Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aliya On 87th during CMS and state inspections, most recent first.
A dependent resident with dementia, hemiplegia, reduced mobility, and a care plan requiring a mechanical lift with two‑person assist for all surface‑to‑surface transfers was improperly transferred by a CNA who had been employed about one month and was not assigned to the resident. At the request of an LPN, the CNA used a gait belt and performed a one‑person stand‑pivot transfer from wheelchair to bed instead of using the ordered mechanical lift. During the transfer, the resident grabbed the bed rail and then the CNA, and immediately afterward complained of right arm pain. Later nursing documentation linked the onset of pain to this transfer, and STAT imaging showed an impacted transverse fracture of the right humeral neck and greater tuberosity. Interviews showed that some staff were unsure of the resident’s transfer method, the CNA was not informed of the need for a two‑person mechanical lift, and not all staff had clearly documented in‑service training on proper transfer techniques, leading surveyors to cite the facility for failing to ensure safe, care‑planned transfers and effective communication of transfer status.
A high fall-risk resident with severe cognitive impairment, impaired upper extremity ROM, and need for extensive assistance with ADLs was on an air mattress without side rails and required total assistance for care. During incontinent care, a CNA rolled the resident away from herself to clean feces, contrary to facility teaching to roll residents toward the caregiver, and the resident continued rolling off the bed onto the floor, sustaining a bleeding head wound and blunt head trauma requiring hospital admission. A nurse in the room heard the fall, found the resident on the floor bleeding from the back of the head, applied pressure, and called 911. Staff interviews confirmed that residents should be turned toward staff during care to prevent falls, and the administrator reported that the incident was not reported to the state agency because they believed reporting was only required if sutures or staples were needed.
Failure to provide timely incontinence care and follow the resident’s skin care plan resulted in new skin breakdown. A dependent resident with bowel and bladder incontinence, a G-tube, impaired cognition, and an existing stage 4 sacral PU was found soaked with urine and feces, with a soiled sacral dressing, new MASD to the perianal area, and a new stage 2 pressure injury on the inner thigh linked to the brief’s pressure, shear, and friction.
Insufficient nursing staffing and delayed resident care: Residents and a CNA reported repeated shortages of CNAs and nurses, especially on weekends and overnight shifts, with delayed med pass, slow call light response, and delays in being changed when wet or soiled. A staffing coordinator said staffing was based on census and that the facility did not use agency staff, while survey review of timecards and PBJ data showed inadequate CNA staffing on some days and multiple weekends, with a one-star staffing rating.
Food items were found improperly labeled, stored, and discarded in the kitchen. An unopened supply of milk past its best-by date was mixed with newer stock, freezer shelving measured less than 6 inches off the floor in several units, and opened BBQ sauce and soy sauce were left at room temperature without use-by dates despite manufacturer instructions to refrigerate after opening. The Dietary Manager and RD confirmed the labeling and storage practices did not match facility guidance.
Trash and debris were observed on the ground around the dumpster, including food scraps, cans, cups, gloves, face masks, and empty cleaning bottles. The Dietary Manager said the area was a mess and should not have trash around the dumpster, and the ESD stated housekeeping was responsible for keeping the area clean and free of trash. Two used culture vials in a plastic bag were also found by the back door, and the ESD said they should have been placed in the hazard compactor.
Staff failed to follow infection control practices when a CNA entered a resident’s contact precaution room without gown and gloves and left without hand hygiene, an LPN performed blood glucose testing with only one glove and no hand hygiene, reused an uncleaned BP device on multiple residents, and EBP signage was missing for a resident with nephrostomy tubes. Staff also did not wear a gown during high-contact care for another resident on EBP.
Missing Care Plans for Residents on Anticoagulants: Two residents receiving anticoagulant therapy had no documented care plan in the EHR. One resident had multiple chronic conditions including AFib, ESRD on dialysis, and heart failure, while the other had HF, cirrhosis, alcohol dependence, epilepsy, and thrombosis. The DON and MDS Director stated that residents on anticoagulants should have individualized care plans with goals and interventions, but none were found for either resident.
Failure to provide timely incontinence care for a resident who was dependent on staff for ADLs and always incontinent of bowel and bladder. A roommate reported the resident had not been changed for hours, and the resident stated she was wet and needed to be changed. When the CNA provided care, the brief and pad were saturated with urine and feces, the perineal and buttock areas were heavily soiled, and the sacral wound dressing was soiled and not intact. The resident had a G-tube, severely impaired cognition, and fragile skin, and the DON stated incontinent residents were to be checked at least every hour and care provided promptly.
Failure to Maintain IV Dressing Integrity and Care Plan: A resident with a midline IV had a transparent dressing that was peeling and remained dated beyond the expected change interval, while the resident’s care plan did not address the IV line. Surveyors also observed an LPN handling the IV dressing with bare hands without hand hygiene or gloves, despite orders to monitor the insertion site and keep the dressing intact.
Failure to provide ordered 1:1 feeding assistance and to include aspiration/swallowing precautions in the care plans for two residents. Both residents had significant cognitive impairment and dysphagia-related orders, including mechanical soft diets, thin liquids, and 1:1 assist with aspiration/swallowing precautions. During lunch observation, staff did not sit with either resident for 1:1 feeding; instead, a CNA said she was monitoring the room generally, not providing 1:1 assist. One resident’s care plan addressed malnutrition and 1:1 feeding, but neither care plan included aspiration or swallowing precautions.
Improper Storage of Oxygen Cannula Tubing: A resident’s PRN oxygen tubing was found not stored in a bag or container when not in use; the nasal cannula was left in an open drawer near other items and later wrapped around the bed rail. The resident said he turns the oxygen on and off as needed and had not been told to store the tubing in a plastic bag or container. The DON and an LPN stated the tubing should be stored in a bag when not in use for infection control reasons, and the facility policy required oxygen tubing to be appropriately stored to prevent contamination.
A high fall-risk, bedbound, nonverbal resident with severe contractures and total dependence for ADLs was care planned for a low bed, call light within reach, and two-person assistance for in-bed care. An assigned CNA, who had not been informed at shift start that the resident required two-person assist, performed linen and incontinence care alone, turned the resident to one side near the edge of the bed, leaned on the low air loss mattress to reach supplies, and caused the resident to slide off the bed, partially onto a floor mat and the floor, resulting in a head laceration. An LPN responding to the fall documented that the resident grimaced and moaned with palpation of the left leg but did not report this new post-fall leg pain to the APN, who documented no active pain and issued no immediate imaging orders. Later observations showed the resident’s bed not maintained in the lowest position and the adaptive call light out of reach, and subsequent imaging revealed a proximal left femur fracture, demonstrating failures to follow fall-prevention, ADL, call light, and pain management policies for this high-risk resident.
A resident with dementia and multiple comorbidities, who had a state-appointed legal guardian documented as the primary surrogate decision maker, experienced a fall in the bathroom resulting in a minor skin tear and was sent to the ER for evaluation. An LPN documented the fall, treatment of the skin tear, and transfer to the hospital, and later left a message for the resident’s second emergency contact, but there was no documentation that the legal guardian was notified of the fall or the hospital transfer. Another LPN documented the resident’s return from the hospital, negative CT scan, stable condition, and maintained safety measures, again without any record of guardian notification. Facility records, including the guardian’s letter of instruction and the physician-family notification policy, and staff interviews (LPNs, unit managers, social work director, and DON) all confirmed that the legal guardian was required to be notified first of falls, changes in condition, and hospital transfers, and that such notifications must be documented, establishing that the facility failed to follow its own policies and the guardian’s instructions in this case.
A resident with a history of cerebrovascular disease, delirium, and mobility issues was identified as high fall risk but did not receive adequate fall prevention interventions. The care plan lacked specific measures, and staff did not consistently provide increased supervision or use equipment like floor mats. The resident fell in the dining room while unsupervised, resulting in an acute subdural hematoma and facial swelling. Staff interviews confirmed that required interventions were not in place at the time of the incident.
A resident was subjected to physical and verbal abuse by a CNA during ADL care, including rough handling, derogatory language, and inappropriate comments. Two other residents in the room corroborated the abusive behavior, with one witnessing the rough treatment and another hearing the altercation. The resident was cognitively intact at the time, and the incident was reported to facility leadership, but the care plan was not updated with new interventions after the event.
A resident who was dependent for mobility was observed on multiple occasions remaining in bed and expressing a desire to get up, but staff did not provide assistance or document any refusals or education as required. Staff interviews revealed inconsistent practices, and the resident's records lacked necessary documentation regarding ADL care and refusals.
Several cognitively impaired residents with high fall risk were observed wearing smooth-bottomed socks instead of required non-skid footwear while out of bed in common areas. Despite facility policy and available supplies, staff did not ensure proper footwear was used, and records confirmed these individuals had significant medical conditions and care plans identifying their fall risk.
Staff did not intervene in time to prevent two residents from engaging in a physical altercation, resulting in both sustaining facial abrasions. The incident occurred in a dementia unit, and both residents were assessed and treated for minor injuries after the event.
A resident with advanced neurocognitive and medical conditions was transferred to a different unit without prior notification to the Power of Attorney (POA), as required by facility policy and residents' rights. The POA only learned of the move after it occurred, and documentation of notification was missing or entered late. Staff interviews confirmed that the notification process was not followed and the required written notice was not provided.
A resident developed a facility-acquired stage 3 pressure ulcer due to the facility's failure to follow its wound prevention policy. Despite being at risk for skin integrity issues, the resident's wound care was inadequately monitored, leading to a stage 4 ulcer with osteomyelitis. Inconsistencies in wound assessments and a lack of timely intervention contributed to the deterioration of the resident's condition.
A resident with dementia and other medical conditions eloped from the facility without staff awareness, despite wearing a wander guard. The resident left for a casino, and staff were unaware until hours later. The facility's policies on elopement and out on pass were not followed, and the resident's care plan lacked adequate measures to prevent such incidents.
The facility failed to post accurate and complete nursing staffing information, affecting all 190 residents. The posted information was outdated and lacked the facility's name and current census numbers. The staffing coordinator confirmed the oversight, and the administrator acknowledged the absence of a policy for the daily staffing form, despite it being a regulatory requirement.
The facility failed to provide snacks to residents when the time between dinner and breakfast exceeded 14 hours, affecting all 190 residents. Meal schedules showed a 14-hour and 45-minute gap, and residents confirmed snacks were not served. The administrator and dietary manager provided conflicting information, with only 11 residents listed as receiving snacks. The facility lacked a policy for snack administration, and the administrator incorrectly claimed compliance with regulations.
