Alta Rehab At Fairmont
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 5061 North Pulaski Road, Chicago, Illinois 60630
- CMS Provider Number
- 145867
- Inspections on file
- 41
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Alta Rehab At Fairmont during CMS and state inspections, most recent first.
Multiple residents with sleep apnea and complex respiratory conditions had physician orders for nightly CPAP/BiPAP that were not consistently followed or documented, and there was no documentation that masks, tubing, and exhalation ports were cleaned daily as required by facility policy. One resident with acute and chronic respiratory failure and morbid obesity reported not receiving BiPAP the first night after admission and was later found very sleepy with increased respirations and transferred to the hospital for acute respiratory failure and altered mental status, while the record lacked evidence that BiPAP was applied at bedtime as ordered. Other residents reported intermittent CPAP/BiPAP use and one stated the device had not been cleaned for months, and review of MARs, TARs, and notes for all affected residents showed no entries indicating daily cleaning of the CPAP/BiPAP equipment, despite the DON’s expectation that such care be performed and documented.
A resident with diabetes and cardiac conditions did not receive scheduled blood glucose checks or insulin administration as ordered, with the RN failing to provide morning medications or perform required monitoring. The omission was confirmed through observation, interviews, and documentation, and facility policy requires timely administration of such medications.
Surveyors found that kitchen staff did not consistently label or dispose of food items according to facility policy, with some salads and thickened water lacking proper dates or being kept beyond the recommended time. Staff confirmed that labeling and timely disposal are required for resident safety, and at least one resident required specialized thickened liquids.
Surveyors found that staff did not date opened multi-dose insulin for three residents and failed to store unopened Latanoprost eye drops at the required refrigerated temperature for two residents. Insulin pens and vials were observed without open dates, and eye drops requiring refrigeration were kept at room temperature, contrary to pharmacy labeling and facility policy. Nursing staff and the DON confirmed the need for proper dating and storage, and facility policies outlined these requirements.
Staff failed to perform hand hygiene and properly use PPE during direct care activities, including medication administration and ADL care, for several residents. The same blood pressure device was used on multiple residents without cleaning, and reusable equipment was not sanitized between uses. Staff did not follow Enhanced Barrier Precaution protocols, such as wearing gowns and gloves during high-contact care, and the facility lacked a policy for cleaning reusable medical equipment.
A resident with severe cognitive impairment returned from a hospital visit still wearing a wristband that displayed personal information, including name, age, date of birth, and gender. Staff acknowledged that the wristband should have been removed to protect the resident's privacy, as its continued presence exposed sensitive information in violation of privacy policies.
A resident with intact cognition was found with Tamsulosin capsules left at the bedside without a physician order, assessment, or care plan for self-administration. The DON and LPN confirmed that medications should not be left at the bedside and that self-administration requires formal assessment and authorization, which was not present in this case.
A resident's Quarterly MDS assessment was not completed within the required 14-day timeframe from the Assessment Reference Date, as confirmed by the MDS/Care Plan Coordinator and facility records. This resulted in a late submission to CMS, contrary to regulatory requirements.
A resident with GERD and dyspepsia consistently ate meals while lying down, despite posted instructions to sit upright and repeated staff education about choking risks. Staff were aware of the resident's preference but did not communicate it to management or update the care plan to reflect this behavior, resulting in the absence of a person-centered care plan addressing the resident's eating position.
A resident with dementia and dysphagia was observed eating lunch in bed with the head of the bed at about 30 degrees, rather than upright as required by their care plan. Staff acknowledged the resident should have been repositioned to prevent aspiration, but the CNA placed the meal tray without doing so. The facility lacked policies for aspiration precautions and feeding setup in bed, contributing to the deficiency.
A resident with dysphagia and other chronic conditions was not provided with the required one-to-one feeding assistance during a meal, despite clear orders, care plan documentation, and posted signage indicating strict aspiration precautions. The resident was observed eating independently without staff present, and facility leadership confirmed there were no policies in place for aspiration precautions or ADL care.
Two residents were affected when staff failed to follow protocols for midline catheter care and aspiration precautions. One resident did not receive required midline dressing changes, measurements, or maintenance flushes, and lacked a care plan for midline use. Another resident with a strict 'no straws' order due to aspiration risk was found with a straw accessible at bedside, and staff did not promptly remove it. The facility also lacked a policy for aspiration precautions.
Two residents with dementia and a history of falls were observed with their beds not in the lowest position, contrary to their care plans and facility policy. Staff interviews confirmed that the beds should have been kept low as a fall precaution, but this intervention was not in place at the time of observation.
A resident with a gastrostomy tube and complex medical needs, including dialysis and heart failure, received water flushes at a rate higher than the most recent physician order. Despite updated orders to reduce the volume and frequency of water flushes, staff continued to administer the previous regimen, as confirmed by observations and staff interviews.
Two residents did not receive oxygen therapy as ordered by their physicians: one had a nasal cannula not applied while the oxygen concentrator was running, and another received a higher oxygen flow rate than prescribed. Staff confirmed the discrepancies between the physician orders and the care provided, and both residents had significant respiratory and cognitive conditions requiring staff assistance.
Two residents were found using bed side rails without current risk assessments, care plans, or documented informed consent, despite facility policy requiring these steps. Staff confirmed that side rail use should be addressed in the care plan and regularly reviewed, but this was not done for either resident.
Surveyors observed a medication error rate of 34.29% during medication administration, with multiple errors involving wrong doses, incorrect timing, and omission of medications by LPNs. Errors included giving the wrong dose of cough and iron medications, administering blood pressure and diabetes medications at the wrong times, and failing to give a prescribed diuretic. The DON confirmed that staff are expected to follow a two-hour window and the '5 rights' of medication administration, but these protocols were not followed during the observed medication passes.
A resident with complex medical needs was discharged without receiving a completed Discharge Instruction, as required. Only the initial sections of the Discharge Assessment were filled out by social services, while nursing failed to complete and provide critical sections covering medications, diet, and follow-up care. The discharge paperwork was not printed, signed, or uploaded to the EHR, resulting in the resident and family not receiving necessary instructions for post-discharge care.
A resident with multiple pressure ulcers was readmitted with documented wounds, but necessary wound care orders were not entered on the Physician Order Sheet, and prescribed treatments were not consistently performed or documented. Nursing staff interviews confirmed that wound care was not initiated as required, and missing signatures on the Treatment Administration Record indicated treatments were not completed, resulting in a failure to provide necessary care for the resident's pressure ulcers.
A resident with significant physical frailty was physically pushed multiple times onto a bed by a larger, cognitively intact roommate during a verbal altercation. Staff present attempted to intervene but were unable to prevent the physical abuse. The aggressor had a documented history of agitation and prior incidents of threatening behavior. Facility policy prohibits abuse, but the measures in place did not prevent this incident.
