that the resident was found lying on his right side on the shower floor, was able to answer questions, reported possible head impact, and complained of right lower extremity pain. A full body check and initial neuro checks were completed, and the resident was later found to have multiple fractures of the right hip and pelvis related to a mechanical fall in the shower from a standing position. Staff interviews confirmed that the resident required significant assistance and supervision for showers and that he should not have been left alone in the shower room. The resident’s primary CNA stated that he required extensive assistance for showers, with two staff and a gait belt due to his restrictions, and that staff performed all of his care. The CNA involved in the incident stated she was accompanying the resident to the shower using his rollator when she saw another call light and left to answer it, instructing him to wait. She acknowledged that she normally set him up in the shower room, that he usually removed his footies while staff were present, and that she believed he would not have fallen if someone had been with him. The RN stated that the resident was not to be left unattended in the shower room and that he had not been informed the resident was going to the shower. The NP and DON both stated that a staff member should have been present in the shower room to supervise and assist the resident, and the DON clarified that residents who require supervision should not be left alone in the shower room and that staff are expected to have all needed supplies ready before entering so they can remain with the resident. The facility’s fall management policy stated that the facility will assess hazards and risks and implement appropriate interventions to minimize fall incidents and injuries, which was not followed when the resident was left unsupervised in the shower. The hospital records documented that the resident sustained right acetabular/pubic rami fractures, a displaced fracture of the right iliac bone with fractures of the roof and medial aspect of the right acetabulum, a displaced fracture of the lateral right ischium, and displaced fractures of the right superior and inferior pubic rami as a result of the mechanical fall in the shower. Following the fall, therapy and nursing assessments described that the resident, who had previously been modified independent with a rollator for transfers and mobility, now required minimum contact guard assistance and use of a mechanical lift due to his new restrictions. The facility’s own fall log listed the resident as having had a fall on the date of the shower incident. These findings collectively show that the resident, who had known mobility limitations and required supervision and assistance for showering, was left unattended in the shower area, contrary to his assessed needs, staff expectations, and facility policy, leading directly to the fall and resulting injuries.
Delayed Medications Due to Nurses Arriving Late and Units Left Without Assigned Nurse
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff were present in the facility as assigned on their schedules, resulting in delayed medications and treatments for multiple cognitively intact residents. Several residents with complex medical conditions, including diabetes mellitus, chronic diastolic heart failure, hypertension, HIV, bipolar disorder, and other comorbidities, reported that nurses were not present on their units at the start of night shift or arrived late. Resident council minutes documented that residents stated there were no nurses on a couple of night shifts, and a concern form identified that a nurse not coming on time caused one resident to receive medications late. Residents serving as council president and vice president reported that there had been occasions when only one nurse was running all three floors and that nurses sometimes came in late. One resident, who is diabetic and on long-term insulin, stated he had received his insulin late on several occasions in the past, prompting him to raise concerns because the issue was happening often. Another resident reported that on multiple night shifts he came to the nursing station and found no nurse available; on one specific night around 11:30 PM he was told he would have to wait for pain medication because the night nurse had not yet arrived, and he had to go to another floor to obtain assistance from a different nurse. A registered nurse confirmed that on a night shift around 11:40 PM, a resident from another floor came to her unit stating there was no nurse on his unit and that he needed pain medication; she went upstairs, administered the medication, and noted that the assigned nurse for that unit arrived close to midnight. The administrator acknowledged being made aware of concerns about nurses running late and noted a trend of nurses arriving up to less than an hour late. The DON stated that residents had brought forward concerns that staff were coming in late and not notifying nursing leadership, and that it was an expectation that another nurse cover a unit when the assigned nurse was not present. The administrator also stated that the facility did not have a staffing policy and instead ensured only that minimum staffing ratios were met.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving one resident within the required two-hour timeframe. The administrator, who serves as the abuse coordinator, was notified by email from the ombudsman at approximately 1:00 PM that a possible sexual abuse incident had been reported by an LPN. Despite the administrator's expectation that all abuse allegations be reported to him immediately and then to the Illinois Department of Public Health (IDPH) within two hours, the initial report was not faxed to IDPH until 5:44 PM, exceeding the mandated reporting window. Interviews confirmed that the LPN had received in-service training on abuse reporting, and the DON was aware of the two-hour reporting requirement, but the administrator was responsible for the actual reporting process. Documentation reviewed included the incident report, in-service attendance records, and the facility's abuse policy, all supporting the finding that the report was not made in a timely manner.