A surveyor observed three oxygen cylinders standing freely without holders near the nursing station, posing a potential hazard. The RN confirmed that the tanks should have been stored in the designated oxygen room. The facility's policy requires oxygen cylinders to be stored in holders to prevent accidents.
The facility failed to properly label, date, and store food items, including gelatin and pork chops, and did not maintain complete temperature logs for refrigeration units. This oversight could potentially lead to foodborne illnesses affecting all residents receiving oral nutrition.
The facility failed to ensure staff wore appropriate PPE during care activities for residents with indwelling catheters, and did not consistently post Enhanced Barrier Precaution (EBP) signs. This led to staff providing care without gowns, despite the need for such precautions. Additionally, PPE supplies were not readily accessible, contributing to non-compliance with infection control protocols.
A facility failed to follow its policy for self-administration of medication, affecting a resident who was found with Nystatin Powder on their nightstand without a physician's order. The resident, who was cognitively intact, had no timely care plan in place for self-administration, posing a potential hazard. The facility's policy requires a physician's order and a care plan, which were not adhered to in this instance.
A resident with cognitive intactness reported bruises from alleged rough handling by staff and verbal abuse by a nurse. The facility's administrator investigated and attributed the bruises to lab draws but failed to report the physical abuse allegation to the state survey agency, only reporting verbal abuse. This oversight violated the facility's abuse prevention policy.
A facility failed to complete a Pre-Admission Screening and Resident Review (PASRR) for a resident with multiple diagnoses, including Vascular Dementia and Bipolar Disorder, before their admission. The resident was admitted before the implementation of a new program, and their information was not submitted, leading to the deficiency being identified during a survey.
A facility failed to review and provide a baseline care plan to a resident with complex medical conditions and their representative within the required timeframe. The resident, who was cognitively impaired, and their family member were not informed about the care plan, leading to confusion and dissatisfaction. The facility's policy requires a baseline care plan to be developed within 48 hours of admission and a summary provided within five days, but there was no documentation of this being done.
A facility failed to update a care plan for a resident with multiple mental health diagnoses, including Bipolar Disorder and Major Depressive Disorder, due to the resident's admission before the Maximus program implementation. The resident's PASRR Level I indicated a need for a Level II review, but the care plan was not updated to reflect this due to the lack of submission to the program. The facility lacked a specific policy for updating care plans for PASRR, contrary to their comprehensive care plan policy.
Two residents in an LTC facility did not receive adequate ADL care, resulting in deficiencies in grooming and personal hygiene. One resident, with conditions like Hemiplegia, had long fingernails causing discomfort, while another resident, with Myopathies, had facial hair and long nails. Despite staff acknowledging these needs, timely care was not provided, and documentation did not support consistent service delivery.
A facility failed to set a low air loss mattress according to a resident's weight, crucial for pressure ulcer prevention. The resident, with Alzheimer's and other conditions, was on a mattress set at 300, despite weighing around 133 lbs. Interviews confirmed the setting should match the resident's weight, and exceeding 300 could worsen the ulcer. The facility's care plan and job descriptions emphasize proper mattress use and adherence to safety procedures.
A resident with moderate cognitive impairment and a history of arthritis and hypertension did not receive necessary foot care, resulting in long, thick, and ridged toenails causing discomfort. Despite the resident's attempts at self-care, facility staff were unaware of the issue, and the resident was not scheduled for a podiatrist visit. The facility's foot care guidelines were not followed, and the resident's physician order sheet lacked foot care orders.
The facility failed to manage oxygen equipment properly for two residents, leading to infection control deficiencies. One resident's nebulizer mask was undated and improperly stored, while another's oxygen tubing was not changed weekly as required. Staff acknowledged these lapses, emphasizing the importance of proper labeling, storage, and timely equipment changes to prevent infection.
The facility failed to reconcile controlled substances at the end of a shift, affecting three residents on the 2nd floor. The Shift Change Accountability Record was missing a signature for a narcotic count during a shift change. Staff interviews confirmed that the narcotic count is usually conducted by oncoming and outgoing nurses, with discrepancies reported to the DON. The facility's policy requires a count and signature at each shift change, which was not followed.
The facility failed to ensure the availability and administration of prescribed medications for two residents. One resident did not receive any of her prescribed medications upon admission, despite some being available in the convenience box. Another resident experienced a delay in receiving her scheduled medication due to it not being found in the convenience box. The facility's medication administration policy was not effectively followed, potentially affecting all 191 residents.
A facility failed to administer medications as ordered for five residents, including antihypertensive and hypoglycemic drugs. Medications were not available in the convenience box, leading to delays. The DON confirmed that medications should be given within a specific time frame, which was not followed. The EMAR showed late administration for several residents, with some medications not given at all.
A facility failed to develop a comprehensive baseline care plan within 48 hours of admission for a resident with significant care needs, including assistance with ADLs due to left-sided weakness from a stroke. The care plan lacked specific instructions for transfer and dressing assistance, contrary to facility policy.
A resident with a history of stroke and moderate cognitive impairment was found with a saturated incontinence brief, indicating a failure to provide timely ADL care. The CNA responsible admitted to not changing the resident since the start of their shift, over four hours prior, and was unclear about the required frequency of checks. This lack of adherence to the care plan and facility policy led to the deficiency.
The facility failed to follow its medication administration and diabetes management policies, leading to deficiencies in care for several residents. A resident with diabetes had critically high blood glucose levels due to improper insulin administration. Medications were not administered or documented as scheduled, and blood glucose levels were not monitored as required. Staff did not document reasons for missed or late medication administrations, contributing to the deficiencies identified.
A resident dependent on staff for toileting was left in a wet incontinence brief for several hours without being checked or changed. The CNA responsible did not check on the resident due to being busy with other duties. The facility's policies require hourly rounding and timely incontinence care to prevent skin breakdown and falls, but these were not followed, leading to the deficiency.
The facility failed to manage food storage and labeling in the residents' personal refrigerator, with items not labeled or discarded timely, and incomplete temperature logs. Staff interviews revealed confusion about responsibilities and adherence to policies, posing potential health risks to residents.
A series of critical failures in adhering to a resident's care plan and physician orders resulted in an Immediate Jeopardy situation. Key issues included not maintaining the head of the bed elevation during and after tube feedings, lack of one-to-one feeding assistance, and inadequate monitoring for aspiration signs. These lapses led to the resident aspirating, experiencing breathing difficulties, and ultimately passing away. Additionally, the facility staff did not follow the code blue policy to call 911 promptly when the resident was unresponsive. Communication breakdowns further exacerbated the situation, with delays in notifying the physician of the resident's acute condition changes, failure to relay critical lab and diagnostic results promptly, and providing inaccurate reports. These deficiencies highlight significant risks in care and communication processes.
A resident with multiple medical conditions, including a pre-existing pressure ulcer, did not receive consistent and documented treatment for the ulcer, leading to an infection and hospitalization. The facility failed to follow care plans and provide adequate incontinence care, contributing to the wound's deterioration.
The facility staff failed to follow aspiration precautions and provide one-to-one feeding assistance for a resident with multiple medical conditions, leading to the resident's acute change of condition and subsequent death. The CNA did not reposition or elevate the head of the bed and was unaware of the one-to-one feeding requirement, resulting in the resident aspirating and experiencing difficulty breathing.
The facility failed to accurately document a resident's vital signs, with records showing no vital signs for several days and later appearing 24 days after the resident expired. Both the Assistant Director of Nursing and the Administrator acknowledged the discrepancies.
Improper One‑Person Gait‑Belt Transfer Causes Humerus Fracture in Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide proper transfer assistance for a dependent resident, failure to communicate the resident’s transfer status to a new staff member, and failure to ensure staff were educated on correct transfer techniques. The resident involved had multiple diagnoses including dementia, anxiety disorder, peripheral vascular disease, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, reduced mobility, and a prior right humerus fracture. The MDS showed the resident was dependent for chair/bed-to-chair transfers, requiring the assistance of two or more helpers, and the care plan and Kardex specified use of a mechanical lift with two-person assist for all surface-to-surface transfers. Staff interviews confirmed that the resident was considered a total assist and normally transferred with a mechanical lift and two staff. On the day of the incident, the resident was up in a wheelchair and requested to return to bed. An LPN, who was not the resident’s primary CNA, asked a CNA who had been working at the facility for about one month and was not assigned to the resident to assist with the transfer. This CNA took the resident from the hallway to the room and, instead of using the ordered mechanical lift with two-person assist, applied a gait belt and performed a one-person stand-pivot transfer from wheelchair to bed. During the transfer, the resident grabbed the bed rail, let go, then grabbed the CNA, and the CNA sat the resident on the bed and then positioned the rest of the resident’s body in bed. The CNA reported that the nurse who requested the transfer did not tell him how the resident was supposed to be transferred, and he stated he was not aware that the resident required a two-person mechanical lift transfer. After the transfer, as the CNA was leaving the room, the resident complained of right arm pain, which the CNA reported he relayed to a nurse, although he could not recall the nurse’s name. Later that evening, nursing notes documented that the resident reported right upper extremity pain that began during the transfer from wheelchair to bed when the arm was twisted. Pain medication was given, but the resident continued to complain of pain, leading to telehealth notification and orders for STAT X‑rays of the right humerus, elbow, shoulder, wrist, forearm, and hand. Radiology results showed an impacted transverse fracture of the right humeral neck and greater tuberosity with associated soft tissue swelling. The provider documented this as an acute new fracture and ordered transfer to the emergency department for further evaluation and treatment. Interviews with the former DON, restorative staff, and therapy confirmed that the resident should have been transferred with a mechanical lift and two-person assist and that improper transfer technique was used during the incident. Additional interviews with other CNAs, nurses, and the unit manager showed inconsistent awareness of the resident’s required transfer method. Some staff correctly identified that the resident required a mechanical lift with two-person assist, while others were unsure of the transfer status or only “probably” believed a mechanical lift was used. The unit manager and administrator stated that staff are expected to obtain transfer information from the Kardex or by asking nursing staff, and that the root cause of the incident was failure to use the correct transfer technique. The resident’s family member reported being told initially that the resident may have fallen out of bed, but later learned from facility leadership that the injury was related to a poor transfer and mishandling, and the resident herself denied falling or being dropped. The survey findings concluded that the facility failed to ensure the resident was transferred according to the care plan and orders, failed to effectively communicate the resident’s transfer requirements to a new CNA, and failed to ensure staff were properly educated and competent in safe transfer procedures, resulting in the resident sustaining a right humerus fracture during the transfer. The report also documents that the facility had policies addressing transfer status determination, mechanical lift use, and restorative nursing programs, which required appropriate screening and individualized care plans. However, interviews revealed that not all staff were clear on where or how to verify transfer status, and some part-time or newer staff reported missing or not being clearly documented on in-service sign-in sheets related to transfer training. The administrator acknowledged that an issue with the resident transfer was identified and that the investigation determined the resident’s transfer was improper. A nurse practitioner/therapy provider stated that improper transfer techniques can cause injury and that, in this case, if proper transfer techniques had been used, the injury could have been avoided. These facts support the deficiency that the facility did not ensure safe, care-planned transfers, adequate communication of transfer status, and sufficient staff education for this dependent resident.