The facility failed to follow its infection control program, particularly in managing isolation for two residents with infectious diseases. Observations showed improper PPE use and disposal, with clear plastic liners used instead of red biohazard bags. Additionally, isolation signage was inaccurate, and staff were not consistently aware of the correct protocols, potentially affecting all 153 residents.
The facility failed to maintain an effective pest control program, with residents reporting mice and roaches in their rooms. Despite evidence of pests, the facility's pest control measures were inadequate, focusing only on common areas and not resident rooms. The maintenance director admitted to incomplete documentation and follow-up on pest sightings, and an inspection revealed improperly set bait stations and large openings in ceiling tiles, indicating a lack of thoroughness in addressing pest issues.
The facility failed to maintain a clean and homelike environment, as a resident was observed urinating and defecating on the floor and bed, causing distress to roommates. Despite being moved to a room with a bathroom, the resident continued these behaviors, and staff were aware but ineffective in addressing the issue. The room had damaged walls, a loud bathroom fan, and multiple soiled urinals, violating residents' rights to a safe and comfortable environment.
A facility failed to protect residents from physical abuse during an altercation between two residents, resulting in injuries. One resident, with a history of bipolar disorder and osteoporosis, reported a thumb injury, while the other, with anxiety and depression, sustained scratches. Conflicting accounts from the residents led to an inconclusive investigation by the facility staff.
A resident with limited mobility and high fall risk fell from bed, sustaining a femur fracture and forehead hematoma, due to inadequate supervision and failure to follow care plan protocols. The CNA repositioned the resident alone, contrary to the requirement for two-person assistance, and was unaware of the resident's fall risk status.
A facility failed to update a resident's family on a grievance regarding insulin ordering issues, despite being aware of the problem. The resident was uncertain about insulin monitoring, and the family was charged for unused insulin. The DON and MDS Coordinator acknowledged the issue, but it was not addressed in a care plan meeting. The resident's Financial Power of Attorney was not informed about the meeting or the grievance resolution, violating the facility's grievance policy.
A resident developed facility-acquired deep tissue injuries (DTIs) on her ankles after staff left her legs crossed for an extended period. Despite having a care plan for skin breakdown prevention, the facility failed to implement necessary interventions, resulting in pressure ulcers. The resident, who was cognitively intact, reported the incident, and the wound care team confirmed the DTIs.
Two residents experienced significant weight loss due to the facility's failure to document monthly weights, consider dietary preferences, and provide adequate meal options. One resident lost 7.1% of their weight in one month, while another lost 11.6% over six months. Despite being on supplements, both residents frequently refused them, and their dietary preferences were not included in assessments.
The facility failed to provide necessary mobility devices, such as wheelchairs, for two residents who required them for transfer assistance. Despite care plans indicating the need for wheelchairs, the Kardexes did not include this information, and staff were unaware of the requirement. The facility also lacked a policy on accommodating resident needs, contributing to the deficiency.
The facility failed to include the potential for abuse or neglect in the care plans of several residents, despite policy requirements. The Care Plan Coordinator acknowledged that these plans were not developed unless residents verbalized concerns, even though all residents are at risk.
The facility failed to follow its menu and emergency planning procedures after the kitchen was closed due to health violations, affecting 155 residents. Meals from a sister facility did not match the posted menu, and no revised menu was provided. The facility lacked a specific emergency plan for kitchen closure, and the menu was not accessible to residents and families as required.
The facility failed to manage a suspected scabies outbreak effectively, as it did not follow its infection control policies, including posting signs, completing infection logs, and performing necessary skin tests. Residents with rashes were not isolated, and treatments were inconsistently administered, potentially affecting all 153 residents.
Two residents in a LTC facility were found to be involuntarily secluded due to inadequate transfer assistance and lack of wheelchairs. Despite their dependence on staff for transfers and expressed desire to get out of bed, the facility failed to provide necessary equipment and assistance, resulting in confinement to bed. Documentation inconsistencies further indicated prolonged periods of seclusion.
A facility failed to properly schedule and prepare a resident for a colonoscopy, ordered due to significant weight loss. The procedure was delayed due to transportation issues and inadequate preparation, with no policies in place for scheduling or transportation. The resident did not receive necessary bowel prep or dietary orders, and the facility lacked documentation of appointments and results.
The facility failed to post and maintain daily nursing staffing information, affecting all 160 residents. The Lead Receptionist and Staffing Coordinator were unaware of the requirements, leading to a lack of posted staffing sheets and improper record-keeping. The last recorded staffing sheet was from February, and the Director of Nursing confirmed the need for daily postings and retention of records.
The facility failed to properly label and date food items in the kitchen, potentially affecting 157 residents on an oral diet. Observations revealed opened bags of corn and chocolate chips without dates, peas with freezer burn, and expired peach cobbler. The Dietary Cook and Supervisor acknowledged the importance of labeling to prevent illness. Facility policies require proper dating and storage of food items.
The facility failed to ensure dumpster lids were closed, potentially affecting all 160 residents. Observations revealed open dumpster lids, and staff interviews confirmed the importance of keeping them closed to prevent rodent infestation and maintain infection control. Facility policies and job descriptions emphasize maintaining a clean and sanitary environment.
The facility failed to properly store oxygen tanks and discard a lancet, affecting two residents. An unsecured oxygen cylinder was found in a resident's room, posing a potential hazard, while a lancet was left on another resident's bedside drawer, risking injury. Both incidents were confirmed by staff, highlighting non-compliance with facility policies on oxygen safety and medical waste disposal.
The facility failed to follow its policy for changing nebulizer tubing and storing nasal cannulas, affecting several residents. Observations showed outdated nebulizer tubing and nasal cannulas left uncovered or on the floor, risking contamination. Staff were unaware of the replacement schedule, and the facility's infection control practices were not consistently applied.
The facility failed to manage medications properly, with expired medications found in storage and loose pills in medication carts. A resident's expired Rosuvastatin was not discarded, and nurses were unable to identify loose pills, risking medication errors. The deficiencies affected one resident directly and potentially impacted all residents assigned to the medication carts and storage room.
The facility failed to properly log refrigerator temperatures and maintain freezers for residents' personal refrigerators, affecting multiple residents. Observations revealed missing temperature log entries and ice buildup in freezers, indicating a lack of daily monitoring and maintenance. Interviews with residents and staff confirmed inconsistent temperature checks and unclear defrosting procedures, posing a potential health risk due to spoiled food.
The facility failed to update a resident's isolation status, leading to potential infection control issues. A resident with MRSA and C. diff had outdated isolation orders, despite completing antibiotics. Additionally, a clean linen cart was improperly brought into a resident's room, risking contamination. Staff also failed to follow hand hygiene and PPE protocols, as observed during care activities.
