Aliya On 87th
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 2940 West 87th Street, Chicago, Illinois 60652
- CMS Provider Number
- 145983
- Inspections on file
- 43
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Aliya On 87th during CMS and state inspections, most recent first.
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.
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 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 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.
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 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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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