Failure to Provide Safe Incontinent Care Resulting in Fall From Bed and Head Trauma
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe environment and adequate supervision to prevent an accident for one resident reviewed for falls. The resident had multiple medical diagnoses including encephalopathy, unsteadiness on feet, dysarthria, glaucoma, osteoarthritis, spinal stenosis, and severe cognitive impairment. The MDS documented impaired upper extremity range of motion and a need for extensive assistance with ADLs, toileting, bed mobility, dressing, and eating. The admission fall risk assessment identified the resident as a high fall risk due to decreased mobility and confusion, and the care plan stated the resident required assistance with daily care needs related to generalized weakness, with staff to anticipate and meet all needs including turning and repositioning. On the day of the incident, the resident was on an air mattress without side rails and required total assistance. A CNA with 18 years of experience reported providing incontinent care and rolling the resident to the opposite side of the bed, away from herself, to clean feces. The CNA stated the resident continued rolling and fell off the air mattress onto the floor, resulting in bleeding from the back of the head. The CNA acknowledged knowing she should have rolled the resident toward herself and that she should have obtained another staff member to assist, but did not do so. A nurse in the room caring for the roommate heard the resident hit the floor, saw the resident on the floor bleeding from the back of the head, applied pressure, and called 911. The resident was transferred to the emergency department and admitted with a diagnosis of blunt head trauma following a fall from bed. The medical practitioner’s post-fall note documented frank bleeding from the back of the head and that the resident was alert and oriented x1. The resident’s family member reported being informed that the resident was turned during care, kept rolling off the bed, and was bleeding from the back of the head, and later learned the resident was admitted to the hospital. Facility staff, including the restorative nurse and DON, stated that nursing staff are taught to always roll residents toward themselves during incontinent care to prevent falls from bed, and that rolling a resident away from the caregiver could cause the resident to roll off the bed. The administrator stated there was no report to the state agency related to this fall and indicated a belief that incidents only needed to be reported if sutures or staples were required.
Failure to Provide Timely Incontinence Care Led to New Skin Breakdown
Penalty
Summary
The facility failed to follow its skin care prevention policies and the resident’s comprehensive care plan for incontinence management and skin protection, resulting in new skin breakdown. The deficiency involved one resident who was dependent on staff for perineal hygiene, bathing, and mobility, was always incontinent of bowel and bladder, had severely impaired cognition, and had a gastrostomy tube with frequent loose stools. The resident also had an existing stage 4 sacral pressure ulcer and was identified as being at risk for pressure ulcers and skin injury. On the morning of the event, the resident’s roommate reported that the resident had not been changed since 4:00 a.m. and had been lying in a soiled diaper for hours. When the resident was observed later that morning, she stated she was wet and needed to be changed. The assigned CNA stated she had started at 6:00 a.m. and had not yet had the opportunity to check on the resident. During the observed morning care, the resident’s brief and pad were saturated with urine and feces, and the perineal and buttock areas were heavily soiled. The resident’s sacral wound dressing was also soiled and not intact. During the same observation, surveyors and staff noted skin breakdown in the perianal area with scant bleeding and a new open wound on the left inner thigh at the edge of the incontinence brief. The wound care nurse and wound care coordinator stated the perianal skin damage was new, and the left thigh wound was new and consistent with pressure injury from shearing and friction caused by the brief. The wound care team later documented new moisture-associated skin damage to the perianal area and a new partial-thickness stage 2 pressure ulcer on the left inner thigh. Facility records showed the resident’s care plan required peri-area care after each incontinent episode, barrier cream use, and incontinence care at routinely timely intervals, but the resident remained soiled for an extended period before care was provided.
Insufficient Nursing Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff every day to meet resident needs and failed to ensure a licensed nurse was in charge on each shift. Interviews with residents and staff described repeated shortages of CNAs and nurses, especially on weekends and overnight shifts. Residents reported delayed medication administration, delayed response to call lights, and delays in being changed when wet or soiled. A CNA stated that the morning shift sometimes had only 4 CNAs on the floor when 5 were needed. During a resident council meeting, multiple residents stated that staffing was not always sufficient to meet resident needs. One resident reported that on the third floor, which had 74 residents, there were sometimes only 2 or 3 CNAs from 10:00 PM to 6:00 AM, and call lights were not answered timely, sometimes requiring waits of more than an hour. Other residents stated they did not get changed timely when wet and soiled, and one resident reported a roommate was only being changed once during the day and once in the evening. Another resident reported medications were sometimes late by more than an hour and call lights could take 45 minutes to two hours to be answered. The staffing coordinator stated she was responsible for scheduling licensed nurses and CNAs and that the facility did not use agency staffing. She described staffing levels by shift and said staffing was adjusted based on daily census, with 192 residents present on the day of interview and a licensed bed capacity of 204. Survey review of timecard reports showed inadequate CNA staffing on some days and multiple weekends from 7/1/25 to 9/30/25 and 1/24/26 to 1/25/26. Payroll Based Journal data for FY Quarter 4 2025 was triggered for excessively low weekend staffing and a one-star staffing rating. Facility census records showed resident counts of 191, 186, 185, 198, and 191 on selected dates reviewed.
Food Storage and Labeling Deficiencies
Penalty
Summary
Food items were not properly labeled, dated, stored, or discarded in the facility kitchen. During an initial kitchen tour, the Dietary Manager stated that food items should be labeled with a delivery date, open date, and use-by date, and that manufacturer storage guidelines should be followed. In the walk-in refrigerator, 12 unopened 8-ounce cartons of whole milk labeled with a best-by date of 02/02/26 were observed mixed with other cartons labeled with a best-by date of 02/14/26. The Dietary Manager stated the cartons dated 02/02/26 were from an older delivery and should have been thrown out on or before that date, and that serving expired milk could make residents sick. In the walk-in freezer, shelving units were measured and three of six were five inches from the floor rather than at least six inches. In the prep area, an opened 1-gallon container of barbeque sauce and an opened 1-gallon container of soy sauce were stored at room temperature with no use-by dates written on them, despite manufacturer instructions to refrigerate after opening. The Regional Registered Dietitian stated the milk should not have been consumed past the best-by date, and that the barbeque sauce and soy sauce should have been stored in the refrigerator after opening. The facility’s diet order list showed six residents were receiving NPO status.
Trash and Debris Left Around Dumpster Area
Penalty
Summary
The facility failed to ensure there was no trash on the ground surrounding the dumpster. During an initial tour of the kitchen area, the surveyor went outside with the Dietary Manager and observed a large amount of trash, garbage, and debris on the ground near the dumpster, including food scraps, empty soda cans, used plastic cups, used gloves, used face masks, and empty bottles of cleaning containers. The dumpster lid was closed, but the surrounding area was visibly littered with refuse. The Dietary Manager stated the area was a mess and said there should not be trash all around the dumpster. The manager also stated the condition was nasty and would attract rodents, and that the facility wanted to keep rodents away from the building rather than attract them toward it. In addition, two bottles of used culture vials in a plastic bag were observed by the back door entry, and the Dietary Manager stated that was a hazard. The Environmental Services Director later stated housekeeping was responsible for picking up garbage on the ground outside and keeping the dumpster area clean and free from trash, and that used culture bottles should have been placed in the hazard compactor instead of being left on the ground.
Infection Control Failures With PPE, Hand Hygiene, Shared Equipment, and EBP Signage
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program when staff did not clean and disinfect shared equipment between resident uses, did not perform hand hygiene or use a pair of gloves before obtaining a resident’s blood glucose, did not wear proper PPE when entering a resident’s room on contact precautions, and did not post an Enhanced Barrier Precautions (EBP) sign for a resident with an indwelling medical device. The report states these failures had the potential to affect all 74 residents on the third-floor unit. For one resident on contact precautions for C-diff, the admission record showed multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes, COPD, dementia, chronic kidney disease, heart failure, and other chronic conditions. The resident’s MDS showed severely impaired cognition and isolation for active infectious disease. On observation, a CNA in training entered the resident’s room to pass a meal tray without wearing gloves and a gown, despite signage at the door stating staff must clean their hands and put on gloves and gown before room entry. The CNA then left the room without performing hand hygiene and continued entering other residents’ rooms to pass meal trays. The DON and infection prevention staff stated that staff and visitors are expected to wear gown and gloves before entering rooms on contact precautions and perform hand hygiene to prevent spread of germs or cross contamination. During medication administration, an LPN entered another resident’s room to obtain a blood glucose reading while wearing only one glove and without performing hand hygiene or alcohol-based hand rub. The LPN used the ungloved hand during the fingerstick process, handled blood-stained items, and did not clean the glucose caddy after use. The same LPN then used an uncleaned wrist blood pressure device on that resident and on two other residents without sanitizing the device between uses. The DON stated that hand hygiene and a pair of gloves are required before blood glucose monitoring, the glucose caddy should not enter the room, and shared blood pressure devices must be sanitized between residents. The facility also failed to post an EBP sign outside a resident’s room who had bilateral nephrostomy tubes and was listed by the facility as requiring EBP for an indwelling device. Staff and leadership stated that residents with nephrostomy tubes should have EBP signage posted and that staff entering the room for direct care should wear gown and gloves. In a separate observation, a CNA provided morning care to another resident on EBP, including wiping the face and upper body and changing the incontinence product, gown, and pad, but did not wear a protective gown during the care. The CNA stated she was not aware she was supposed to wear a gown while providing care to that resident.