The facility failed to secure a handrail in Unit 2B, potentially affecting all residents in the unit. A CNA confirmed the handrail had been unsecured for a long time, and the Maintenance Director was unaware of the issue. The DON emphasized the importance of fixed handrails for resident safety, as residents rely on them for support. An email from the Administrator highlighted the need to ensure all handrails are properly secured.
The facility failed to maintain the dignity of two residents by not covering their indwelling catheter drainage bags. One resident with neurogenic bladder had an exposed urinary drainage bag, despite the presence of a privacy bag. An LPN confirmed the expectation to use privacy bags. Another resident's catheter bag was also left uncovered, facing the door, until an LPN placed it in a privacy bag. The facility's policy emphasizes covering catheter bags to uphold resident dignity.
A facility failed to maintain the privacy of electronic health records when an LPN left a resident's medication administration record open and unattended on a laptop. The DON confirmed that staff are expected to close or minimize the screen when leaving the computer to prevent unauthorized access, in compliance with HIPAA.
Two residents experienced deficiencies in their living environment, with one unable to close their bathroom door for privacy and another having a stained ceiling and damaged floor tiles. An LPN and the Maintenance Director confirmed these issues, acknowledging the need for repairs to ensure safety and privacy.
A facility failed to conduct a new PASARR assessment for a resident diagnosed with schizoaffective disorder and major depression after admission. The Social Services Director confirmed the oversight, noting that the admissions and social services departments are responsible for ensuring PASARR assessments are completed when new psychiatric diagnoses occur. Despite the facility's policy requiring such assessments, none were conducted following the resident's new diagnoses.
The facility failed to provide adequate ADL care for two residents, compromising their personal hygiene. One resident with cognitive impairment did not receive timely incontinence care, resulting in a wet bed and worn pad. Another resident with diabetes had unclean fingernails with food debris, despite expressing a desire for nail care. Facility policies requiring regular care were not followed, leading to these deficiencies.
The facility failed to ensure medications were administered as ordered, affecting two residents. The MARs for these residents showed missing documentation for several medications, suggesting they may not have been administered. Both residents have intact cognition and multiple medical conditions. Facility policy requires immediate documentation of medication administration, which was not followed.
A facility failed to discard a piston syringe used for catheter care after a single use, as required by its guidelines. Instead, the syringe was reused three times within 24 hours for a resident with an indwelling catheter, increasing the risk of infection. The DON and Infection Preventionist confirmed that this practice violated aseptic technique, potentially leading to catheter-associated UTIs.
Failure to Follow CPAP/BiPAP Orders and Perform Required Daily Equipment Cleaning
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for BiPAP/CPAP use and to ensure daily cleaning of BiPAP/CPAP equipment for multiple residents with sleep apnea and complex respiratory conditions. One resident with acute and chronic respiratory failure, morbid obesity (BMI ≥70), obstructive sleep apnea, and chronic heart failure was admitted with an order for BiPAP via full mask at bedtime. The admission summary and physician documentation confirmed that this resident was to receive BiPAP nightly. The resident reported that on the first night after admission he did not receive BiPAP, only oxygen via nasal cannula, and that he subsequently "passed out" and was transferred to the hospital the following morning. The clinical record for that night did not show documentation that BiPAP was applied at bedtime as ordered. Nursing staff interviews were inconsistent: the admitting RN stated BiPAP should have been documented on the MAR/TAR if given, and the night RN later stated she did not place the BiPAP mask until after 1:00 a.m., removed it around 4:00 a.m., then briefly reapplied it around 5:00 a.m., with no corresponding documentation in the record. On the morning after admission, staff observed this same resident to be very sleepy and difficult to keep awake, with increased respiratory rate. The CNA reported that the resident was on oxygen, looking at him but not speaking, and not eating breakfast, prompting notification of the nurse. The day RN confirmed that at shift change the resident was sleeping in bed with oxygen via nasal cannula and that the BiPAP machine was not on. The nurse practitioner evaluated the resident twice that morning, noting that he was not waking up, had tachypnea with respiratory rates in the high 20s to low 30s, and required increased oxygen, leading to transfer to the hospital for altered mental status and acute respiratory failure. The NP and physician both stated that failure to provide BiPAP at bedtime as ordered could potentially contribute to a change in mental status, although they also cited the resident’s chronic respiratory failure, morbid obesity, obstructive sleep apnea, and other comorbidities as contributing factors. The facility’s own policy required that CPAP/BiPAP be ordered by a physician, set up by respiratory therapy, and that mask, tubing, and exhalation port be cleaned daily. For four additional residents with intact cognition and diagnoses including obstructive sleep apnea, chronic respiratory failure, COPD, morbid obesity, and other serious conditions, surveyors observed CPAP or BiPAP machines at bedside and confirmed active physician orders for nightly use. These residents reported using their devices at bedtime, sometimes inconsistently due to discomfort or personal preference, and one resident stated that staff had not cleaned the CPAP device for months, only wiping off excess water from the mask. For all five residents reviewed (including the first resident), the February and March MARs, TARs, and progress notes did not reflect that CPAP/BiPAP masks, tubing, and exhalation ports were cleaned daily as required by facility policy. The DON confirmed that nurses were expected to follow physician orders for CPAP/BiPAP, document administration on the MAR/TAR or in progress notes, and clean the devices daily for infection control, stating that if it was not documented, it was considered not done. This combination of missing documentation of ordered BiPAP use and lack of documented daily cleaning of CPAP/BiPAP equipment constituted the identified deficiency.
Failure to Administer Scheduled Medications and Blood Glucose Monitoring
Penalty
Summary
A deficiency occurred when a resident with multiple medical diagnoses, including type 2 diabetes mellitus with diabetic autonomic neuropathy, heart failure, and atrial fibrillation, did not receive scheduled medications as ordered. The resident's care plan required regular blood glucose monitoring and administration of insulin with meals, as well as other medications for cardiac conditions. On the day in question, the resident reported not having received any medications or blood glucose checks by lunchtime, despite orders for blood glucose monitoring before meals and insulin administration. Observation and interviews confirmed that the assigned RN had not administered the resident's morning medications, nor had she performed the required blood glucose checks at the scheduled times. The RN acknowledged that the resident should have had blood sugar checks and insulin administered at specific times, but these actions were not completed. Documentation in the resident's progress notes and medication administration records further indicated that the insulin and blood glucose checks were missed until later in the afternoon, and the nurse practitioner was notified after the omission was discovered. Facility policy and the RN's job description both require medications to be administered as prescribed and within specified time frames, particularly for time-sensitive medications such as insulin and blood pressure medications. The Director of Nursing confirmed that staff are expected to follow physician orders and administer medications within the appropriate window, and that failure to do so is not acceptable. The nurse practitioner also stated that all medications are expected to be given when due and that missed doses can have adverse effects.