Failure to Remove Floor Mat Creates Tripping Hazard Leading to Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident's environment was free from accident hazards, specifically regarding the improper placement of a floor mat. One resident with a history of falls, dementia, amnesia, and a previous hip fracture was found sitting on the floor between her bed and her roommate's bed after a fall. The resident was unsupervised at the time and was wearing rubber shoes. A nurse responding to the incident observed a floor mat placed between the beds, which is contrary to facility policy, as floor mats should only be placed at the bedside when residents are in bed and removed when residents are ambulating to prevent tripping hazards. The nurse noted a swelling on the right side of the resident's head following the fall. The resident's care plan identified her as being at risk for falls due to impaired cognition, unsteady gait, and a history of falling. The roommate also had a care plan indicating high fall risk, with an intervention for floor mats to be used only when in bed. Facility policy and staff interviews confirmed that floor mats left on the floor when residents are ambulating pose a tripping hazard. The incident occurred when the floor mat was not removed as required, directly contributing to the resident's fall and injury.
Failure to Ensure Call Light Accessibility and Proper Staff Response
Penalty
Summary
Surveyors found that staff failed to ensure call devices were within reach for two residents and did not consistently inquire about residents' needs when responding to call lights. In one instance, a resident's call device was found behind the nightstand and tangled, making it inaccessible. A Licensed Practical Nurse acknowledged the device was not within reach and corrected its placement. A Certified Nursing Assistant admitted not checking the call light's placement during the last room visit. In another case, a staff member responded to a call light by informing a resident about lunch but did not ask what assistance was needed before turning off the call light and leaving the room. Both residents involved had significant medical histories and cognitive impairments. One resident had a history of falls, hypertension, osteoporosis, and a moderate cognitive impairment, with care plans specifying the need for the call light to be within reach. The other resident had severe dementia, poor vision, and required substantial assistance with self-care, with a care plan identifying high fall risk and the need for safety measures. Facility policies and job descriptions require call lights to be within reach and staff to inquire about residents' needs, but these procedures were not followed in the observed incidents.
Failure to Develop and Implement Care Plans for Behavioral and Fall Risks
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents with known behavioral and fall risks. One resident, with a history of falling, hypertension, and severe dementia, exhibited a persistent behavior of grabbing onto objects while being transported in a wheelchair. Multiple staff members, including CNAs, LPNs, and the Memory Care Director, observed and were aware of this behavior prior to an incident where the resident grabbed another wheelchair and fell. Despite these observations and the resident's severely impaired mental status, the behavior was not care planned until after the fall occurred. Another resident, also with severe dementia and a history of falls, was identified as being at high risk for falls and had a care plan intervention stating not to leave the resident in bed while awake. However, during the survey, staff were observed leaving the resident alone in bed while awake on multiple occasions, despite the care plan directive. The resident attempted to get out of bed unassisted, and staff acknowledged that the intervention was not being followed at the time. Facility policies and job descriptions reviewed by the surveyor indicated that care plans should be individualized, person-centered, and updated promptly when new behaviors are observed. The failure to timely develop and implement care plans for known behaviors and to follow established interventions for fall prevention directly contributed to the deficiencies identified for both residents.
Failure to Care Plan for Known Grabbing Behavior Resulting in Resident Injury
Penalty
Summary
The facility failed to implement appropriate interventions for a resident with a known behavior of grabbing onto objects while being transported in a wheelchair, which resulted in a fall and injury. Multiple staff members, including CNAs and nurses, were aware that the resident frequently grabbed onto items such as rails, tables, and other wheelchairs during transfers, and this behavior had been observed since the resident was moved to the second floor. Despite this, the behavior was not care planned or addressed with specific interventions prior to the incident. On the day of the incident, a CNA was transporting the resident out of the dining room when the resident grabbed the wheel of another resident's wheelchair, causing her hand to become caught and leading to a fall. The resident sustained a closed fracture of the index finger and a contusion with swelling on the forehead. The incident occurred because the path was not cleared of other wheelchairs, and the staff did not implement any interventions to mitigate the known risk associated with the resident's behavior. The resident had a history of falls, severe cognitive impairment, and dementia, as documented in her medical records. Staff interviews confirmed that the behavior of grabbing onto objects was well known among staff but was not included in the resident's care plan until after the incident. The lack of a care plan and failure to update it when the behavior was first observed contributed directly to the resident's injury.