Missing Care Plans for Residents on Anticoagulants
Penalty
Summary
The facility failed to follow its policy to develop a comprehensive person-centered care plan for each resident. Interview and record review showed that R104, admitted with diagnoses including paroxysmal atrial fibrillation, type 2 diabetes mellitus, hypertensive heart disease with heart failure, presence of a cardiac pacemaker, end stage renal disease, dependence on renal dialysis, gout, mixed hyperlipidemia, and other chronic conditions, was observed ambulatory with a cane, steady gait, alert and oriented x3, and stated he was receiving blood thinner medication. His physician orders included apixaban 5 mg by mouth every 12 hours for thrombosis, and the MDS indicated anticoagulant medication use, but no care plan was found in the EHR for anticoagulant medication use. R178 was admitted with diagnoses including heart failure, alcoholic cirrhosis of the liver without ascites, alcohol dependence, focal epilepsy with seizures of localized onset, and other arterial embolism and thrombosis of the abdominal aorta. His physician orders included Eliquis (apixaban) 5 mg by mouth every 12 hours, and the MDS showed anticoagulant medication use, but no care plan was found in the EHR for anticoagulant medication use. The DON stated that residents on anticoagulant medication should have a care plan, and the MDS Director stated that care plans are individualized, include goals and interventions, and should be in place for residents on anticoagulant medication because of the potential or risk for bleeding. Review of both residents' care plans with the MDS Director confirmed that no care plan was found for anticoagulant medication use.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure timely incontinence care was provided to one resident who was unable to perform activities of daily living independently. On 2/4/26, a roommate reported that the resident had not been changed since 4:00 a.m. and had been lying on a soiled diaper for hours. When the resident was interviewed, she stated she was wet and needed to be changed, and she did not remember when her diaper was last changed. The resident was observed in bed and able to verbalize needs. During observation between 11:43 a.m. and 11:56 a.m., the assigned CNA provided morning care and the resident’s incontinence brief and pad were noted to be saturated with urine and feces. The resident’s perineal area and buttocks were heavily soiled with urine and feces, and the sacral wound dressing was soiled and not intact. The assigned night-shift CNA stated she last changed the resident’s brief at approximately 4:30 a.m. before leaving at 6:00 a.m., and said the resident required frequent diaper changes because of frequent bowel movements related to tube feeding. The resident’s record showed diagnoses including cerebral infarction, gastrostomy status, flaccid hemiplegia affecting the left nondominant side, and adult failure to thrive. The MDS indicated severely impaired cognition, dependence on staff for perineal hygiene, bathing, and mobility, and that the resident was always incontinent of bowel and bladder. The care plan directed staff to provide peri-area care after each incontinent episode and to provide incontinence care at routinely timely intervals. The DON stated staff were expected to check incontinent residents at least every hour and provide incontinence care promptly when needed, and also stated the resident had fragile skin and was at risk for skin breakdown.
Failure to Maintain IV Dressing Integrity and Care Plan
Penalty
Summary
The facility failed to follow physician orders for a resident with a midline IV line by not keeping the transparent dressing secure and intact and by not addressing the IV line in the resident’s comprehensive care plan. The resident’s order summary included instructions to monitor the IV insertion site every shift, ensure the dressing and placement were intact, and notify the MD of abnormalities every shift. The care plan did not include a focus on the resident’s IV line, even though the resident had a midline IV in the right antecubital area and no current IV medications or fluids were listed. Surveyors observed the resident sitting in the day room with the IV dressing peeling off on the medial side, and the dressing date remained 1/24/26 on both observations. During interview, nursing staff stated the resident was no longer receiving IV antibiotics, did not know why the IV remained in place, and were unsure who was responsible for changing the dressing. When the dressing was observed again, an LPN handled the IV and dressing with bare hands and did not perform hand hygiene or don gloves. Facility staff later stated nurses were responsible for changing IV dressings every seven days or as needed when not intact, and the facility policy required dressing changes every seven days or when the dressing integrity was compromised.
Failure to Provide Ordered 1:1 Feeding Assistance and Care Plan Precautions
Penalty
Summary
The facility failed to provide 1:1 feeding assistance and failed to include aspiration and swallowing precautions in the comprehensive care plans for two residents, R84 and R192. R84 had diagnoses including Parkinson’s disease, lack of coordination, and dementia, and the speech therapy discharge summary documented swallowing precautions including close supervision, upright positioning at 90 degrees, aspiration precautions, monitoring for aspiration-related illness, alternating liquids and solids, slow rate, monitoring for pocketing, oral care, and stopping feeding if pocketing or aspiration symptoms occurred. R84’s quarterly MDS showed severely impaired cognition, loss of liquids and solids from the mouth while eating or drinking, a mechanically altered diet, and a need for supervision or touching assistance with eating. R84 also had dietary orders for a mechanical soft-textured diet with thin liquids and an order for 1:1 assist with aspiration and swallowing precautions, but the comprehensive care plan did not include focuses or interventions related to those precautions. R192 had diagnoses including traumatic brain injury, dementia, and mild cognitive impairment. The speech therapy discharge summary recommended a mechanical soft/thin diet with 1:1 assistance and precautions including upright positioning at 90 degrees, aspiration precautions, monitoring for aspiration-related illness, alternating liquids and solids, slow rate, monitoring for pocketing, and 1:1 assistance. R192’s quarterly MDS showed severely impaired cognition, partial/moderate assistance needed with eating, and a mechanically altered diet. R192 also had dietary orders for mechanical soft texture with thin liquids, an order for 1:1 assist with swallowing precautions, and a separate order for 1:1 feed with meals for nutritional intake. Although the care plan included a focus on malnourishment and an intervention for 1:1 feeding assist, it did not contain focuses on aspiration or swallowing precautions. During lunch observations, staff did not provide the ordered 1:1 feeding assistance to either resident. V12 dropped off R192’s lunch tray marked 1:1 assist and swallowing precautions, but no staff sat with R192 during the meal. R84’s lunch tray was also marked 1:1 assist, aspiration precautions, and swallowing precautions, yet no staff sat with R84. V13 stated that [V13] was watching everyone on that side of the room and was not doing 1:1 feeding assist. Continuous observation showed R192 eating without 1:1 assistance and later stopping active eating, and R84 finished the meal without 1:1 assistance. The DON stated that 1:1 feeding assist means a staff member should sit down and help feed the resident during meals, including for safety reasons such as aspiration precautions.
Improper Storage of Oxygen Cannula Tubing
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met when oxygen cannula tubing for one resident was found stored improperly when not in use. On 02/04/26, the resident’s oxygen tubing was attached to an oxygen concentrator, but the nasal cannula end was lying in an open drawer, resting on top of an opened bag of cookies, with a used plastic urinal bottle hooked on the edge of the drawer near the cannula. The tubing was not stored in a bag or container, and the oxygen concentrator was not turned on while the resident was not in the room. Later observations showed the same resident’s nasal cannula tubing wrapped around the bed grab bar while the oxygen concentrator remained off. The resident stated he turns his oxygen on and off when he feels like he needs it, said the last time he used it was the night before, and stated no one told him to store the tubing in a plastic bag or container when not in use. The resident’s diagnoses included anemia in other chronic diseases classified elsewhere, pleural effusion, hypertensive heart disease without heart failure, heart failure, other artificial openings of urinary tract status, secondary malignant neoplasm of bone, and insomnia. The resident’s order was for oxygen at 2 liters per minute PRN via nasal cannula to maintain oxygen saturation at 92% or greater as needed for shortness of breath, and the facility policy stated oxygen tubing should be appropriately stored to prevent contamination when not in use.
Failure to Implement Fall-Prevention, ADL Assistance, and Post-Fall Pain Assessment for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision and care in accordance with the resident’s assessed needs and care plan. Resident R2 was identified as bedbound, nonverbal, severely cognitively impaired (BIMS score 00), with multiple contractures of all extremities, functional quadriplegia, and a history of a displaced subtrochanteric fracture of the left femur. R2’s MDS documented total dependence for bed mobility and all ADLs, requiring the assistance of two or more helpers, and the restorative nurse confirmed that R2 was assessed as a two‑person ADL assist and a high fall risk prior to the incident. R2’s care plan and facility policies required that the bed be maintained in the lowest position, that approved repositioning techniques be used, and that the call light be kept within reach for safety. On the evening of 1/4/2026, CNA V11, who was assigned as R2’s primary CNA, provided in‑bed ADL/linen care to R2 alone, without a second staff member, despite R2’s documented need for two‑person assistance. V11 reported that R2 was bedbound, nonverbal, contracted in both arms and legs, and had a floor mat next to the bed. While changing linens, V11 moved the bed away from the wall, positioned themself between the bed and the wall, and turned R2 onto the right side, away from V11, to tuck a clean linen roll under R2. When V11 realized a new incontinence brief was not within reach, V11 leaned over R2 and pressed an arm into the low air loss mattress to reach for the brief at the foot of the bed. This caused R2 to slide toward the opposite edge of the bed. As R2 began to fall, V11 attempted to stop the fall by grabbing R2’s leg, but R2 continued to slide off the bed, landing partly on the floor mat and partly on the floor, with the head slightly off the mat. V11 observed pain in R2’s facial expression when grabbing the leg and reported seeing that R2 was in pain. LPN V8, who responded immediately while covering the primary nurse’s assignment, found R2 on the left side on the floor mat with a bleeding laceration on the left forehead. V8 performed a post‑fall assessment, palpating along R2’s contracted extremities and noted that when the left leg was palpated from the knee up to the hip, R2 grimaced and made moaning noises, indicating pain in the left leg. V8 cleansed and dressed the forehead laceration and assisted with lifting R2 back to bed, then medicated R2 with PRN acetaminophen. However, when V8 spoke with the APN (V31) during the post‑fall notification process, V8 did not report the new left leg pain findings from the assessment. The APN’s progress note documented a witnessed fall with a small head laceration and “no active pain, bleeding or complaints,” and no new orders were issued on the date of the fall. Subsequent documentation and interviews showed that R2 continued to exhibit pain and moaning with palpation of the left lower extremity, and an X‑ray obtained two days later revealed a proximal left femur fracture. The facility’s DON and NP both stated that nurses are expected to recognize and report nonverbal signs of pain, especially in nonverbal, contracted residents after a fall, and that new pain post‑fall should be communicated to the practitioner for possible imaging, but this did not occur immediately after R2’s fall. Additional observations by the surveyor and staff interviews highlighted further failures to consistently implement fall‑prevention interventions already in R2’s care plan and facility policies. R2 was listed on the unit’s high fall risk roster, and the restorative nurse stated that for bedbound residents, staff are to keep the bed in the lowest position, position the resident in the center of the bed during care, and ensure the call light is within reach. However, on a later observation date, R2’s bed was found at a higher position than previously observed, and the adaptive call light pad was hanging over the headboard toward the wall, away from R2, until an LPN lowered the bed and repositioned the call light near R2’s head. The primary nurse on the evening of the fall (V7) acknowledged that R2 was a two‑person assist for ADLs but did not inform the new CNA (V11) of this requirement at the beginning of the shift, only reiterating it after the fall. Collectively, these actions and omissions show that the facility did not follow its own fall prevention, ADL assistance, call light, and pain management policies for a high‑risk, fully dependent resident, resulting in a fall from bed with a head laceration and unreported post‑fall leg pain that was later associated with a left femur fracture. Family interviews further described the condition of R2 immediately after the fall and in the days following. R2’s healthcare power of attorney and another family member reported arriving shortly after being notified of the fall and observing blood dripping from the left side of R2’s head and blood on the floor. They questioned the nurse about sending R2 to the hospital for examination and were told that R2 was stable and would be monitored in the facility per practitioner direction. They also reported asking whether a full body examination for possible broken bones would be done and were told it would be performed. On 1/6/2026, the family was informed by facility staff that imaging suggested possible bilateral hip fractures, and later at the hospital they were told that R2 had a comminuted displaced left femur fracture. The family stated that R2 was in significant pain, making loud noises, and that they received conflicting information from the facility about the nature of R2’s injuries. These accounts align with the clinical findings that R2 exhibited nonverbal signs of pain in the left leg after the fall, which were not promptly communicated to the practitioner at the time of the initial post‑fall assessment.