Failure to Properly Label and Store Food Items in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to follow proper food labeling and storage practices in the kitchen, which could affect all 141 residents receiving food from this area. During an initial kitchen tour, it was found that cartons of thickened lemon-flavored water in the milk cooler were not sealed and either lacked an opened date or had an outdated opened date. In the reach-in refrigerator, several salad bowls and plates were labeled inconsistently, with some missing use-by dates and others exceeding the facility's stated three-day use period for salads. Staff interviews confirmed that salads should be used within three days and that proper labeling is required for resident safety. The Dietary Manager and Cook both acknowledged the importance of labeling and discarding food items according to policy to prevent serving expired food to residents. The facility's policy requires opened food items to be labeled with an opened-on date and disposed of once expired. At the time of the survey, there was at least one resident who required honey-thick water, highlighting the need for strict adherence to food safety protocols. The failure to consistently label and dispose of food items as per policy was directly observed and confirmed by staff.
Failure to Properly Date and Store Insulin and Eye Drops
Penalty
Summary
Surveyors observed that the facility failed to properly date opened multi-dose insulin for three residents and did not ensure that multi-dose eye drops were stored at the appropriate temperature for two residents. During inspections of medication carts and a medication room, opened Lantus insulin pens and vials were found without open dates, despite pharmacy labels indicating that insulin should be dated upon opening and discarded after 28 days. Additionally, unopened Latanoprost eye drops, which require refrigeration until opened, were found stored at room temperature in medication carts, contrary to pharmacy labeling and facility policy. Interviews with nursing staff, including an RN, an LPN, and the DON, confirmed that medications such as insulin and Latanoprost should be dated when opened and stored according to manufacturer and pharmacy recommendations. The facility's own policies and reference guides also specify proper storage temperatures and expiration dating for these medications. Physician order sheets for the affected residents documented active orders for Lantus insulin and Latanoprost eye drops, further confirming the need for proper medication management as outlined in the facility's procedures.
Failure to Follow Infection Control and PPE Protocols
Penalty
Summary
Surveyors observed multiple failures in infection prevention and control practices among staff during direct resident care. Staff members, including an agency LPN and CNAs, did not perform hand hygiene before and after entering or exiting resident rooms, nor after direct contact with residents. The same blood pressure device was used on several residents consecutively without cleaning or disinfecting it between uses. Staff also failed to perform hand hygiene when donning and doffing gloves and PPE, and reusable medical equipment such as blood pressure cuffs and pulse oximeters were not sanitized between residents. In rooms with Enhanced Barrier Precautions (EBP) signage, staff did not follow required protocols. Staff were observed entering rooms and providing care, such as medication administration and vital sign checks, without performing hand hygiene or properly donning and doffing PPE, including gowns and gloves. In one instance, a CNA provided activities of daily living (ADL) care, including changing linens and briefs for a resident with chronic wounds and a gastrostomy tube, without wearing a gown as required by EBP protocols. Another CNA, identified as an orientee, also failed to wear a gown while handling soiled linens and entering and exiting the resident's room. Interviews with the Director of Nursing confirmed that staff are expected to perform hand hygiene and sanitize reusable equipment between residents to prevent infection. However, the facility was unable to provide a policy for cleaning reusable medical equipment when requested by surveyors. The facility's existing hand hygiene and infection control policies require routine handwashing and maintenance of necessary equipment, but these were not followed as observed during the survey.
Failure to Remove Hospital Wristband Exposing Resident's Personal Information
Penalty
Summary
A resident with severe cognitive impairment and multiple medical diagnoses, including dementia, alcoholic cirrhosis, and dysphagia, was observed wearing a hospital wristband that displayed personal information such as name, age, date of birth, and gender. The wristband was still on the resident's wrist after returning from a recent hospital visit, making the resident's identifying information visible to anyone. Staff, including a registered nurse and the director of nursing, acknowledged that the wristband should have been removed upon the resident's return to protect privacy, as the exposed information constituted a violation of privacy policies and was considered a HIPAA concern. Facility policy requires that resident labels be placed in a manner that is both conspicuous and respectful of dignity, which was not followed in this instance.
Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
A deficiency was identified when a resident was observed with two capsules of Tamsulosin/Flomax in a medication cup at their bedside. The resident, who had an intact cognition per the most recent MDS, stated that the medication was brought by a nurse but was unsure when. Upon inquiry, an LPN confirmed the medication was scheduled for nighttime administration and suggested it may have been left by the night nurse. Review of the resident's electronic health record revealed no assessment or care plan for self-administration of medication, and there was no physician order permitting the resident to keep medication at the bedside. The facility's policy requires an interdisciplinary team assessment and a prescriber's order before allowing residents to self-administer medications. The DON confirmed that nurses are not supposed to leave medications at the bedside and that self-administration should be formally assessed, care planned, and ordered by a physician. The resident's records showed an active order for Tamsulosin to be given at bedtime, but no documentation supported self-administration or leaving medication at the bedside, resulting in noncompliance with facility policy and regulatory requirements.
Late Completion of Quarterly MDS Assessment
Penalty
Summary
The facility failed to complete the Quarterly Minimum Data Set (MDS) assessment for one resident within the required regulatory timeframe. According to interview and record review, the MDS/Care Plan Coordinator confirmed that the MDS, which is used to describe the resident and guide their care, must be submitted to CMS every quarter or more frequently if there is a significant change in the resident's condition. For the resident in question, the Assessment Reference Date (ARD) was completed late, and the assessment was not finalized within 14 days as required by the RAI manual. Documentation showed that the assessment completion date exceeded the 14-day window, resulting in a late submission.
Failure to Care Plan Resident's Preference for Eating Position
Penalty
Summary
The facility failed to develop and implement a person-centered care plan that addressed a resident's preference to eat while lying down, despite clear evidence of the resident's ongoing behavior and associated risks. Observations showed the resident eating meals in bed with the head of the bed only slightly elevated, resulting in the resident bending their neck to eat and experiencing coughing during meals. Signage above the bed instructed staff to ensure the resident was upright while eating and drinking, but the resident reported consistently eating in a reclined position and sliding down even when staff attempted to elevate the bed. The resident also stated that staff would pull them up, but they would slide back down, and this occurred at every meal. Interviews with staff revealed that both a CNA and an LPN were aware of the resident's preference to eat lying down and had educated the resident about the risks of choking and aspiration. However, neither staff member reported this preference or behavior to the Director of Nursing or management. The Director of Nursing confirmed they were not aware of the resident's eating position and that the care plan did not address the resident's preference or the associated risks. The facility was unable to provide a care plan that incorporated the resident's choice to eat while lying down, despite the resident's medical diagnoses of gastro-esophageal reflux disease and dyspepsia, and the facility's policy requiring care plans to reflect resident preferences and needs.