Inadequate Care Plan for Resident with Severe Dementia
Penalty
Summary
The facility failed to provide a person-centered care plan for a resident with severe dementia, major depressive disorder, and a history of a type II Dens fracture. The resident, who was non-verbal and non-ambulatory with contractures, was assessed as dependent on all activities of daily living (ADLs), including bed mobility and transfers. Despite this, the care plan inaccurately documented the use of a gait belt for transfers and ambulation, which contradicted the resident's assessed needs for a mechanical lift and total assistance. Interviews with staff revealed inconsistencies in the understanding and implementation of the resident's care plan. Some staff members believed the resident could perform bed mobility independently, while others recognized the resident's dependency. The Assistant Director of Nursing and the Director of Nursing acknowledged the inaccuracies in the care plan and the need for its review. The care plan's outdated information led to confusion among staff, resulting in improper handling of the resident's transfers and mobility needs. The facility's policy required the interdisciplinary team to maintain current care plans and make adjustments based on significant changes in the resident's condition. However, the lack of communication and endorsement among certified nursing assistants (CNAs) and the failure to update the care plan contributed to the deficiency. The resident's care plan was not reflective of their actual needs, leading to inadequate care and potential harm.
Failure to Follow Transfer Care Plan Results in Resident Injury
Penalty
Summary
The facility failed to adhere to the functional abilities assessment and transfer care plan for a resident who sustained a left femur fracture. The resident, who has severe dementia and a history of anterior displaced type II Dens fracture, was assessed as dependent on all activities of daily living (ADLs) and non-ambulatory. Despite this, multiple staff members considered the resident capable of bed mobility without assistance, contradicting the resident's care plan and assessment, which indicated the need for a mechanical lift for transfers. On the day of the incident, a Certified Nursing Assistant (CNA) observed that the resident's left knee appeared larger than the right, leading to an X-ray that confirmed a left femur fracture. The resident's care plan was inconsistent, initially indicating the use of a gait belt for transfers and ambulation, but later requiring a mechanical lift due to the resident's dependency on all ADLs. Staff interviews revealed confusion and inconsistency in the resident's transfer methods, with some staff using a two-person assist instead of the mechanical lift as required. The Assistant Director of Nursing and the Director of Nursing acknowledged the inaccuracies in the resident's care plan and the need for review. The facility's policy on transfer techniques emphasized the use of proper equipment, such as a mechanical lift, to ensure safe transfers. However, the mechanical lift was reportedly not always available, leading to deviations from the prescribed care plan and contributing to the resident's injury.
Failure to Assess and Document Self-Administration of Medications
Penalty
Summary
The facility failed to properly assess and determine if a resident was appropriate for self-administration of medications, did not obtain a physician's order for such self-administration, and neglected to develop a person-centered care plan addressing this issue. During an observation, a resident was found with multiple loose pills in a clear pouch on their bedside table, which they had not taken due to not having eaten. The resident was able to identify the medications and their intended times of administration, indicating a level of awareness and cognitive ability. Further investigation revealed that a nurse had given the resident their 9:00 AM medications in a pouch at the resident's request, as the resident was going to dialysis and intended to take them later. However, there was no documentation or physician's order allowing the resident to self-administer these medications. Additionally, the resident had several other medications at their bedside, including over-the-counter supplements and inhalers, for which there were no physician orders documented. The Director of Nursing acknowledged that there was no policy in place for self-administration of medications and that residents should not keep medications at their bedside. The facility's policy requires a physician's order and an assessment to determine a resident's ability to self-administer medications, which was not followed in this case. The lack of proper assessment, documentation, and adherence to policy led to the deficiency identified by the surveyors.