Failure to Notify Legal Guardian of Resident Fall and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s state-appointed legal guardian of a fall, associated hospital transfer, and subsequent return, despite clear documentation that the guardian was the resident’s primary surrogate decision maker. The resident was admitted from an acute care hospital with diagnoses including dementia without behavioral disturbance, difficulty in walking, lack of coordination, dysphagia, protein-calorie malnutrition, dehydration, muscle weakness, hypertensive heart disease, iron deficiency, and adult failure to thrive. The care plan, initiated in late December, documented that the resident had a surrogate decision maker and, as of the end of March, a state-appointed guardian, with instructions to contact the adult guardianship division. A social worker’s progress note on 3/31/2025 recorded that the resident had been appointed a public guardian and included the guardian’s information, and a letter from the county public guardian’s office directed that staff must notify the appointed guardian in the event of an emergency and that compliance with this procedure was mandatory. On the night of 4/8/2025, the resident experienced a fall in the bathroom. An LPN (V7) later recalled responding to a call light and finding the resident lying on the left side on the bathroom floor; the resident did not remember what happened after standing up from using the bathroom. The LPN observed a minimal skin tear on the left eyebrow, cleaned the area, and applied a gauze dressing. Progress notes dated 4/9/2025 at 2:10 AM documented that the resident was sent to the emergency room, but there was no documentation that the legal guardian was notified of the fall or the transfer. A subsequent progress note at 2:19 AM documented that the LPN left a voice message with the resident’s second emergency contact about the fall and the hospital observation, again with no documentation that the legal guardian was notified. Additional progress notes on 4/9/2025 at 6:12 AM and 6:40 AM, documented by another LPN (V18), recorded that the hospital reported a negative CT scan, that the resident was on the way back to the facility, and that the resident returned from the hospital with no new orders, an alteration of skin to the left eyebrow without redness or swelling, no pain, and stable vital signs, with safety measures maintained. These notes did not document any notification to the legal guardian regarding the resident’s updated status or the fall incident. A facility fall incident description form for the 4/8/2025 fall showed that a family member was notified the following morning, but did not show that the legal guardian was notified. Multiple staff interviews, including with LPNs, unit managers, the social work director, and the DON, confirmed that facility practice and policy required that a legal guardian, when present, be notified first of falls, changes in condition, and hospital transfers, and that such notifications be documented in the resident’s chart. Staff acknowledged that in this case the legal guardian should have been notified and that the notification was not documented, confirming the failure to follow facility policy and the guardian’s instructions regarding notification. Interviews with involved nursing staff further clarified the inaction. The LPN who documented the fall and hospital transfer (V7) stated that if a resident has a POA or legal guardian on file, that person should be notified of any changes and again when the resident returns from the hospital, with the conversation documented. When presented with the admission record and progress notes, this LPN acknowledged that the legal guardian should have been contacted and that the chart only showed a message left for the second emergency contact. Another LPN (V18), who documented the resident’s return from the hospital, stated that if the progress notes showed the resident came back from the hospital, the legal guardian should have been notified, but was unsure whether such notification occurred and confirmed that it was not documented. The DON and other managers reiterated that the legal guardian should always be notified first and that documentation of attempts or messages was required, underscoring that the facility did not follow its own notification policy or the public guardian’s written instructions for this resident’s 4/8/2025 fall and related events.
Failure to Implement Adequate Fall Prevention for High-Risk Resident
Penalty
Summary
The facility failed to follow its fall prevention policy and did not ensure a safe environment for a resident identified as a high fall risk. The resident, who had a history of cerebrovascular disease, delirium, difficulty walking, and lack of coordination, was assessed as a high fall risk upon admission, with a fall risk score of 23. Despite this, the resident's care plan only included minimal interventions such as keeping the room free of clutter and rounding every two hours, which were not adequate for her risk level. Staff interviews revealed that high fall risk interventions, such as floor mats and increased supervision, were not consistently implemented. On one occasion, the resident fell in the dining room while attempting to get up from her wheelchair without assistance. At the time, only one CNA was present in the dining room, who was occupied cutting up another resident's food. The CNA was unable to intervene in time, and the resident was found on the floor with mild swelling to her face. The DON acknowledged that another staff member should have been monitoring the resident when the assigned CNA was assisting someone else. The resident was later diagnosed with an acute subdural hematoma and right eye hematoma following the fall. Additionally, the resident experienced a seizure while in her wheelchair in the cafeteria, during which she slumped over but did not fall. Staff noted that seizure precautions, such as bed bolsters or floor mats, were not in place. The facility's failure to implement and document appropriate fall prevention interventions for a high-risk resident, as required by their policy, resulted in the resident sustaining significant injuries.
Failure to Prevent Physical and Verbal Abuse During ADL Care
Penalty
Summary
A deficiency occurred when facility staff failed to protect a resident from physical and verbal abuse during activities of daily living (ADL) care. The incident involved a certified nursing assistant (CNA) who was reported by a resident to have entered his room, spoken to him in a rude and dismissive manner, and subsequently used derogatory language. The resident described the CNA as being physically rough, including grabbing and throwing his leg, making inappropriate sexual comments, and hitting him on the chest, stomach, and arm. The resident repeatedly asked the CNA to leave, and the abusive behavior ceased only when his roommate intervened by opening the curtain. Two other residents in the shared room provided corroborating accounts. One resident stated he heard the CNA yelling and cursing at the resident and witnessed the CNA moving the resident's legs roughly. Another resident reported hearing yelling between the CNA and the resident but did not witness the physical interaction. Both residents expressed concerns about staff behavior, with one indicating a general fear of abuse by staff members. Interviews with facility staff confirmed that the incident was reported to the administrator and that the CNA in question was identified and suspended pending investigation. The resident involved was found to be cognitively intact, as were the other residents in the room. The facility's abuse policy prohibits all forms of abuse, including physical and verbal abuse, but the care plan for the resident was not updated with new interventions following the incident. Documentation shows that the incident was reported to the medical director and the resident's family, and the facility's protocol was followed after the allegation was made.
Failure to Provide and Document Assistance with ADLs for Dependent Resident
Penalty
Summary
Facility staff failed to provide necessary assistance with activities of daily living (ADL) for a dependent resident who was unable to get out of bed independently. On two consecutive days, the resident was observed lying in bed in a night gown, expressing a desire to get out of bed but stating that staff would not assist and that he did not know the location of his wheelchair. Interviews with staff revealed conflicting accounts, with some stating the resident usually refuses to get up, while others confirmed the resident should be assisted unless he refuses. The resident was documented as cognitively intact and having poor trunk control and weakness on one side, requiring a Geri chair for mobility, which was found stored near his room. Review of the resident's records, including progress notes and the plan of care, showed no documentation of refusals to get out of bed or education provided regarding the importance of mobility, despite staff stating that such documentation is required when a resident refuses care. Additionally, the facility did not provide any policies specific to the importance of getting residents out of bed. These actions and omissions resulted in a failure to ensure that dependent residents received appropriate ADL care and assistance as required.
Failure to Provide Required Non-Skid Footwear for Cognitively Impaired Residents at High Fall Risk
Penalty
Summary
The facility failed to implement fall prevention interventions for several cognitively impaired residents who were identified as being at high risk for falls. During observations in the second-floor dining room, five residents were seen wearing smooth-bottomed socks rather than the required non-skid footwear, despite being out of bed and in common areas. Staff interviews confirmed that non-skid socks were available in storage, and facility policy required all residents to wear skid-proof footwear at all times when out of bed. However, the residents continued to wear inappropriate footwear for an extended period, and staff acknowledged the oversight when it was brought to their attention. Record reviews for the affected residents revealed diagnoses including dementia, major depressive disorder, altered mental status, unsteady gait, muscle weakness, and other conditions contributing to high fall risk. Each resident had care plans and fall risk assessments indicating their vulnerability to falls, with some unable to complete mental status assessments due to severe cognitive impairment. The facility's own fall prevention program required identification and implementation of interventions for residents at risk, but these measures were not followed for the residents observed.
Failure to Prevent Resident-to-Resident Physical Altercation
Penalty
Summary
The facility failed to follow its abuse policy for two residents when staff did not immediately intervene during an altercation between them. According to staff interviews and documentation, a certified nurse aide observed one resident wandering and redirected her to sit near the nurses station. Another resident approached, and after a brief verbal exchange, both residents began physically striking each other. The staff member intervened only after the altercation had started, and both residents sustained scratches and abrasions to their faces as a result. Wound assessments and nursing notes confirmed that both residents had superficial facial injuries, which were treated with first aid and monitored. The incident occurred in a dementia unit, and staff reported no prior history of altercations between these two residents. The facility's abuse policy prohibits all forms of abuse and requires the establishment of an environment that prevents mistreatment, but in this instance, staff did not act quickly enough to prevent physical harm between residents.