Failure to Properly Position Resident During Meals
Penalty
Summary
A deficiency was identified when a resident with diagnoses including dementia, dysphagia (oropharyngeal phase), and a history of falls was observed eating lunch while lying in bed with the head of the bed at approximately 30 degrees, rather than in an upright position. The resident's lunch tray was placed on the bedside table across the bed, and the resident was seen feeding themselves in this position. Staff interviews confirmed that the resident was not properly positioned for eating, with both a Licensed Practical Nurse and a Certified Nursing Assistant acknowledging that the resident should have been repositioned to at least a 45-degree angle to prevent aspiration. The CNA admitted to placing the meal tray without first repositioning the resident and stated an intention to reposition the resident in the future. The resident's care plan specifically indicated the need for upright positioning during meals due to a swallowing problem, and the resident required setup or clean-up assistance for eating as well as partial/moderate assistance to move from lying to sitting. Despite these documented needs, the facility did not have policies in place for choking or aspiration precautions, nor for feeding setup in bed, as confirmed by the Administrator and Director of Nursing. The lack of proper positioning and absence of relevant policies contributed to the deficiency in ensuring the resident did not lose the ability to perform activities of daily living safely.
Failure to Provide Required 1:1 Feeding Assistance for Resident on Aspiration Precautions
Penalty
Summary
A deficiency occurred when a resident with a history of dysphagia, Alzheimer's disease, type 2 diabetes mellitus, and chronic obstructive pulmonary disease was not provided with the required one-to-one feeding assistance during lunch. The resident was observed eating independently in bed with the head of the bed elevated, despite clear signage and dietary orders indicating the need for strict aspiration precautions and one-to-one feeding. The meal ticket, posted signage, and clinical records all specified that the resident required staff to feed her, using small spoonfuls and ensuring the mouth was cleared before offering additional bites, and that the resident should not be left alone with the meal tray. Further interviews confirmed that the speech pathologist had discharged the resident from therapy with recommendations for mechanical soft solids, thin liquids, and full staff assistance with feeding, emphasizing the risk of choking or aspiration if not assisted. The care plan also documented the need for partial to moderate assistance and one-to-one feeding. When the surveyor requested the facility's policies and procedures for aspiration precautions and ADL care, the administrator stated that no such policies existed.
Failure to Follow Midline Catheter and Aspiration Precaution Protocols
Penalty
Summary
The facility failed to follow its own policies and procedures regarding the care and management of a resident with a midline catheter and another resident with aspiration precautions. For one resident with a midline catheter, staff did not measure the upper arm circumference or the external catheter length, did not change the midline dressing in a timely manner, did not provide the required maintenance flush, and did not develop a comprehensive care plan for midline use. The resident reported that the midline dressing had not been changed since admission, and there was no documentation of required measurements or flushing. The Director of Nursing confirmed that these actions were necessary to monitor for complications and should have been documented and care planned according to facility policy. For another resident with a history of hemiplegia, dysphagia, and impaired cognition, the facility failed to ensure that physician orders for aspiration precautions were followed. Despite an active order and posted signage indicating a strict 'no straws' restriction due to aspiration risk, a cup of water with a straw was observed within the resident's reach. Staff confirmed the order and signage but did not remove the straw until prompted. The facility also lacked a policy and procedure for aspiration precautions, as confirmed by the administrator.
Failure to Implement Fall Prevention Interventions for At-Risk Residents
Penalty
Summary
Surveyors observed that the facility failed to implement fall prevention interventions for two residents identified as being at risk for falls. Both residents were found in their beds, which were not in the lowest position, despite care plans and staff interviews indicating that the beds should be kept low to reduce the risk of injury from falls. One resident was observed with a fall mat next to the bed, and both residents required assistance to get out of bed. Staff, including an LPN and a CNA, confirmed that the beds should have been in the lowest position as a fall precaution, but this intervention was not in place at the time of observation. Both residents had medical histories that included dementia and previous falls, and their care plans specifically identified them as fall risks, requiring interventions such as keeping the bed in the lowest position. Facility policy also required individualized fall prevention measures based on resident assessments. Despite these documented needs and policies, the required interventions were not consistently implemented, as evidenced by direct observation and staff interviews.
Failure to Administer Enteral Water Flushes per Physician Orders
Penalty
Summary
A deficiency occurred when the facility failed to ensure that water flushes for a resident with a gastrostomy tube were administered according to the most current physician orders. Observations and interviews revealed that the resident's feeding pump was set to deliver water flushes at 160 ml every 6 hours, despite a documented recommendation and approved order to decrease water flushes to 100 ml every 8 hours. The discrepancy was noted during multiple observations, and staff confirmed the settings on the pump did not match the updated orders. The Director of Nursing and Registered Nurse both referenced the need to follow physician orders for enteral feedings and flushes, but the actual practice did not align with the documented changes. The resident involved had significant medical complexities, including end stage renal disease requiring dialysis, chronic heart failure, and severe cognitive impairment. The dietician had recommended the reduction in water flushes due to concerns about fluid overload and the resident's ability to tolerate excess fluids, given their dialysis and cardiac status. Despite these recommendations and the nurse practitioner's approval, the water flushes continued at the previous, higher rate, contrary to the updated physician order.
Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents by not following physician orders regarding oxygen therapy. One resident was observed lying in bed with the oxygen concentrator set to 2 liters per minute (lpm), but the nasal cannula tubing was not applied and was instead wrapped around the bed rail with the nasal prong on the floor. The resident was not in distress at the time, but the oxygen was not being delivered as ordered. A Certified Nursing Assistant later applied the nasal cannula and acknowledged it should have been in place. Another resident was found receiving oxygen via nasal cannula at a flow rate of 3 lpm, despite a physician's order for continuous oxygen at 2 lpm. This discrepancy was confirmed by both an agency LPN and a Registered Nurse, who verified the order and the incorrect setting. The Director of Nursing stated that oxygen administration must follow the physician's order, as it is considered a medication. Both residents had significant medical histories, including chronic respiratory conditions and cognitive impairments, and required staff assistance for mobility and care.
Failure to Assess and Care Plan for Side Rail Use
Penalty
Summary
The facility failed to properly assess and document the use of side rails for two residents, resulting in deficiencies related to resident safety and care planning. For one resident with diagnoses including dementia, hypertension, and chronic kidney disease, observations showed the resident using two upper half side rails while in bed. Despite the resident's cognitive impairment and need for substantial to maximal assistance with bed mobility and transfers, there was no current side rail assessment, no physician order for side rail use, and no care plan addressing side rails since the resident's admission. The last side rail assessment on record was from a previous admission, and staff confirmed that no updated assessment or care plan had been completed for the current stay. Another resident, admitted with multiple complex medical conditions such as end stage renal disease and vertebral fractures, was also observed with two upper side rails in use. This resident required total or partial assistance with most activities of daily living and was dependent for transfers. Although a side rail assessment was present in the electronic health record, there was no care plan addressing the use of side rails. Staff interviews confirmed that side rail use should be included in the care plan and that assessments should be completed and reviewed regularly, but this was not done for the resident in question. The facility's own policy requires that alternatives to bed rails be attempted and documented, that a risk versus benefit assessment be completed, and that informed consent be obtained prior to installation. The policy also mandates that the use of side rails be addressed in the resident's care plan, including details on medical need, monitoring, and interventions to minimize risks. These steps were not followed for the two residents, as evidenced by the lack of assessments, care plans, and documentation of alternatives or informed consent.