Failure to Follow Care Plan and Monitor Resident Leads to Serious Injury
Penalty
Summary
The facility failed to adhere to its change in condition policy and the care plan for a resident, resulting in a fall and serious injury. The resident, who had a history of Alzheimer's disease and dementia, was observed by staff to be anxious and exhibiting unusual behavior, including a forward-leaning gait and rapid pacing. Despite these changes, the facility did not adequately monitor or intervene according to the care plan, which required assistance with ambulation and monitoring for changes in the resident's ability to navigate the environment. On the day of the incident, the resident was noted to be restless and moving quickly, which was a deviation from her usual behavior. Staff, including a CNA and an RN, observed these changes but did not effectively communicate the resident's altered gait and behavior to the nurse practitioner or physician. The resident was left unsupervised, leading to a fall in the hallway where she hit her head, resulting in bilateral subdural hemorrhages and subsequent hospitalization. The facility's policies on change of condition, comprehensive care planning, and fall management were not followed. The staff failed to complete a thorough assessment and notify the physician of the resident's change in condition, as required by the facility's protocols. Additionally, the post-fall risk assessment was incomplete, lacking critical information about the resident's fall history, which could have informed appropriate interventions to prevent the fall.
Incomplete Fall Assessments for Two Residents
Penalty
Summary
The facility failed to accurately complete Fall Assessments for two residents, which has the potential to affect their safety and care. For one resident, identified as R2, a Facility Reported Incident documented that the resident was found on the floor in the hallway and was subsequently sent to the emergency room, where they were diagnosed with a left shoulder and left hip fracture. Upon reviewing R2's post-fall Fall Risk Assessment, it was found that a critical question regarding the history of falls in the past three months was left unanswered. This omission was acknowledged by the Director of Nursing, who stated that all questions should be answered to ensure the resident is on the correct level of fall precautions. Another resident, identified as R3, experienced a fall and was sent to the emergency room, where they were diagnosed with bilateral subdural hematoma. Similar to R2, R3's post-fall Fall Risk Assessment was incomplete, with the same question about the history of falls left unanswered. The LPN responsible for completing the assessment admitted to not filling out the question due to a lack of information about the resident's fall history from a previous facility and forgetting to follow up with the power of attorney. The facility's policies on fall management and dementia care emphasize the importance of completing Fall Risk Assessments accurately and developing care plans that address residents' risk factors, including a history of falls. The facility's job descriptions for the Administrator, Director of Nursing, and Staff Nurse highlight the responsibility to ensure that all procedures and protocols are followed to maintain the highest degree of quality care. However, the failure to complete the Fall Risk Assessments accurately for these two residents indicates a lapse in adhering to these policies and responsibilities.
Deficiencies in Respiratory Care Equipment Management
Penalty
Summary
The facility failed to ensure proper respiratory care for several residents by not adhering to equipment change schedules and labeling protocols. One resident's nebulizer tubing was observed to be dated two weeks prior, contrary to the facility's policy of changing nebulizer setups weekly. The Director of Nursing confirmed that the nebulizer tubing and mask should be changed every seven days to prevent infection control issues. This resident had a diagnosis of chronic pulmonary embolism and required nebulizer treatments for shortness of breath and wheezing. Additionally, three residents were found with nasal cannulas that were not labeled with the date of change, and one resident's humidifier bottle was also not dated. The facility's policy requires nasal cannulas to be changed monthly and as needed, with the date of change clearly labeled. One resident, who was unable to be interviewed due to severe cognitive impairment, was observed with oxygen tubing that lacked a date, and a nurse confirmed the oversight and corrected it immediately. Another resident, who was cognitively intact, had a portable oxygen tank with undated tubing, which the resident reportedly changed themselves. The facility's policies on oxygen therapy devices, including nasal cannulas and high humidity devices, stipulate specific schedules for changing equipment to prevent cross-contamination and ensure safe respiratory care. However, the facility staff, including nurses and the Director of Nursing, demonstrated a lack of adherence to these policies, resulting in potential risks for the residents involved. The failure to follow established protocols for respiratory equipment maintenance and labeling was observed during the survey, highlighting deficiencies in the facility's infection control practices.