Failure to Notify Resident's Representative Prior to Room Change
Penalty
Summary
The facility failed to notify a resident's responsible party prior to moving the resident to a new room on a different unit. The resident, who had multiple diagnoses including Neurocognitive Disorder with Lewy Bodies, dementia, and other significant health conditions, was rarely or never understood and was unable to participate in a BIMS assessment. The resident's daughter was listed as Power of Attorney (POA) in the electronic health record (EHR). The resident was transferred from the first floor to the second floor, which is a dementia unit, but there was no documentation in the EHR indicating that the POA was notified about the room change or the reason for it prior to the move. The POA reported that she was not informed verbally or in writing about the transfer and only learned of the move when another family member could not locate the resident during a visit. The POA stated that she had called the facility after the move occurred and was not told about the transfer at that time. Staff interviews confirmed that the notification should have occurred prior to the move and should have been documented in the EHR, but this did not happen. A late entry was made in the EHR after the fact, but the POA maintained that no prior notification was given. Facility policy and state residents' rights documents require that residents and their representatives receive advance written notice and an explanation for any room change. The Notification of Room/Roommate Change form for the resident was incomplete, lacking documentation of notification to the representative, the date written notification was provided, and the reason for the change. Staff interviews further confirmed that the expected process was not followed, and the administrator acknowledged the oversight and improper documentation practices.
Failure to Prevent and Manage Pressure Ulcer
Penalty
Summary
The facility failed to adhere to its wound prevention policy, resulting in a resident developing a facility-acquired stage 3 pressure ulcer on the sacrum. The resident, a seventy-year-old with multiple medical diagnoses including osteoarthritis, atrial fibrillation, and acute respiratory failure, was admitted without any pressure ulcers as per the Minimum Data Set (MDS) assessment. The care plan indicated the resident was at risk for skin integrity issues due to self-care deficits and impaired mobility, with interventions such as daily skin checks and peri-care after incontinence episodes. However, the resident developed a sacral wound that progressed to a stage 4 ulcer with osteomyelitis, as noted in an emergency room document. The wound care assessments revealed inconsistencies and a lack of timely intervention. Initially, the wound was documented as healed, but it re-opened and worsened over time. The wound care team failed to monitor the resident's skin after the initial healing, relying on nursing staff to report any changes. Despite the wound showing signs of decline, such as increased slough, there were no significant changes in the treatment plan until the wound had deteriorated significantly. Interviews with staff indicated that the resident was sometimes not repositioned due to refusal, and there was a lack of coordination in ensuring the resident was available for wound assessments. The facility's policy on skin management emphasized the importance of consistent implementation of protocols for monitoring and documentation. However, the facility did not reevaluate the treatment plan despite the wound showing no signs of healing after three weeks. The wound physician noted that the decline might be related to dialysis, but the dialysis unit stated they could accommodate the resident's needs. The lack of timely reassessment and modification of the treatment plan contributed to the worsening of the resident's condition.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure proper supervision and monitoring for a resident at high risk of elopement, resulting in the resident leaving the premises without authorization or staff awareness. The resident, who has a medical history including cerebral infarction, diabetes mellitus, dementia, and pathological gambling, was able to exit the facility and go to a casino. The facility's policies on elopement and out on pass were not adhered to, as the resident was not signed out, and staff were unaware of the resident's absence until hours later. Interviews and observations revealed that the resident was wearing a wander guard, but it was ineffective, as staff did not respond to the alarm. The elevator required a code to operate, which was known to family and staff, but it remains unclear how the resident managed to leave the facility. The Director of Nursing and other staff were unable to confirm who assisted the resident in leaving, and there was confusion regarding whether a friend or family member was involved. The facility's failure to update the resident's care plan to address the risk of elopement further contributed to the incident. Despite the resident's high risk status, the care plan only mentioned the use of a wander guard, which was not consistently effective. The lack of immediate response to the wander guard alarm and the absence of a comprehensive elopement prevention strategy in the care plan highlight significant lapses in the facility's supervision and monitoring protocols.
Inaccurate and Incomplete Nursing Staffing Information
Penalty
Summary
The facility failed to ensure the accuracy and completeness of the posted nursing staffing information, affecting all 190 residents. On observation, the staffing information displayed near the front door was outdated, showing a date of 1/3/2025 instead of the current date, and lacked the facility's name and current census numbers. The staffing coordinator, responsible for updating the information, confirmed that the receptionist updates it on weekends by pulling the correct sheet from behind the current posting. However, the staffing information for 1/5/2025 was not posted, and the coordinator could not provide a reason for this oversight. The administrator acknowledged the absence of a policy for the daily staffing form, despite it being a regulatory requirement.
Failure to Provide Snacks Between Meals
Penalty
Summary
The facility failed to provide snacks to residents when the duration between dinner and breakfast exceeded 14 hours, affecting all 190 residents. The facility's meal schedule showed that the time between dinner and breakfast was 14 hours and 45 minutes, which is longer than the 14-hour maximum duration allowed without offering snacks. During a resident council meeting, all residents present confirmed that snacks were not served, and they expressed a desire for snacks if they were available. One resident mentioned that even when snacks were available, there was not enough for everyone. The facility's administrator and dietary manager provided conflicting information regarding snack distribution. The administrator claimed that snacks were served nightly, but the dietary manager provided a document listing only 11 residents who received snacks. The dietary manager admitted that snacks were previously given to all residents but were stopped due to perceived waste. The Director of Nursing stated that all residents should be offered snacks if they want them, but was unfamiliar with the snack distribution document. The facility did not provide a policy for snack administration, and the administrator incorrectly stated that the facility was in compliance with the regulation regarding meal duration.
Unsafe Storage of Oxygen Cylinders
Penalty
Summary
The facility failed to ensure a safe environment free from hazards, as observed during a survey on the first-floor unit. The surveyor noted three oxygen cylinder tanks positioned across from the nursing station, standing freely without being secured in a holder. This observation was made in the presence of the Registered Nurse, Weekend Supervisor, who acknowledged that the oxygen tanks should have been stored in the designated oxygen room when not in use. The surveyor and the RN observed that one of the tanks was full with 2000 psi, while the other two had 1000 psi each. The RN confirmed that free-standing oxygen tanks pose a risk of tipping over and potentially exploding. Further inquiry with the Director of Nursing revealed that the facility's policy mandates that oxygen cylinders be stored in holders at all times to prevent them from falling and causing friction, which could lead to a fire. The facility's policies, dated January 2024 and January 2023, outline the standards for safe handling and storage of oxygen cylinders, referencing guidelines set by the National Fire Protection Association and the Compressed Gas Association. These policies emphasize the importance of storing oxygen cylinders in designated areas to protect them from mechanical shock and falling objects.
Improper Food Storage and Labeling
Penalty
Summary
The facility failed to properly label, date, and store prepared food items, as well as store unthawed meats, which could potentially lead to the spread of foodborne illnesses affecting all residents receiving oral nutrition. During the survey, it was observed that temperature logs for the refrigerator, freezer, and cooler were missing for several days, indicating a lack of monitoring of food storage conditions. Additionally, five long steel pans of flavored gelatin were found undated and uncovered, and two uncovered black tubs of pork chops were improperly stored in the refrigerator. Interviews with the cook and dietary manager revealed that the gelatin was made the previous night and should have been dated, and that the pork chops should have been thawed in a covered container. The dietary manager confirmed that temperature logs should be recorded twice daily and that all food items should be dated and covered. The facility's policies on food storage and labeling were not adhered to, as evidenced by the undated and uncovered food items and incomplete temperature logs.
Inadequate PPE Use and Signage for Infection Control
Penalty
Summary
The facility failed to ensure that staff donned appropriate personal protective equipment (PPE) before performing activities of daily living (ADL) care for several residents, specifically those with indwelling catheters. Observations revealed that staff members entered rooms and provided care without wearing gowns, despite the presence of Enhanced Barrier Precaution (EBP) signs indicating the need for such precautions. For instance, two certified nursing assistants (CNAs) entered a resident's room to assist with a mechanical lift without wearing gowns, even though the resident had an indwelling catheter and should have been on EBP. Additionally, the facility did not post EBP signs for residents who required them, such as those with indwelling catheters. This lack of signage led to confusion among staff, who were unaware of the need to wear PPE when providing care to these residents. The infection preventionist nurse confirmed that residents with indwelling catheters should be on the EBP list and have appropriate signage to prevent the transmission of infections. However, the list was not updated to include all necessary residents, and signs were not consistently posted. The facility also failed to provide accessible PPE supplies near residents' rooms, which further contributed to staff not wearing the required protective gear. In one instance, a licensed practical nurse (LPN) was observed changing a urine leg bag without a gown, despite the presence of an EBP sign. The Director of Nursing acknowledged that EBP signs are intended to inform staff of the necessary PPE to wear during high-contact care activities, but the lack of accessible supplies and proper signage led to non-compliance with infection control protocols.
Failure to Follow Self-Administration Policy for Medication
Penalty
Summary
The facility failed to adhere to its policy regarding the self-administration of medication by residents, specifically affecting one resident, R53, and potentially impacting all residents on the 3rd floor. During an observation, a container of Nystatin Powder was found on R53's nightstand, which the resident was not supposed to self-administer without a physician's order. The Restorative Director, V10, confirmed that no medication should be left at the bedside, as it poses a hazard to the resident and others. The Director of Nursing, V2, also confirmed that there was no physician's order for R53 to self-administer the medication, and the care plan for self-administration was not completed in a timely manner. R53's medical records indicated a cognitive status of being intact, with diagnoses including essential hypertension, type 2 diabetes mellitus, and contact dermatitis. The facility's policy requires a physician's order and a care plan for residents to self-administer medications, which was not followed in this case. The lack of a timely care plan and physician's order for R53's self-administration of Nystatin Powder highlights the facility's failure to ensure proper medication management and adherence to their own guidelines.
Failure to Report Alleged Physical Abuse
Penalty
Summary
The facility failed to adhere to its abuse prevention policy by not reporting an allegation of physical abuse to the state survey agency within the required time frame. This deficiency involved a resident with a diagnosis of right-sided hemiplegia, type 2 diabetes mellitus, unspecified dementia without behavioral disturbance, and cerebral infarction. The resident, who was cognitively intact, reported bruises on their left wrist and inner forearm, claiming they were caused by staff handling them too roughly. Additionally, the resident alleged verbal abuse by a nurse who threatened them regarding medication compliance. The facility's administrator was informed of these allegations but only reported the verbal abuse to the state survey agency, omitting the physical abuse allegation. The administrator conducted an investigation and concluded that the bruises were from lab draws, which are uncommon places for such procedures. Despite this conclusion, the physical abuse allegation was not included in the initial report to the state survey agency. The administrator mistakenly believed that informing the surveyor was sufficient and did not document or submit the investigation details to the state survey agency as required by the facility's abuse prevention policy. This oversight resulted in a failure to comply with the mandated reporting procedures for suspected abuse, neglect, or mistreatment.
Failure to Complete PASRR Prior to Admission
Penalty
Summary
The facility failed to ensure that a Pre-Admission Screening and Resident Review (PASRR) was completed prior to the admission of a resident, identified as R137. This resident, who was admitted on December 7, 2021, has diagnoses including Hemiplegia and Hemiparesis, Aphasia, Vascular Dementia, Bipolar Disorder, Major Depressive Disorder, and Weakness, with a Brief Interview of Mental Status score of 08. During a survey conducted on January 5, 2025, the surveyor could not locate a PASRR for R137 in the facility's electronic records. The Admission Coordinator, identified as V41, acknowledged that R137 was admitted before the implementation of the Maximus program and that the resident's information was not submitted to the program. V41 also confirmed that a new PASRR was initiated after the survey began on January 5, 2025.
Failure to Provide Baseline Care Plan to Resident and Representative
Penalty
Summary
The facility failed to review and provide a copy of the baseline care plan to a resident and their representative within the required timeframe. This deficiency affected a resident with multiple complex medical conditions, including gout, type 2 diabetes mellitus, end-stage renal disease, chronic obstructive pulmonary disease, Alzheimer's disease, and heart failure. The resident was cognitively impaired, as indicated by a BIMS score of 11. The resident's family member expressed confusion and dissatisfaction due to not being informed about the resident's care plan. The facility's policy mandates that a baseline care plan be developed within 48 hours of admission and that a summary be provided to the resident and their representative within five days. However, there was no documentation indicating that the care plan was reviewed with the resident or their family member, nor was there evidence that a copy of the care plan was provided. The Director of Nursing acknowledged that care plan meetings are scheduled based on family convenience and confirmed that there was no documentation of the care plan being given to the resident or their representative.
Failure to Update Care Plan for Resident with Mental Health Needs
Penalty
Summary
The facility failed to provide a person-centered care plan for a resident with multiple diagnoses, including Hemiplegia, Hemiparesis, Aphasia, Vascular Dementia, Bipolar Disorder, Major Depressive Disorder, and Weakness. The resident, who was admitted on December 7, 2021, had a Brief Interview of Mental Status score of 08 and was on medications for Major Depressive Disorder and Bipolar Disorder. A Level I PASRR dated January 5, 2025, indicated the need for a Level II onsite review due to the resident's mental health conditions. However, the care plan was not updated to reflect the Level II PASRR recommendations because the resident was admitted before the implementation of the Maximus program, and their information was not submitted to the program. The Admission Coordinator acknowledged that the resident's information was not submitted to the Maximus program, and the care plan was not updated prior to the survey. The Social Service Director confirmed that PASRR should be completed before admission and the care plan updated post-Level II screening. The Director of Nursing admitted there was no specific policy for updating care plans for PASRR. The facility's comprehensive care plan policy from January 2023 requires the care plan to include a focus, measurable goals, and interventions specific to the resident's needs, which was not adhered to in this case.
Deficiency in ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care to two dependent residents, resulting in deficiencies in grooming and personal hygiene. Resident R137, diagnosed with conditions including Hemiplegia, Hemiparesis, and Vascular Dementia, was observed with long fingernails on his 4th and 5th fingers, which were digging into his hand. Despite expressing discomfort and a desire for the nails to be cut, the issue was not addressed promptly. Similarly, Resident R176, with diagnoses including Myopathies and Dysphagia, was observed with facial hair and long fingernails. R176 reported not having received a shower since being on the current floor and expressed a desire for her facial hair to be shaved and nails trimmed. The facility's staff, including a Certified Nursing Assistant and the Restorative Director/LPN, acknowledged the residents' needs but failed to provide timely care. The facility's policies state that showers, nail care, and shaving should be offered and performed as needed, particularly on shower days. However, documentation did not support that these services were consistently provided, as evidenced by the lack of recorded showers for R176. The Director of Nursing confirmed that showers and nail care should be offered twice a week and as needed, but the facility's practices did not align with these policies, leading to the observed deficiencies.
Improper Mattress Setting for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that the low air loss mattress for a resident, identified as R100, was set according to the resident's weight, which is crucial for pressure ulcer prevention and treatment. R100, who has a history of Alzheimer's, atherosclerotic heart disease, hypertension, and chronic kidney disease, was observed lying on a low air loss mattress with a setting at 300. The resident's monthly weight reports indicated weights of 132.4 lbs in November 2024, 133.6 lbs in December 2024, and 132.8 lbs in January 2025. The facility's care plan for R100 included the use of a pressure redistribution or low air loss therapy mattress when in bed, but the mattress setting was not adjusted to the resident's weight as required by the manufacturer's operation manual. Interviews with the Director of Nursing and the Wound Care Coordinator confirmed that the mattress settings should be based on the resident's weight, and it was noted that the setting should not exceed 300 for R100. The failure to adjust the mattress setting appropriately could potentially worsen the resident's pressure injury. The facility's job descriptions for nursing staff emphasize adherence to safety policies and procedures, including monitoring the resident's condition and providing necessary care, which was not adequately followed in this instance.
Failure to Provide Adequate Foot Care for a Resident
Penalty
Summary
The facility failed to provide adequate foot care for a resident, identified as R64, who is dependent on staff for activities of daily living, including foot care. R64, who has a history of pain in the right knee, rheumatoid arthritis, generalized osteoarthritis, and essential hypertension, was observed by a surveyor with long, thick, and ridged toenails on both feet, indicating a need for foot care. The resident reported discomfort and attempted self-care by applying baking soda and toothpaste to the affected areas, which were wrapped in tissue paper. Despite the resident's moderate cognitive impairment, as indicated by a BIMS score of 12, they expressed awareness of their worsening foot condition and the lack of staff-provided foot care since their admission. Interviews with facility staff, including a social service representative and a registered nurse, revealed a lack of awareness and communication regarding the resident's need for foot care. The podiatrist's visits to the facility were infrequent, and the resident was not scheduled for a podiatrist appointment. The facility's documentation and guidelines for foot care were not followed, as the resident's physician order sheet did not include foot care orders, and the resident was not listed for podiatrist evaluation. The Director of Nursing acknowledged that CNAs are responsible for foot care and reporting abnormalities, but the deficiency in care was evident as the resident's needs were not addressed, potentially leading to further complications such as infection.
Deficiencies in Oxygen Equipment Management
Penalty
Summary
The facility failed to properly manage and maintain oxygen equipment for two residents, leading to deficiencies in infection control practices. For one resident, a nebulizer mask was observed undated and uncontained on the nightstand, contrary to facility policy which requires such equipment to be labeled with a date and stored in a bag when not in use. The resident confirmed using the nebulizer mask the previous day and storing it on the dresser. The Registered Nurse acknowledged the mask should have been dated and stored properly to prevent infection. The Director of Nursing reiterated the importance of labeling and storing the nebulizer mask to decrease infection risk. Another resident was found using oxygen tubing that had not been changed since 12/23/24, despite facility policy requiring weekly changes to prevent infection. The Licensed Practice Nurse confirmed the tubing was overdue for a change, and the Director of Nursing emphasized the expectation for weekly changes to prevent bacterial contamination. The resident's care plan included oxygen therapy related to COPD, with orders to change the tubing weekly for infection control. These lapses in following established protocols for oxygen equipment management highlight deficiencies in the facility's infection control practices.
Failure to Reconcile Controlled Substances at Shift Change
Penalty
Summary
The facility failed to adhere to its policy of reconciling controlled substances at the end of each shift, which has the potential to affect all three residents receiving controlled substances on the 2nd floor. The Shift Change Accountability Record for Controlled Substances dated January 2025 was missing a signature to verify that a controlled substance count was conducted during the 3rd shift to shift change on January 5, 2025. This oversight was observed on January 6, 2025, when the 2nd floor medication cart was found missing the narcotic count for the 3rd shift dated January 5, 2025. Interviews with staff revealed that the narcotic count is typically conducted shift to shift by the oncoming and outgoing nurse, and discrepancies are reported to the Director of Nursing. The facility's policy requires that all schedule II substances be counted each shift or whenever there is an exchange of keys between off-going and on-coming licensed nurses, with both nurses signing the Shift/Shift Controlled Substance Count Sheet to acknowledge the count's accuracy. However, this procedure was not followed, as evidenced by the missing signature on the accountability record.
Medication Availability and Administration Deficiency
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of its residents, as evidenced by the lack of availability of prescribed medications for two residents. One resident, upon admission, did not receive any of her prescribed medications, including Atorvastatin Calcium, Gabapentin, Metformin, Metoprolol Succinate ER, Pantoprazole Sodium, and Sacubitril Valsartan, as they were not available. The facility's convenience box contained some of these medications, but they were not administered. The Director of Nursing indicated that nurses typically obtain medications from the convenience box after verification, but this protocol was not followed. Another resident experienced a delay in receiving her scheduled dose of Metoprolol Succinate ER. The medication was not found in the convenience box, despite being listed as available. The facility's medication administration policy requires staff to check for misplaced medications and contact the pharmacy if medications are not present, but this procedure was not effectively implemented. The facility's failure to ensure the availability and proper administration of medications has the potential to affect all 191 residents.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that five residents were free from significant medication errors, as observed by surveyors. For one resident with hypertensive heart disease and type II diabetes mellitus, medications such as Metformin, Metoprolol Succinate ER, and Sacubitril Valsartan were not administered as ordered upon admission. The facility's convenience box, which should have contained these medications, was not utilized effectively, leading to a delay in administration. The Director of Nursing confirmed that the protocol for acquiring medications was not followed, as the medications were not available in the convenience box. Another resident with heart failure and hypertension did not receive Metoprolol Succinate ER within the regulatory time frame, as the medication was not found in the convenience box. Additionally, three other residents had their medications marked late on the Electronic Medication Administration Record (EMAR), with one resident's medications still in their packages, indicating they were not administered. The Licensed Practical Nurse admitted to not having administered the medications yet, despite them being scheduled for earlier in the day. The Director of Nursing acknowledged the regulatory requirement for timely medication administration, which was not adhered to in these cases.