High Medication Error Rate Due to Incorrect Dosing, Timing, and Omission
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 34.29% as observed during medication administration for three residents. Surveyors directly observed licensed nursing staff preparing and administering medications that did not match the physician orders and Medication Administration Records (MAR). Errors included administering the wrong dose of Mucinex and ferrous sulfate to one resident, and giving medications such as Senna, Nifedipine, and insulin at incorrect times to another resident. Additionally, a third resident received multiple medications at the wrong times, and a dose of furosemide was omitted entirely during the observed medication pass. Interviews with the Director of Nursing confirmed that nurses are expected to follow the facility's medication administration policy, which includes a two-hour window for timely administration and adherence to the '5 rights' of medication administration. The facility's own procedures require medications to be administered safely and effectively, with verification against the MAR at each step. Despite these policies, the observed actions of the nursing staff led to multiple medication errors involving wrong dose, wrong time, and omission of ordered medications.
Failure to Complete and Provide Discharge Instructions at Resident Discharge
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a Discharge Instruction was completed and provided to a resident upon discharge, which is necessary for a safe and effective transition of care. The process for completing the Discharge Assessment involved multiple departments, with the Social Services Director completing initial sections and nursing staff responsible for the remaining sections, including medications, diet/nutrition, ADL/bowel & bladder/restorative nursing, education/appointments, and skin condition on discharge. However, upon review, it was found that only the initial sections were completed, and the critical nursing sections remained incomplete. The Discharge Instruction was not printed, signed by the resident or responsible party, or provided at the time of discharge. Interviews with facility staff revealed that the nurse responsible for discharging the resident did not remember completing or providing the Discharge Instruction, and there was no reminder system in place to ensure completion. The Medical Records/Transportation staff confirmed that the discharge paper was not uploaded to the electronic health record, as it was never placed in the scan box by nursing. The facility's process required the nurse to print and provide the completed Discharge Assessment for the resident or family to sign, but this step was missed, resulting in the absence of documentation and notification regarding the resident's needs post-discharge. The affected resident had significant medical conditions, including hemiplegia, hemiparesis, sequelae of cerebral infarction, and morbid obesity. The resident's care plan indicated a desire to be discharged home with family and required written instructions to ensure continuity of care. The incomplete Discharge Instruction meant that essential information regarding medications, follow-up appointments, diet, and other care needs was not communicated to the resident or family, as required by facility policy and procedure.
Failure to Provide Prescribed Wound Care for Pressure Ulcers
Penalty
Summary
A resident with multiple complex medical diagnoses, including bacteremia, morbid obesity, chronic kidney disease, and chronic respiratory failure, was readmitted to the facility with several unhealed pressure ulcers. Upon readmission, the resident had documented wounds to the left buttocks, bilateral buttocks, left hip, and sacral area, as well as other sites. Despite these documented wounds, there were no corresponding treatment orders for these areas on the resident's Physician Order Sheet (POS) at the time of readmission. Interviews with nursing staff, including the wound care nurse, LPN, and wound care coordinator, revealed that it was the responsibility of the admitting nurse or wound care nurse to ensure that hospital treatment orders were entered and that wound care began upon admission. However, the review of the Treatment Administration Record (TAR) and POS showed missing treatment orders and missing signatures for wound care treatments, indicating that prescribed wound care was not performed for certain wounds. Staff members acknowledged that if treatment orders are not present or not signed out, it is assumed that the treatment was not performed, which could result in wounds worsening or becoming infected. Documentation from the resident's care plan and hospital records confirmed the presence of pressure ulcers and the need for ongoing wound care. Despite this, the facility failed to ensure that necessary wound care orders were entered and that treatments were administered as prescribed. The absence of a wound care coordinator at the time further contributed to the lack of oversight and follow-through on wound care orders, as confirmed by staff interviews and review of facility policies and job descriptions.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident (R1) from physical abuse by another resident (R2). On the morning of the incident, staff members, including a CNA and an RN, heard yelling and cursing coming from the shared room of R1 and R2. Upon entering, staff observed both residents engaged in a verbal altercation. Despite attempts by the CNA to de-escalate the situation and physically intervene by pulling on R2's shirt, R2 managed to push R1 down onto the bed multiple times. The CNA and other staff present were unable to prevent R2 from making physical contact with R1 during the altercation. R1 was described as physically fragile, with a history of liver cell carcinoma, bone neoplasm, spinal fusion, pathological fracture, severe malnutrition, and other significant medical conditions. R1 was wheelchair-bound and cognitively intact. R2, who was significantly larger in stature, also had multiple medical diagnoses but was ambulatory and cognitively intact. Prior to this incident, R2 had demonstrated verbally and physically agitated behavior, including an earlier episode where R2 swung a cane at staff. Both residents had a history of verbal arguments, and R2's care plan noted a risk for abuse/neglect due to agitated behavior, with interventions to observe R2 when in the company of peers. The incident was witnessed by multiple staff members and corroborated by documentation in progress notes and interviews. R2 admitted to pushing R1 and expressed ongoing aggression towards R1 after being removed from the room. The facility's policy affirms the right of residents to be free from abuse and requires the establishment of a secure environment, but in this case, the measures in place were insufficient to prevent the physical abuse of R1 by R2.
Inadequate Infection Control Practices for Isolation Precautions
Penalty
Summary
The facility failed to adhere to its infection prevention and control program, specifically in managing isolation protocols for residents diagnosed with infectious diseases. Two residents, one diagnosed with Influenza A and RSV, and the other with Influenza, were placed on droplet/contact isolation. However, the facility did not ensure that appropriate Personal Protective Equipment (PPE) was used and disposed of correctly. Observations revealed that the required PPE, such as N95 masks, was not included in the isolation protocol, and PPE disposal was not conducted in accordance with the facility's guidelines, as evidenced by the use of clear plastic liners instead of red biohazard bags. Additionally, the facility failed to maintain proper signage for isolation precautions. The signs on the residents' doors did not accurately reflect the required contact and droplet precautions, and staff were not consistently aware of the correct isolation protocols. The infection prevention nurse confirmed that the facility's protocol required contact and droplet precautions for residents with Influenza A and RSV, yet the signage and staff responses did not align with these requirements. This lack of adherence to established protocols has the potential to affect all 153 residents in the facility.
Inadequate Pest Control Measures in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of mice and roaches in resident rooms. Three residents reported sightings of pests, including mice and roaches, in their rooms. One resident provided video evidence of a roach crawling on the wall and a picture of a dead roach on a heater. Despite these reports, the facility's pest control measures were inadequate, with pest control services only inspecting common areas and not resident rooms. The facility's pest control program was not effectively implemented, as the maintenance director admitted to not following up on all reported pest sightings. The pest control log was incomplete, with missing entries for treatment dates and technician initials. Additionally, the maintenance director acknowledged that some reported pest sightings were not documented or followed up on, indicating a lack of thoroughness in addressing pest issues. During an inspection of a resident's room, a surveyor found a bait station that was not set and a glue station with live and dead insects adhered to it. The maintenance director was unaware of how to use the bait station and admitted that it had not been set. Furthermore, there were large openings in the ceiling tiles, which could serve as entry points for pests. These findings highlight the facility's failure to address pest control issues effectively, potentially affecting the health and safety of all residents.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for residents, as evidenced by the conditions observed in the rooms of three residents. One resident, identified as R2, was reported to have been urinating and defecating on the floor and bed, using sheets to clean himself, and disposing of waste improperly. Despite being moved to a room with a bathroom, R2 continued these behaviors, causing distress to his roommates, R1 and R3, who reported the incidents to staff and the facility administrator. The facility staff, including LPNs and CNAs, were aware of the situation but failed to effectively address the issue, as R2 continued to refuse to use the bathroom or call for assistance. The physical environment of the facility was also found to be lacking. Observations included a dried brown substance on R2's mattress and floor mat, multiple soiled urinals beneath R2's bed, and a loud screeching noise from the bathroom exhaust fan, which R2 indicated was a reason for not using the bathroom. The room shared by R2 and R3 had damaged walls, spray foam protruding from the baseboard, a dangling baseboard beneath the heater, and a discolored ceiling tile with large openings. These conditions contributed to an environment that was neither clean nor comfortable, violating the residents' rights to a homelike setting. The facility's policies on resident rights and housekeeping services were not adhered to, as the environment did not meet the sanitation needs of the residents. Despite repeated education and encouragement from staff, R2's behavior persisted, and the facility's failure to maintain a clean and orderly environment was evident. The surveyor's findings highlighted the facility's inability to provide adequate care and support for daily living, as required by regulatory standards.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by an altercation between two residents, R1 and R2. The incident occurred when R2 allegedly grabbed R1's thumb, causing pain, and R1 retaliated by grabbing R2's chest, resulting in multiple scratches and pain. Both residents had conflicting accounts of the event, with R1 claiming that R2 initiated the altercation by physically and verbally assaulting her, while R2 stated that she acted in self-defense after R1 grabbed her shirt. The facility's staff were unable to substantiate the incident due to the differing stories provided by the residents. R1's medical history includes bipolar disorder, major depressive disorder, osteoporosis with a history of pathological fractures, and HIV. At the time of the incident, R1 reported pain in her left thumb, which was later examined and found to have an inconclusive diagnosis of an acute fracture. Despite being advised to seek medical attention, R1 refused to go to the hospital and later canceled an orthopedic appointment, expressing distrust in the facility's associated doctors. R1's care plan indicated a low risk for abuse, but the assessment did not account for her mental health diagnoses, which could have increased her risk level. R2's medical history includes anxiety disorder, depression, and bipolar disorder. Her care plan identified her as being at moderate risk for abuse, with interventions to monitor her interactions with peers. Following the altercation, R2 was found to have scratch marks on her chest, which were documented by the nursing staff. The facility's policy on abuse prevention and reporting emphasizes the importance of creating a secure environment for residents and identifying those with increased vulnerability to abuse. However, the facility's response to the incident was limited to separating the residents and changing their rooms, without a clear resolution to the conflicting accounts of the altercation.
Inadequate Supervision and Fall Risk Management
Penalty
Summary
The facility failed to provide adequate supervision and a safe environment for a resident, resulting in a fall and injury. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction, was dependent on staff for mobility and required a two-person assist for repositioning. Despite these needs, a Certified Nursing Assistant (CNA) attempted to reposition the resident alone, leaving her at the edge of the bed. This action led to the resident falling from the bed, resulting in a right femur fracture and a hematoma on the forehead. The Director of Nursing (DON) confirmed that the resident was at risk for falls due to limited mobility and required two staff members for transfers and repositioning. The CNA involved was unaware of the resident's fall risk status and did not follow the care plan, which specified the need for two-person assistance. The facility's fall prevention program was not adequately implemented, as the resident's bed was not maintained in a low position, and the CNA was not informed of the resident's high fall risk status. The resident's care plan and fall risk assessments indicated a high risk for falls, with interventions such as keeping the bed in a locked position and ensuring frequently used items were within reach. However, these measures were not effectively communicated or adhered to by the staff. The failure to follow established protocols and provide the necessary level of assistance directly contributed to the resident's fall and subsequent injuries.
Failure to Update Family on Insulin Grievance
Penalty
Summary
The facility failed to adhere to its grievance policy by not updating the family of a resident regarding an ongoing issue with insulin ordering. The resident, identified as R4, expressed uncertainty about the monitoring of his insulin. The Director of Nursing (V2) acknowledged that there was an issue with the pharmacy charging the family for insulin that was not used and had to be discarded after 28 days. Despite being aware of the issue, V2 admitted that it was not addressed during a care plan meeting. The Minimum Data Set Care Plan Coordinator (V8) also confirmed receiving an email from R4's son about the insulin charges and noted that nurses were incorrectly ordering new insulin instead of adjusting the dosage from existing supplies. The resident's Financial Power of Attorney (V7) was not informed about the care plan meeting and had not received any updates on the grievance since July. The facility's Administrator (V1) was unaware of the insulin issue and stated that it was not discussed in the care plan meeting because the family did not bring it up. The facility's grievance policy requires grievances to be resolved within five business days, but the family was not notified of any extension or resolution, indicating a failure to follow the policy.
Failure to Prevent Pressure Ulcers in Resident
Penalty
Summary
The facility failed to implement interventions to prevent the development of deep tissue injuries (DTIs) for a resident who was admitted with multiple diagnoses, including a hip fracture and chronic conditions. The resident, who was cognitively intact, reported that staff crossed her legs at the ankles during care and did not reposition them afterward, leaving them in that position for approximately eight hours. This resulted in the development of pressure ulcers on her ankles, which were later identified as facility-acquired DTIs by the wound care team. The resident's care plan included interventions for the prevention and treatment of skin breakdown, but these were not effectively implemented. Observations and interviews with the wound care staff confirmed the presence of DTIs on the resident's ankles, which were initially thought to be venous or arterial ulcers. The facility's pressure ulcer prevention policy emphasized the use of positioning devices to reduce pressure and friction, but this was not adhered to in the resident's care, leading to the deficiency.