Failure to Label Opened Multi-Dose Vials
Penalty
Summary
The facility failed to properly label opened multi-dose vials, which is a requirement for ensuring the safety and efficacy of medications. During an observation of medication storage on the first floor, a surveyor found an opened house stock vial of Tuberculin Purified Protein Derivative in the medication refrigerator without a label indicating when it was opened. The LPN present was unaware of the need to label the vial with an open date, indicating a lack of adherence to the facility's policy. Similarly, on the second floor, a surveyor observed that a resident's Travoprost eye drops were opened without a label of the open date. The RN present acknowledged the oversight and the importance of labeling medications to ensure their effectiveness. The resident involved, who was prescribed Travoprost for primary open-angle glaucoma, has a severe cognitive impairment, as indicated by a BIMS score of 05. The facility's policy requires that multi-dose vials be labeled with the opened and expiration dates, as well as the nurse's initials, to ensure they are used within their effective period. The Director of Nursing confirmed that multi-dose medications should be dated upon opening, as they have a different expiration date once opened. The failure to label these medications as per the facility's policy could potentially affect the efficacy of the medications administered to residents.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility failed to ensure that a resident's call light was accessible and within reach, which affected one resident in the sample reviewed for accommodation of needs. During an observation, the resident was found sitting in a wheelchair, unable to reach the call light, which was wrapped around a dresser drawer behind him. The resident expressed that he did not know where the call light was and mentioned that he had to yell for staff assistance when he could not find it. The Director of Nursing confirmed that the call light was not within reach and secured it to the resident's gown. The resident's medical history includes a history of falling, unequal limb length, unsteadiness on feet, difficulty walking, and a need for assistance with personal care, among other conditions. The resident's care plan, initiated in 2017, indicated that the call light should be within reach to mitigate the risk of falls. The facility's policy on call light use also mandates that call lights be positioned conveniently for residents and within their reach at all times. Despite these guidelines, the call light was not accessible to the resident, leading to the deficiency.
Improper Infection Control in Catheter Care
Penalty
Summary
The facility failed to ensure proper infection control practices were followed in the care of a resident with an indwelling catheter. Specifically, equipment used for bladder irrigation, such as a piston syringe and saline solution, were not discarded after use, which is contrary to the facility's policy. The piston syringe was found to be dated 7/6/24, and the saline solution bottle was dated 6/29/24, both of which were past their recommended usage periods. The Licensed Practice Nurse confirmed that the piston syringe should be changed every 72 hours and the saline solution should be discarded after 30 days of opening to prevent infection. The resident involved had a diagnosis of benign prostatic hyperplasia with lower urinary tract symptoms and neuromuscular dysfunction of the bladder, necessitating the use of an indwelling urinary catheter. The resident's care plan required catheter irrigation every shift per medical order. Despite these requirements, the equipment was not disposed of after use, as confirmed by the Director of Nursing, who stated that both the saline solution and piston syringe should be discarded after use to prevent infection. The resident's mental status was documented as severely impaired, which may have impacted their ability to advocate for their own care.
Infection Control Lapses in Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, as evidenced by two specific incidents involving staff members. In the first incident, a Certified Nursing Assistant (CNA) was observed in the dining area on the third floor handling food for a resident immediately after cleaning up a spill without performing hand hygiene. The CNA acknowledged the mistake, recognizing that hand hygiene should have been performed before handling food for another resident. This lapse in protocol occurred despite the facility's policy requiring hand hygiene between contacts with different residents and before handling food. In the second incident, the same CNA was observed providing Activities of Daily Living (ADL) care to a resident on Enhanced Barrier Precautions (EBP) isolation without donning the required Personal Protective Equipment (PPE), specifically a gown. The resident was on EBP due to a chronic wound, necessitating additional precautions to prevent infection. Although the CNA was aware of the EBP sign and the requirement to wear PPE, they failed to do so, mistakenly believing there was no PPE available, despite the presence of a stocked isolation bin outside the resident's room. The residents involved in these incidents had significant medical histories. One resident had diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and End Stage Renal Disease, while the other had a chronic wound and was receiving antibiotic therapy. Both residents were cognitively intact, as indicated by their Brief Interview for Mental Status (BIMS) scores. The facility's policies clearly outlined the necessity of hand hygiene and PPE use, yet these protocols were not followed, potentially affecting the health and safety of the residents on the third floor.
Failure to Implement Enteral Feeding Recommendation
Penalty
Summary
The facility failed to implement the enteral feeding recommendation made by the Registered Dietician/Clinical Dietician for a resident, leading to significant weight loss and elevated BUN levels. The resident, who had multiple diagnoses including severe dementia, malnutrition, and chronic kidney disease, was observed receiving enteral feeding and flushing that did not meet their nutritional needs. The dietician had recommended increasing the enteral feeding volume and concentration, but this recommendation was not carried out because the family needed to approve it. The resident's weight continued to decline, and their BUN levels remained elevated, indicating inadequate hydration and nutrition. The Director of Nursing confirmed that nurses are expected to follow doctor's orders for G-tube feeding and flushing and to document these actions in the Medication Administration Record (MAR). However, the MAR showed multiple instances where the enteral feeding and flushing were not signed off as administered. The Clinical Dietician noted that the current enteral feeding regimen was insufficient to meet the resident's nutritional needs, and any missed feedings or flushes could contribute to further weight loss and elevated BUN levels. The Nurse Practitioner was aware of the resident's significant weight loss and the dietician's recommendation to increase enteral feeding but was not informed that the order had not been implemented. The resident's electronic health record lacked documentation showing that the dietary recommendation was carried out or that the Nurse Practitioner or Physician was notified. The facility's policy on enteral nutritional feeding requires verification of medical orders and documentation on the MAR, which was not consistently followed in this case.
Failure to Implement Enhanced Barrier Precautions and Provide PPE
Penalty
Summary
The facility failed to follow their policy and procedures to ensure signage indicating Enhanced Barrier Precaution (EBP) was posted outside of a resident's room. Additionally, the facility did not make Personal Protective Equipment (PPE) available and accessible outside of the resident's room or nearby. Staff also failed to wear proper PPE when providing high-contact resident care activities to a resident with multiple diagnoses, including severe dementia, diabetes, and chronic kidney disease. During an observation, the surveyor noted that the resident's room lacked the required EBP signage, and no PPE supplies were accessible. The staff members involved in the resident's care were observed wearing only gloves and not gowns, contrary to the facility's EBP policy. The Director of Nursing (DON) confirmed that the resident with a gastrostomy tube should have been under EBP, and staff should have worn proper PPE, including gowns and gloves, during high-contact care activities. The facility's EBP policy, dated 12/14/23, mandates the use of gowns and gloves for residents with indwelling medical devices and requires posting CDC EBP signs outside the resident's room and making PPE accessible. The failure to adhere to these protocols has the potential for cross-contamination among the 29 residents residing on the 2nd floor.
Failure to Document and Treat Resident's Lower Leg Condition
Penalty
Summary
The facility failed to maintain proper assessment, monitoring, and documentation of a resident's lower leg and feet condition, as per their policy on the prevention and treatment of skin alterations. The resident, who had a history of diabetes mellitus, venous insufficiency, and peripheral vascular disease, had physician orders for the application of bacitracin antibiotic ointment on their feet. However, the Treatment Administration Record (TAR) showed multiple instances where the treatment was not documented as performed. Interviews with staff revealed inconsistencies in the application of the prescribed treatment, with some staff applying a different ointment and others failing to document the treatment altogether. The Assistant Director of Nursing (ADON) and the Wound Care Nurse both confirmed that there was no documentation of the treatment for gangrene on the resident's feet, despite the resident being transferred to the hospital with a diagnosis of dry gangrene. The ADON noted that the resident's legs and feet had been discolored and mottled since their admission, but there was no formal assessment or documentation of the condition. The Wound Care Nurse also confirmed that there was no referral for the resident to be seen by a Wound Nurse Practitioner, and no records indicated that the resident had been assessed for their condition. The MDS Coordinator admitted to missing the inclusion of the bacitracin antibiotic ointment treatment in the resident's care plan when it was first ordered. The care plan was only updated several months later, and it did not address the resident's bilateral lower extremities on a quarterly basis. The facility's policy on the prevention and treatment of skin alterations required regular assessments and documentation, which were not followed in this case. This lack of proper care and documentation led to the resident being transferred to the hospital with a severe condition that had not been adequately addressed by the facility.
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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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