Failure to Develop Comprehensive Baseline Care Plan
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed and implemented within 48 hours of admission for a resident, as required by their policy. The resident, who was admitted with diagnoses including morbid obesity, cerebral infarction, and a history of falling, required assistance with activities of daily living (ADLs) due to left-sided weakness following a stroke. Despite these needs, the baseline care plan did not include necessary instructions for transfer and dressing assistance, which are critical for the resident's care. During the survey, it was revealed that the Minimum Data Set (MDS) Coordinator acknowledged the omission of specific instructions for dressing and transfer assistance in the care plan. The facility's policy mandates that a baseline care plan should include all necessary information to provide effective and person-centered care, including ADL needs and supervision requirements. However, the care plan for this resident lacked these essential components, leading to a deficiency in meeting the resident's immediate care needs.
Failure to Provide Timely ADL Care for Dependent Resident
Penalty
Summary
The facility failed to provide timely and adequate care for a resident who was dependent on staff for activities of daily living (ADL), including toileting and dressing. The resident, who had a history of stroke resulting in left-sided weakness and moderate cognitive impairment, was found to be wearing a saturated incontinence brief during a surveyor's visit. The resident reported not being changed since the previous evening, indicating a lack of adherence to the care plan which required peri-care after each incontinent episode. The Certified Nursing Assistant (CNA) responsible for the resident admitted to not having changed the resident's brief since the start of their shift, which began over four hours prior to the surveyor's observation. The CNA also failed to provide a clear answer regarding the frequency of checks and changes for incontinent residents, despite the facility's policy requiring checks every two hours. This lack of timely care and failure to implement care plan interventions contributed to the deficiency identified by the surveyor.
Medication Administration and Monitoring Deficiencies
Penalty
Summary
The facility failed to adhere to its medication administration and diabetes management policies, resulting in significant deficiencies in care for several residents. The report highlights that the facility did not monitor blood glucose levels as ordered, failed to document actual times for medication administration, and did not follow physician orders for medication and supplement administration. Specifically, one resident with type II diabetes mellitus and metabolic encephalopathy had consistently high blood glucose levels, with a critical high reading of 399, due to the failure to administer Humalog insulin before meals as ordered. The report also details instances where medications were not available or administered as scheduled. One resident's family member reported that upon admission, the facility did not have the resident's medications. The Medication Administration Record (MAR) showed that several medications were not administered at specified times, and the facility's Director of Nursing confirmed that medications should have specific administration times, which were not documented. Additionally, the report notes that staff did not monitor blood sugars for residents receiving hypoglycemic medications, which is a requirement under the facility's policies. Further observations revealed that several residents did not receive their medications on time, and the reasons for missed or late administrations were not documented as required. The report includes instances where medications were not signed out, and blood sugar levels were not recorded, leading to potential harm. The facility's policies require that medications be administered at the proper time and that any deviations be documented, but these procedures were not followed, contributing to the deficiencies identified by the surveyors.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide necessary toileting assistance to a resident who is dependent on staff for such care. On the morning of July 9, 2024, the resident, who was admitted to the facility on July 5, 2024, reported being wet for several hours without being checked or changed by staff. The resident, who cannot bear weight on their leg and uses incontinence briefs, stated that the last change occurred between 6:45 and 7:00 AM, and no staff had inquired about their need for a change since then. A Certified Nursing Assistant (CNA) responsible for the resident admitted to not checking on the resident since the morning change due to being occupied with other residents. The Director of Nursing confirmed that staff are expected to round on residents hourly and provide incontinence care as needed. The resident's medical history includes conditions such as polyneuropathy, monoplegia of the lower limb, and reduced mobility, which necessitate substantial assistance with toileting. The resident's care plan emphasizes timely toileting to reduce fall risk, and facility policies highlight the importance of incontinence care to prevent skin breakdown. Despite these guidelines, the resident was left in a saturated incontinence brief, which was only addressed after the surveyor's intervention.
Improper Food Storage and Labeling in Resident Refrigerator
Penalty
Summary
The facility failed to properly manage the storage and labeling of food items brought in by residents, family members, and visitors, which were stored in the first-floor dining room refrigerator designated for residents' personal use. During an inspection, it was observed that several food items were not labeled with the resident's name, room number, or the date they were placed in the refrigerator. Additionally, some items were found to be past their discard date, and the refrigerator temperature log was incomplete for several days. Interviews with staff revealed a lack of clarity and adherence to the facility's policy regarding the labeling, dating, and discarding of food items. The Registered Nurse (V8) and Housekeeper (V9) acknowledged that the refrigerator was not cleaned daily and that items were often placed without proper labeling. The Dietary Manager (V10) and Housekeeping Assistant (V12) also expressed uncertainty about their responsibilities and the facility's policy, indicating a lack of communication and oversight in ensuring compliance with food safety standards. The Director of Nursing (V2) confirmed that both the kitchen and housekeeping departments were responsible for weekly checks of the refrigerator, but acknowledged that items could remain in the refrigerator beyond the recommended discard period. The facility's policy required that food items be labeled and dated, with cooked or prepared foods discarded within 48 hours, and refrigerator temperatures recorded daily. However, these procedures were not consistently followed, posing a potential risk to the health and safety of the residents.
Critical Failures in Resident Care and Communication Leading to Immediate Jeopardy
Penalty
Summary
The report details a series of critical failures in providing appropriate treatment and care to a resident, R1, which ultimately led to an Immediate Jeopardy situation. The facility failed to adhere to the resident's care plan and physician orders, including keeping the head of the bed elevated during and after tube feedings, providing one-to-one feeding assistance, and monitoring for signs of aspiration. These failures resulted in R1 aspirating, experiencing difficulty breathing, and ultimately passing away in the facility. The staff also did not follow the facility's code blue policy to call 911 promptly when R1 was unresponsive and in distress, further exacerbating the situation. Additionally, there were significant communication breakdowns within the facility. The staff failed to notify the physician in a timely manner of R1's acute change in condition, did not relay critical laboratory and diagnostic test results promptly, and provided inaccurate reports to the physician. These communication failures hindered the timely and appropriate medical interventions that could have potentially prevented the tragic outcome for R1. The lack of documentation, delayed reporting, and miscommunication among the staff contributed to the severity of the deficiency identified during the survey.
Failure to Provide Necessary Treatment for Pressure Ulcer
Penalty
Summary
The facility staff failed to provide necessary treatment and services to promote healing and prevent infection of an existing pressure ulcer for a resident (R2). R2 was admitted to the facility with a pre-existing pressure ulcer, but the facility did not consistently document the physician-ordered treatments for R2's sacral pressure ulcer from 03/06/24 through 03/11/24 and 03/12/24 through 03/17/24. This lack of documentation and treatment led to R2's sacral wound becoming infected, resulting in hospitalization and the need for intravenous antibiotics. R2's medical history included multiple conditions such as Paroxysmal Atrial Fibrillation, Essential Hypertension, Hyperlipidemia, Hemiplegia, Dysarthria, Fall, Ataxia, Cerebral Infarction, Fracture of Right Femur, Chronic Atrial Fibrillation, Acute Kidney Failure, Repeated Falls, Muscle Weakness, Dysphagia, Difficulty in Walking, Cognitive Communication Deficit, Urinary Tract Infection, and Pressure Ulcers. Despite these conditions, the facility's care plan and interventions were not adequately followed. The facility's records showed missing initials for treatment administration on specific dates, and there was no further wound documentation after 03/12/24. Interviews with staff and family members revealed that R2 was often found wet or soiled, indicating a lack of proper incontinence care, which could have contributed to the wound's deterioration. The wound care coordinator and other staff members acknowledged the presence of slough and evolving tissue damage but failed to document and address the wound's progression adequately. The hospital records confirmed the infection, with cultures showing bacteria such as E. coli, which is consistent with contamination from stool due to the wound's proximity to the anus.
Failure to Follow Aspiration Precautions and Provide One-to-One Feeding Assistance
Penalty
Summary
The facility staff failed to have the necessary skills and competencies to meet the healthcare needs of a resident (R1), resulting in the resident's acute change of condition and subsequent death. R1 was admitted with multiple medical diagnoses, including pneumonitis due to inhalation of food and vomit, dysphagia, and cerebral infarction. The care plan for R1 required the head of the bed to be elevated 45 degrees during and 30 minutes after tube feeding, and for R1 to receive one-to-one feeding assistance with a pureed diet and honey-thick liquids. However, these precautions were not followed by the staff on multiple occasions. On the day of the incident, a Certified Nurse Assistant (CNA) provided R1 with a dinner tray without repositioning or elevating the head of the bed. The CNA was unaware that R1 required one-to-one feeding assistance and did not read the swallowing precautions posted above R1's bed. As a result, R1 was found lying flat in bed, vomiting, and experiencing difficulty breathing. Despite the efforts of the nursing staff to stabilize R1 through suctioning and oxygen administration, R1 continued to show signs of distress and ultimately passed away the following morning. Interviews with the facility staff revealed a lack of awareness and adherence to R1's care plan and physician orders. The CNA admitted to not knowing about the one-to-one feeding requirement and not noticing the swallowing precautions sign. The Registered Nurse (RN) and Licensed Practical Nurse (LPN) involved in the incident also failed to document vital signs and did not call 911, believing the situation could be managed with nursing interventions. The facility's Director of Nursing and other staff members acknowledged that residents with gastric feeding tubes should never be laid flat and emphasized the importance of following aspiration precautions to prevent such incidents.
Inaccurate Documentation of Resident's Vital Signs
Penalty
Summary
The facility failed to provide an accurate record of a resident's vital signs. The resident, who had multiple medical diagnoses including pneumonitis, dysphagia, cerebral infarction, and hypertension, was admitted with a physician's order to monitor vital signs every shift for 30 days and then daily. However, the resident's medication administration sheet showed no vital signs documented for several days. Later, vital signs appeared in the record 24 days after the resident had expired, raising concerns about the accuracy and timeliness of the documentation. The Assistant Director of Nursing acknowledged the discrepancy, stating that vital signs should be documented immediately after being obtained and that no nurse should document in a resident's chart after the resident has expired. The Administrator also confirmed the inconsistency in the documentation, noting that the same document showed different information on different days. This failure to maintain accurate and timely records is a significant deficiency in the facility's documentation practices.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bria Of Forest Edge | 1.1 mi | ★★★★★ | 4 | 0 |
| Mercy Circle | 1.8 mi | ★★★★★ | 3 | 0 |
| Avantara Evergreen Park | 1.8 mi | ★★★★★ | 4 | 0 |
| Warren Barr Oak Lawn | 2 mi | ★★★★★ | 3 | 0 |
| Landmark At 95th Rehabilitation And Nursing Center | 2.7 mi | ★★★★★ | 17 | 0 |
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