Failure to Provide Adequate Nutritional Care Leads to Significant Weight Loss
Penalty
Summary
The facility failed to ensure adequate nutritional care for two residents, resulting in significant weight loss. Resident R2, diagnosed with end-stage renal disease and protein-calorie malnutrition, experienced a 7.1% weight loss in one month. The facility did not document R2's monthly weights as required by policy, missing several months of records. R2 reported that meal portions had decreased since a change in ownership, and the facility no longer offered menu choices or double portions. Despite being on supplements for weight management and wound healing, R2 frequently refused these supplements, and their dietary preferences were not included in nutritional assessments. Resident R1, with a history of hypertension secondary to renal disorders, lost 11.6% of their body weight over six months. R1 expressed dissatisfaction with the kidney diet provided, which they no longer required, and reported nausea from the meals. R1 requested specific foods like cottage cheese but rarely received them, relying on Ensure when meals were inadequate. Despite significant weight loss, R1's dietary preferences were not considered in their nutritional assessments, and there was no follow-through on their requests to see a dietician. The facility's registered dietician and medical director acknowledged the significant weight loss in both residents but attributed it to existing medical conditions and medication effects. However, the facility's failure to document weights consistently, consider dietary preferences, and provide adequate meal options contributed to the residents' unplanned weight loss. The facility's policy required monthly weight documentation and reporting of significant weight changes, which was not adhered to, leading to these deficiencies.
Failure to Provide Required Mobility Devices for Residents
Penalty
Summary
The facility failed to ensure that staff were aware of and provided necessary mobility devices for residents, specifically wheelchairs, as required for their transfer assistance. This deficiency was observed in two residents, R2 and R5, who were both dependent on staff for chair/bed to chair transfers and required wheelchairs as per their care plans. However, their Kardexes did not include information about the required mobility devices, and the staff, including a CNA and the Restorative Nurse, were unaware of the need to provide these devices. R2, who had been in the facility for over two years, reported not having been provided a wheelchair, and R5 also confirmed the absence of a wheelchair in her room. The Restorative Nurse acknowledged the oversight and stated that wheelchairs could be provided if needed, but none were available in storage at the time of inspection. The facility's lack of a policy on wheelchair provision and accommodation of resident needs further contributed to the deficiency. The Assistant Director of Nursing confirmed the absence of such a policy when requested by the surveyor. The failure to include mobility devices in the Kardex and the lack of a clear policy on accommodating resident needs resulted in the residents not receiving the necessary equipment for their mobility and transfer assistance, potentially affecting all 153 residents in the facility.
Failure to Include Abuse/Neglect Risk in Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans that included the potential for abuse or neglect for four out of five residents sampled, which could potentially affect all 153 residents in the facility. The residents in question had been admitted to the facility between seven to twenty-three months prior to the survey. Despite the facility's policy requiring the development of a baseline care plan within 48 hours of admission, and the potential for a comprehensive care plan to replace the baseline plan if completed within the same timeframe, the care plans for these residents did not address the risk of abuse or neglect. During the survey, the Care Plan Coordinator (V9) acknowledged that comprehensive care plans are developed for admissions, quarterly, annually, and upon significant changes. However, V9 admitted that the care plans for the residents did not include potential for abuse or neglect unless the residents verbalized such concerns. The surveyor pointed out that all residents are at risk for abuse, to which V9 agreed, yet confirmed that the care plans for the sampled residents did not include this aspect. This oversight indicates a failure to adhere to the facility's policy and best practices for care planning.
Failure to Follow Menu and Emergency Planning Procedures
Penalty
Summary
The facility failed to adhere to its policy procedures and ensure that the menu was followed, affecting 155 residents. This deficiency was identified during a survey following a Facility Reported Incident (FRI) where the Health Department issued a non-serve citation due to mouse droppings found in the employee dining room, leading to the closure of the facility's kitchen. As a result, the facility enacted its Emergency Management Plan and began transporting food from a sister facility. However, the meals provided did not align with the posted menu, and no revised menu was posted to reflect the changes. The Assistant Dietary Manager confirmed that the meals served were based on what was received from the sister facility, rather than the planned menu. Further investigation revealed that the facility did not have a specific emergency plan policy for kitchen closure, and the menu was not posted in areas accessible to residents and families, as required by the 2020 menu posting policy. The Director of Nursing provided documentation indicating the number of residents affected and presented the Emergency Preparedness and Training Policy, which lacked specific plans for emergency menu and food preparation. Additionally, a Certified Nursing Assistant stated that the menu was never posted, and staff only had access to diet cards, not the daily menu. This lack of adherence to menu policies and emergency planning contributed to the deficiency.
Inadequate Infection Control During Scabies Outbreak
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, particularly in managing a suspected scabies outbreak. Observations and interviews revealed that the facility did not follow its own policies and procedures, such as posting required infection control signs and ensuring that the infection log was complete with necessary details like symptom onset dates and treatment dates. The facility also failed to follow physician orders and did not document skin integrity impairments or report ongoing rash and itching to the physician or nurse practitioner in a timely manner. These lapses were noted in the cases of two residents who were reviewed for scabies, among others. The report highlights specific instances where the facility's actions were inadequate. For example, one resident was not isolated despite having a rash and refusing treatment, and another resident in the same room was also affected. The facility's infection log was incomplete, with missing onset dates and treatment details for several residents. Additionally, the facility did not perform skin scrapings for scabies testing on all affected residents, relying instead on prophylactic treatment without confirmed diagnoses. This approach was inconsistent with the facility's own scabies control policy, which requires skin scrapings for diagnosis. Interviews with staff, including the Assistant Director of Nursing and the Nurse Practitioner, revealed a lack of clarity and consistency in handling the outbreak. Staff admitted to not performing skin tests on all residents with rashes and not adhering to the prescribed treatment schedule. The Medical Director acknowledged that isolation precautions should have been implemented for residents with rashes of unknown origin, but this was not consistently done. The facility's failure to adhere to its infection control policies and procedures potentially affected all 153 residents, as the outbreak was not effectively contained or managed.
Failure to Provide Transfer Assistance Leads to Involuntary Seclusion
Penalty
Summary
The facility failed to ensure that two residents, R2 and R5, were free from involuntary seclusion due to inadequate transfer assistance. R2, who is dependent on staff for chair/bed to chair transfers and uses a mechanical lift, was observed lying in bed without a wheelchair. Despite R2's intact cognition and expressed desire to get out of bed, staff did not provide the necessary assistance or equipment. Documentation inconsistencies were noted, with entries marked as 'N/A' or blank for bed to chair transfers, indicating that R2 was confined to bed for several days. