Aliya Of Evanston
Inspection history, citations, penalties and survey trends for this long-term care facility in Evanston, Illinois.
- Location
- 1300 Oak Avenue, Evanston, Illinois 60201
- CMS Provider Number
- 146058
- Inspections on file
- 32
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Aliya Of Evanston during CMS and state inspections, most recent first.
A resident with significant urologic and renal history and an indwelling catheter requested a catheter change due to urine overflow. An RN declined to perform the procedure and had an LPN from another floor insert the new catheter. After insertion, there was no urine output, but the LPN reassured the resident without further assessment, and the resident’s repeated call light use and phone calls for help over several hours went largely unanswered or were significantly delayed. When the RN later deflated the catheter balloon, blood gushed into the catheter tubing, bag, and onto the resident’s diaper and bedding, which the resident captured on video. The resident called 911 and was hospitalized, where imaging showed the catheter balloon inflated in the bulbar urethra with active bleeding and a distended bladder filled with blood and air, along with a marked hemoglobin drop and hemodynamic instability. Facility records lacked nursing progress notes describing the catheter insertion, absence of urine output, bleeding, or assessments during the critical time frame, despite policy requiring detailed catheter documentation and monitoring.
A resident with paraplegia and complex urologic history requested a new indwelling catheter due to urine overflow. An RN declined to perform the catheter change and had an LPN from another floor insert it; after insertion, there was no urine output, but the LPN reassured the resident instead of reassessing. Over several hours, the resident’s call light went unanswered, and multiple calls to the facility’s main line were delayed or not answered while the LPN later admitted he had fallen asleep. The RN and LPN discussed in the hallway who would address the problem, and when the RN finally deflated the catheter balloon, significant bleeding into the catheter bag, linens, and onto the resident occurred. The resident ultimately called 911 himself and was hospitalized with CT-confirmed traumatic urethral catheter placement, large-volume hematuria, and hemodynamic instability. There was no contemporaneous nursing documentation of the catheter insertion, lack of output, repeated calls for help, or bleeding, despite facility catheterization guidelines requiring detailed charting and follow-up for low output.
A resident with complex medical and behavioral health needs did not receive scheduled morning medications and reported the absence of nursing staff after breakfast, leading to feelings of abandonment and lack of safety. The resident also experienced rude treatment from a CNA when expressing concerns, indicating a failure to uphold resident rights to safety and dignity.
The facility failed to follow its pneumococcal vaccination policy requiring all new admissions to be screened and offered the pneumonia vaccine within the first week of admission. Record review showed that four residents with multiple chronic conditions, including CVA, type II DM, COPD, CAD, HTN, malnutrition, and mobility impairments, had no documentation that a pneumococcal vaccine was offered or given since admission. The Infection Preventionist reported that new admissions are not offered the pneumococcal vaccine upon entry but are instead intended to receive it at a later vaccine clinic, and also acknowledged that no such clinic had been held during the past six months, resulting in the residents not being offered the vaccine as required by facility policy.
The facility did not follow its psychotropic medication policy requiring informed consent before starting treatment, as two residents received antipsychotic medications (Quetiapine and Clozapine) for several days before consents were signed. Both residents had complex medical and psychiatric histories, including conditions such as DM, multiple fractures, schizoaffective disorder, toxic encephalopathy, and dementia. The Interim DON acknowledged that psychotropic orders should not be entered before consent and reported that consents were obtained during care plan meetings held days after admission, contrary to the written policy stating that consent must be obtained before entering the medication order into the record.
Surveyors identified a 16% medication error rate when two residents did not receive medications as ordered or per manufacturer instructions. One resident with osteoarthritis, asthma, and hypertension did not receive a prescribed inhaler dose that was nonetheless signed as given, did not receive an ordered oral medication that was unavailable, and had topical Voltaren Gel applied without using the dosing card, in unmeasured amounts, and not to all ordered sites. Another resident with a history of stroke and insulin-dependent type 2 DM received only the sliding-scale dose of insulin lispro instead of both the ordered standing dose and sliding-scale dose, with no documentation explaining the omission of the standing dose.
A resident with intact cognition and multiple medical conditions was transferred to the hospital for a psychiatric evaluation without being informed in advance or having the transfer properly documented. Staff failed to obtain and record a physician's order, did not document the behaviors leading to the transfer, and did not follow facility policy for communication and documentation during the discharge process.
Two cognitively intact residents with chronic health conditions engaged in repeated verbal abuse toward each other during group activities, including name-calling related to weight in both English and Spanish. Staff and other residents confirmed this was an ongoing issue, and while staff attempted redirection and supervision, these measures failed to prevent escalation and emotional distress. The facility did not implement effective interventions to stop the verbal abuse, contrary to its own abuse prevention policy.
Two residents were involved in an incident where one made racially charged and demeaning comments to another, causing emotional distress. Despite a history of aggressive and disruptive behavior by the perpetrator, staff failed to initiate a formal investigation or implement preventive measures, and the required reporting procedures were not followed.
A resident with multiple chronic conditions reported to the receptionist that another resident made a racially charged comment, but no formal investigation or report was initiated by facility administration, despite policy requiring immediate reporting of abuse allegations to the state agency.
A resident with multiple chronic conditions reported to the receptionist that another resident made a racially insensitive comment, but no formal investigation or documentation was initiated by facility administration, despite policy requiring all abuse allegations to be investigated.
The facility failed to ensure resident privacy by not having staff knock before entering rooms, affecting two residents. One resident, with multiple health issues, and another who is blind, reported staff entering without knocking or announcing themselves. Observations confirmed this practice, despite facility policy and management expectations to the contrary.
The facility failed to discard expired medications in the 2nd floor medication room, potentially affecting all 51 residents. A surveyor found an expired Tuberculin vial and a bottle of acetaminophen without an expiration date. A nurse confirmed the TB vial should be discarded after 30 days, as per facility policy.
The facility failed to follow its 3-compartment sink policy when a cook did not submerge a utensil in the quat solution for the required 60 seconds, using it again for food preparation. Additionally, two sandwiches were found without a label date, contrary to the facility's policy on labeling and dating foods. The Dietary Supervisor confirmed the importance of these procedures for food safety.
The facility failed to monitor refrigerator temperatures and food safety in residents' rooms, as evidenced by missing temperature logs and improper temperature settings. Observations revealed that refrigerators contained improperly labeled and undated food items, with some past their sell-by dates. Staff interviews indicated that housekeeping was responsible for monitoring, but the required documentation was not available.
A facility failed to refer a resident with a history of bipolar disorder and alcohol abuse for a Level II PASARR evaluation. The resident was admitted with a Level I determination indicating no Level II was required, despite documented mental health issues. The Admissions Director did not initiate a referral, and the Social Service Director acknowledged the need for a new Level I request. The resident exhibited aggressive behavior and depressive symptoms, highlighting the necessity for a comprehensive evaluation.
The facility failed to follow physician orders for oxygen administration and infection control protocols for two residents. One resident's oxygen cannula was improperly stored and outdated, and their oxygen saturation was below prescribed levels without corrective action. Another resident received oxygen at a higher flow rate than prescribed, with outdated equipment. The facility's policies were not adhered to, leading to these deficiencies.
A facility failed to follow proper infection control practices when a Nurse Practitioner exited a resident's room wearing an isolation gown, despite the resident being under droplet precautions for influenza A. The Acting DON confirmed that PPE should be removed inside the room, and facility documents supported this protocol.
A resident with bipolar disorder and dementia alleged that a CNA hit and fondled him. The facility's investigation found no evidence, citing the resident's confusion and lack of physical signs. However, the resident later provided a detailed account to a surveyor. The CNA was suspended but returned to work on a different floor. The facility's investigation may not have been thorough, as the administrator was unaware of additional allegations until informed by the surveyor.
A resident with moderate cognitive impairment and a high risk of falls was found without necessary fall prevention measures in place, including a non-functional call light and a missing floor mat. Additionally, the resident's wheelchair had a malfunctioning brake, potentially contributing to a recent fall. Staff confirmed the absence of these measures, which are outlined in the facility's fall prevention policy.
Failure to Assess and Manage Indwelling Catheter Leading to Traumatic Urethral Bleeding
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and services for an indwelling urinary catheter for one resident, resulting in a prolonged period without assessment or intervention when the catheter was not draining. The resident, who was cognitively intact with a BIMS score of 15/15 and had significant urologic and renal diagnoses including paraplegia, cystitis with hematuria, hydronephrosis, acute kidney failure, and prior hematuria with stent placement, requested a new catheter when his urine was overflowing. An RN on duty declined to perform the catheter change and asked an LPN from another floor to insert the catheter. The LPN reported being very busy on his own floor but proceeded to insert a new indwelling catheter late at night. After the catheter insertion, the resident observed that no urine was draining and questioned whether the catheter was correctly placed. The LPN told him to give it time and drink water. Over the next several hours, the resident had no urine output and repeatedly sought help by using his call light and calling the facility’s main line multiple times, with delayed or no responses. At one point, the LPN admitted to the resident that he had fallen asleep. Eventually, the RN entered the room, deflated the catheter balloon, and blood immediately gushed into and over the catheter bag and onto the resident’s diaper and bedding. The resident documented the timing of his calls on his cell phone and recorded video showing significant blood in the catheter tubing, bag, and on his diaper. The resident ultimately called 911 himself and was transported to the hospital, where imaging showed the catheter balloon inflated in the bulbar urethra with free air and active extravasation, a distended bladder with a large amount of blood and air, and a significant drop in hemoglobin associated with hemodynamic instability. The facility’s records contained almost no nursing documentation of the catheter insertion, the absence of urine output, the resident’s repeated calls for help, the bleeding episode, or any assessments or interventions between approximately 11:30 PM and 3:00 AM. The DON, NP, Medical Director, and Administrator all confirmed that there were no progress notes from the involved nurses describing what occurred during that time, despite facility policy requiring documentation of catheter size, procedure, urine characteristics, and monitoring of intake and output, and despite a prior similar episode of catheter-related bleeding for this resident that had also resulted in a 911 call and hospital transfer.
Failure to Recognize and Respond to Catheter Complication and Resident’s Urgent Calls
Penalty
Summary
The deficiency involves the facility’s failure to ensure nursing staff had and demonstrated the competencies needed to recognize, assess, and respond to an acute change in condition and urgent calls for help for a resident with an indwelling urinary catheter. The resident, who is cognitively intact with a BIMS score of 15/15 and has diagnoses including paraplegia, urinary device management, cystitis with hematuria, hydronephrosis, acute kidney failure, and kidney/ureter calculi, requested a new catheter when his urine was overflowing. An RN on the unit declined to perform the catheter change and asked an LPN from another floor to insert the catheter. The LPN reported being very busy on his own floor, but proceeded to insert the catheter late at night. After insertion, no urine drained, and when the resident questioned the placement, the LPN told him to give it time and drink water. Over the next several hours, the resident experienced continued lack of urine output and repeatedly attempted to obtain assistance. He activated his call light without response, then called the facility’s main line multiple times, with calls documented on his cell phone. On one call, the LPN answered and asked for 25 minutes before coming; on another, the LPN later admitted to the resident that he had fallen asleep. The resident reported hearing the LPN and RN in the hallway discussing who would address the problem. Eventually, the RN entered the room, deflated the catheter balloon, and blood immediately gushed into and over the catheter bag, onto the sheets, diaper, and the resident. The RN appeared startled and called the LPN back into the room. The resident then made additional calls to the building line as bleeding continued, and when the nurses returned, he told them not to touch him and to call an ambulance. The resident ultimately called 911 himself, and paramedics arrived and transported him to the hospital. Hospital records documented a traumatic indwelling catheter insertion with CT imaging showing the catheter balloon inflated in the bulbar urethra with free air and contrast extravasation consistent with active bleeding, a distended bladder with a large amount of blood and air, and a hemoglobin drop from 13.2 to 6.5 with hemodynamic instability requiring ICU-level care. The facility’s Administrator later stated she was not aware of the severity of the injury until reviewing the hospital diagnosis of traumatic urethral bleeding. The DON reported that the RN had said she was not comfortable with male catheters and had asked the LPN for help, and that she was unsure what caused the bleeding. The NP believed the catheter had been inserted in the wrong place and not fully advanced. There were no nursing progress notes by either nurse documenting the assessment, catheter insertion, lack of urine output, resident’s repeated calls for help, or the bleeding episode between late night and early morning, despite facility policy requiring documentation of catheter size, procedure, urine characteristics, and resident response, and guidance to check for low output and notify a physician or NP when indicated. The only notes around the event were brief entries indicating the resident was sent to the hospital and later admitted for traumatic urethral bleeding, and the medical record contained no documentation that the resident had ever removed his own catheter.
Failure to Ensure Resident Safety and Timely Medication Administration
Penalty
Summary
The facility failed to ensure a resident's right to feel safe and secure, as required by its Residents Rights Policy. A male resident with multiple medical diagnoses, including cervical disc degeneration, asthma, diabetes, kidney failure, hypertension, dementia with behavioral disturbances, bipolar disorder, alcohol abuse, depression, and adult failure to thrive, reported not receiving his scheduled morning medications on Christmas Day. The resident stated that he typically receives his medications between 8:00AM and 9:00AM, but on the day in question, he had breakfast and did not receive his medications as expected. He also reported that there was no nurse present on the second floor until well after breakfast, which contributed to his feelings of abandonment and lack of safety. The resident further stated that when he voiced his concerns about the absence of a nurse and the delay in receiving his medications, a CNA responded rudely to him. This interaction, combined with the lack of timely medication administration and absence of nursing staff, led the resident to feel unsafe and unsupported in the facility. The facility's policy documents the right of residents to safety and protection from abuse and neglect, but these rights were not upheld in this instance.
Failure to Follow Policy for Timely Pneumococcal Vaccination of New Admissions
Penalty
Summary
The deficiency involves the facility’s failure to follow its own pneumococcal vaccination policy by not screening and offering the pneumonia vaccine to new residents within the first week of admission. The facility’s policy, titled “Pneumococcal Vaccinations” and reviewed on 1/6/2025, states that all current residents or their responsible party will be screened and offered the pneumonia vaccine within the first week of admission and annually, if eligible. Record review showed that four residents’ immunization reports contained no documentation that a pneumococcal vaccine was offered or given since admission. These four residents included an older male with multiple diagnoses such as cerebral infarction, type II DM, obesity, epilepsy, sleep apnea, and acute kidney failure; an older female with rhabdomyolysis, protein calorie malnutrition, HTN, cellulitis, CAD, and depression; an older male with muscle disorder, gait and mobility abnormalities, lack of coordination, intracerebral hemorrhage, HTN, hemiplegia, dysphagia, and anxiety; and an older female with venous insufficiency, gait and mobility abnormalities, protein calorie malnutrition, acute respiratory failure, type II DM, and COPD. During an interview, the Infection Preventionist stated that the facility does not offer the pneumococcal vaccine to new admissions immediately upon entering the facility, but instead plans to offer them at a scheduled clinic at a later date. The Infection Preventionist further stated that in the six months in this role, no vaccine clinic had yet been held, confirming that pneumococcal vaccines had not been offered to these new residents in accordance with facility policy.
Failure to Obtain Informed Consent Before Initiating Psychotropic Medications
Penalty
Summary
The facility failed to follow its own psychotropic medication policy requiring residents or their representatives to be informed of risks and benefits and to provide informed consent before psychotropic medications are initiated. For one resident, an adult female with multiple diagnoses including type II DM, cellulitis of the face, multiple fractures, sleep apnea, hyperlipidemia, sciatica, alcohol abuse, schizoaffective disorder, and cocaine abuse, the Physician Order Summary Report showed that Quetiapine Fumarate, an antipsychotic, was started on 10/8/2025. However, the corresponding psychotropic consent form was not signed until 10/15/2025, meaning the resident received the antipsychotic medication for seven days prior to documented consent. For another resident, an adult female with diagnoses including toxic encephalopathy, dysphagia, cognitive communication deficit, need for assistance with personal care, multiple fractures, paranoid schizophrenia, and dementia, the Physician Order Summary Report showed that Clozapine was started on 9/9/2025. The psychotropic consent form for this resident was signed and dated 9/17/2025, indicating she received the antipsychotic medication for eight days before consent was obtained. During an interview, the Interim DON stated that orders for psychotropic medications should not be entered prior to obtaining consent and explained that she obtained consents for these residents at their care plan meetings, which are usually held 3–7 days after admission. The facility’s written policy states that once informed consent is obtained, the order will be entered into the medical record, which did not occur in these two cases.
Medication Administration Errors and Failure to Follow Physician and Manufacturer Instructions
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered as ordered and according to manufacturer instructions, resulting in a 16% medication error rate (4 errors out of 25 opportunities) during observation of medication administration. One resident, an older female with bilateral primary osteoarthritis, asthma, and essential hypertension, had multiple medication administration errors. Her physician orders included Advair Diskus inhaled every 12 hours, spironolactone 50 mg orally once daily, and Voltaren Gel 1% applied to both knees and feet twice daily with a 2 g dose. During a medication pass, the RN did not administer Advair Diskus as ordered but documented it as given in the MAR and instead showed the surveyor an Incruse Ellipta inhaler. Spironolactone was also not administered because it was reportedly not available, despite being ordered previously, and there was no indication at that time that the MAR was properly documented to reflect it was not given. The same resident experienced errors with the administration of Voltaren Gel. The RN donned gloves and applied an unspecified “ample” or “desirable” amount of Voltaren Gel to each knee using his gloved hand, without using the dosing card supplied by the manufacturer to measure the ordered 2 g dose. The gel was not applied to the resident’s feet as required by the physician’s order, and the amount applied to the knees did not correspond to a measured 2 g dose. Manufacturer guidelines for Voltaren Gel specify that the proper amount must be measured using the dosing card, with the gel applied within the oblong area up to the appropriate gram line and then rubbed into the skin, but this process was not followed. Another resident, an older male with a history of cerebral infarction and type 2 diabetes mellitus with hyperglycemia, also experienced a medication administration error involving insulin lispro. His physician orders included a standing order to inject 4 units SQ with meals for hyperglycemia and an additional sliding scale order (2 units for blood glucose 150–199 mg/dL, 3 units for 200–249 mg/dL, etc., with instructions to call the MD if blood glucose exceeded 350 mg/dL). During observation, an RN administered only 2 units of insulin lispro when the resident’s blood sugar was 167 mg/dL, stating that she followed only the sliding scale and believed the 4-unit order was merely a reminder and that the two orders “go together.” There was no documentation in the progress notes explaining why the 4-unit standing dose was not given, despite the care plan indicating that diabetes medications were to be administered as ordered by the physician and monitored for side effects and effectiveness.
Failure to Inform and Document Resident Transfer for Psychiatric Evaluation
Penalty
Summary
The facility failed to follow its discharge and change in resident condition policies during the transfer of a cognitively intact male resident with multiple diagnoses, including osteoarthritis, diabetes, morbid obesity, and nicotine dependence. The resident was transferred to the hospital for a psychiatric evaluation without being informed in advance of the reason for the transfer, as required by facility policy. The resident reported being awakened in the early morning hours and told by a nurse that he was going to the hospital, but was not given an explanation. He initially refused the transfer and called 911, resulting in police involvement before he ultimately agreed to go to the hospital. Documentation in the resident's medical record was incomplete. There was no record of the physician's order for the transfer, no documentation of the behaviors that led to the decision, and no evidence that the resident was informed of the transfer or the reason for it. Staff interviews confirmed that while some steps may have been taken, such as obtaining a physician's order and informing the resident, these actions were not documented as required by policy. The facility's discharge and change in condition policies require notification of the resident and responsible party, physician involvement, and thorough documentation in the medical record, none of which were fully met in this case. The incident was triggered by reports of the resident being verbally aggressive toward other residents and staff, leading to a decision to initiate an involuntary petition for psychiatric evaluation. Despite the facility's stated process for handling such behaviors, including assessment by social services, administrative review, and physician orders, the required documentation and communication steps were not followed or recorded. The lack of documentation and failure to inform the resident in advance constituted a violation of both facility policy and resident rights.
Failure to Prevent Resident-to-Resident Verbal Abuse During Activities
Penalty
Summary
The facility failed to prevent and protect two residents from ongoing verbal abuse between each other during facility activities. Both residents, who are cognitively intact and have multiple chronic medical conditions, engaged in repeated name-calling, specifically using derogatory terms related to weight, in both English and Spanish. This behavior was observed during group activities such as smoking breaks and movie viewings, with both residents confirming their participation in the inappropriate exchanges. Staff interviews revealed that the verbal altercations between the two residents were a known, ongoing issue. Activity aides and the activity director reported that the residents frequently called each other inappropriate names, and while redirection was sometimes effective, it did not prevent escalation during the incident in question. On the day of the reported event, staff attempted to intervene by separating the residents, but the verbal abuse continued, resulting in one resident becoming very upset and expressing a desire for the name-calling to stop. Other residents and staff corroborated that the verbal abuse was a recurring problem and that one of the residents often intimidated both staff and other residents. Despite supervision during activities and previous attempts at redirection, the facility did not implement effective interventions to prevent further incidents. The facility's own policy defines verbal abuse as the use of disparaging or derogatory language, which was not adequately prevented in this case.
Failure to Investigate and Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident (R3) from abuse by another resident (R2), resulting in emotional distress. R3, who had multiple medical diagnoses including osteoarthritis, diabetes, and morbid obesity, and was cognitively intact, reported that R2 made racially charged and demeaning comments to him in the dining room. R3 immediately reported the incident to the receptionist, who stated she informed the former administrator upon his arrival. However, there was no documentation or evidence that a formal investigation or report was initiated regarding this specific incident. Further review revealed that R2 had a documented history of escalating non-compliant behaviors, aggression, and vocalizing racial slurs towards other residents and staff, which had previously led to a referral for inpatient psychiatric evaluation. Despite this history, no preventive measures or immediate interventions were implemented to protect R3 or other residents. The current administrator was not made aware of the incident until after the fact, and both the administrator and the registered nurse confirmed that no formal investigation or report was conducted as required by the facility's abuse policy.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Survey Agency as required by policy. A resident with multiple diagnoses, including osteoarthritis, diabetes, morbid obesity, hyperlipidemia, and sleep apnea, reported an incident in which another resident made a racially charged comment, referring to him as a 'slave.' The resident, who was cognitively intact, was upset by the incident and immediately reported it to the facility receptionist. The receptionist stated that she informed the former administrator upon his arrival and was assured the matter would be addressed. Despite the report, no formal investigation or report was initiated regarding the incident. The former administrator denied knowledge of the allegation, and the current administrator confirmed that no investigation or report had been made. The facility's abuse policy requires immediate reporting of any abuse allegation to the Illinois Department of Public Health, but this protocol was not followed in this case.
Failure to Investigate Alleged Abuse Following Resident Complaint
Penalty
Summary
A resident with multiple medical conditions, including osteoarthritis, diabetes, morbid obesity, hyperlipidemia, and sleep apnea, reported an incident in which another resident made a racially insensitive comment, referring to the resident as a 'slave.' The resident, who was cognitively intact, was upset by the comment and reported the incident to the facility receptionist. The receptionist stated that she informed the former administrator of the complaint upon his arrival and was assured that the matter would be addressed. Despite the report, the former administrator later stated that he was not made aware of the allegation, and no formal investigation or documentation of the incident was initiated. The current administrator confirmed that no investigation or report was conducted regarding the incident. The facility's abuse policy requires that all incidents or allegations involving abuse be documented and investigated, but this protocol was not followed in this case.
Failure to Ensure Resident Privacy
Penalty
Summary
The facility failed to uphold the residents' right to privacy by not ensuring that staff knocked on the door before entering residents' rooms. This deficiency was observed in the cases of two residents. One resident, a male with a medical history including hypertension, sleep apnea, obesity, and chronic heart failure, expressed concerns about staff entering his room without knocking or announcing themselves. Another resident, who is blind and has undergone multiple eye surgeries, also reported that staff did not knock or introduce themselves, despite a sign on the door requesting this courtesy. During observations, a housekeeping staff member was seen entering the rooms of these residents without knocking, despite being aware of the requirement. Both residents had previously filed grievances about this issue, indicating a pattern of non-compliance with privacy protocols. Interviews with facility management, including the Nursing Manager, Regional Director of Operations, and Interim Director of Nursing, confirmed that staff are expected to knock and wait for a response before entering a resident's room. The facility's policy on residents' rights to privacy also mandates this practice.
Expired Medications Not Discarded in Medication Room
Penalty
Summary
The facility failed to discard expired opened medications from the 2nd floor medication room, which has the potential to affect all 51 residents residing in the facility. During a medication room inspection, a surveyor observed an open house stock Tuberculin purified Protein Derivative (TB) vial that was about 75-80% full in the medication fridge, with an open date of 9/26/24, indicating it was expired. Additionally, a bottle of house stock acetaminophen 500mg was found on the medication cart without an expiration date. During an interview, a Registered Nurse confirmed that the opened TB vial should be discarded after 30 days and expired medications should be returned to the return bin for pharmacy pick-up. The facility's policy and best practices document state that outdated drugs should be immediately withdrawn and disposed of according to drug disposal procedures.
Non-compliance with Sanitation and Food Labeling Policies
Penalty
Summary
The facility failed to adhere to its 3-compartment sink policy, as observed when a cook, identified as V13, did not submerge a used utensil in the Quaternary Ammonium Compounds (quat) solution for the required 60 seconds. Instead, the utensil was submerged for approximately 2 seconds before being used again to prepare food. This was confirmed by V13, who acknowledged the deviation from the standard procedure, which mandates sanitizing items in the quat solution for at least 60 seconds to eliminate bacteria. The Dietary Supervisor, V12, also confirmed the purpose of the procedure and the requirement for air drying. Additionally, the facility did not comply with its Labeling and Dating Foods Policy. During an inspection, two individually wrapped ham and cheese sandwiches were found without a label date. The Dietary Supervisor, V12, immediately labeled the sandwiches with the current date. V12 explained that prepared food is considered good for 72 hours and that labeling is essential to track the use-by date. The policy requires that all ready-to-eat, potentially hazardous food be re-dated with a use-by date according to safe food guidelines or the manufacturer's expiration date.
Failure to Monitor Refrigerator Temperatures and Food Safety
Penalty
Summary
The facility failed to monitor and maintain the temperature of refrigerator units in residents' rooms, as evidenced by the absence of temperature logs and improper temperature settings. During observations, it was noted that the refrigerators in the rooms of four residents did not have temperature logs, and the temperatures were either too high or too low, deviating from the facility's policy of maintaining temperatures between 32°F and 41°F. For instance, one refrigerator was found at 48°F, while another was at 14°F. Additionally, the refrigerators contained improperly labeled and undated food items, some of which were past their sell-by dates. Interviews with staff, including a Restorative Aide, a CNA, and the Housekeeping Director, revealed that housekeeping was responsible for monitoring the refrigerator temperatures. However, the Housekeeping Director was unable to produce the temperature logs when requested, indicating a lapse in documentation and monitoring procedures. The facility's policy requires daily checks of refrigerator temperatures and proper labeling and dating of food items, but these procedures were not followed, leading to the observed deficiencies.
Failure to Refer Resident for Level II PASARR Evaluation
Penalty
Summary
The facility failed to refer a resident for a Level II PASARR evaluation, which is required for individuals with serious mental illness or intellectual disabilities. The resident in question, identified as R27, was admitted to the facility with a PASRR Level I determination indicating that no Level II evaluation was required. However, the resident had a documented history of bipolar disorder and alcohol abuse, which should have prompted a Level II evaluation. The Admissions Director, V17, relied on the initial determination from the hospital and did not initiate a Level II referral, while the Social Service Director, V9, acknowledged that a new Level I should have been requested given the resident's mental health history. The resident's medical records revealed a history of bipolar disorder and recent hospitalization for alcohol abuse with withdrawal delirium. Progress notes indicated ongoing issues with aggressive behavior, anxiety, and depressive symptoms, which further underscored the need for a comprehensive Level II PASARR evaluation. Despite these indicators, the facility did not take the necessary steps to ensure the resident received the appropriate assessment, resulting in a deficiency in the facility's compliance with PASARR requirements.
Failure to Follow Oxygen Administration and Infection Control Protocols
Penalty
Summary
The facility failed to adhere to physician orders regarding oxygen administration and infection control protocols for two residents. For one resident, the oxygen nasal cannula was found on the floor and not stored in a plastic bag, and the oxygen humidifier was outdated. The resident's oxygen saturation was below the prescribed level, yet oxygen was not administered as required. The registered nurse acknowledged the need for proper storage and weekly changes of the nasal cannula and humidifier but did not take corrective action during the observation. For another resident, the oxygen was set at a higher flow rate than prescribed, and the nasal cannula and humidifier were not dated or changed weekly as required. The acting Director of Nursing confirmed the expectation for weekly changes and proper administration of oxygen as per physician orders. The facility's policy on oxygen safety and use was not followed, contributing to the deficiencies observed during the survey.
Failure to Follow PPE Protocols for Resident with Influenza A
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices for a resident under droplet precautions. During unit rounds, a Nurse Practitioner was observed exiting a resident's room while still wearing an isolation gown, contrary to the facility's protocol that requires all personal protective equipment (PPE) to be removed before leaving the room. The resident in question had been diagnosed with influenza A and was under contact and droplet isolation. The Acting Director of Nursing confirmed that PPE should be removed inside the resident's room and acknowledged that the room should have been marked with both contact and droplet precaution signs. Facility documents reviewed also indicated that all PPE, except a respirator if worn, should be removed before exiting the patient room.
Inadequate Investigation of Sexual Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving a resident with a history of bipolar disorder and dementia. The incident was reported on 11/8/24 when the resident claimed that a CNA had hit him on the shoulder and later fondled his genitals. The facility's initial investigation concluded that the abuse could not be substantiated due to a lack of physical evidence and the resident's mild confusion. However, the resident later provided a detailed account of the alleged abuse to a surveyor, describing the CNA's actions and physical appearance. The facility's administrator reported the incident to the state department and conducted interviews with staff and other residents, but found no corroborating evidence or complaints about the CNA. The CNA was suspended during the investigation but later returned to work, albeit on a different floor from the resident. The administrator expressed disbelief in the resident's claim of having encountered the CNA at another facility, as no such facility existed. The facility's policy mandates documentation and investigation of all abuse allegations, but the report indicates that the investigation may not have been comprehensive, as the administrator was unaware of the resident's additional allegations until informed by the surveyor.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement fall prevention measures for a resident with a high risk of falls, as identified in their care plan. The resident, who has moderate cognitive impairment and requires substantial assistance for transfers, was observed without a floor mat in place, which is a specified precaution in their care plan. Additionally, the resident's call light was not functioning, preventing them from alerting staff for assistance. The resident's wheelchair was also found to have a malfunctioning brake, which could have contributed to a recent fall resulting in a vertebrae fracture. Interviews with facility staff confirmed the absence of necessary fall prevention measures. A registered nurse acknowledged that the resident's call light should be within reach and operational, and a fall mat should be in place at all times. The regional nurse consultant emphasized the importance of these measures in preventing injuries and falls. The facility's policy on fall prevention and management outlines the need to identify residents at risk and implement preventive strategies, which were not adequately followed in this case.
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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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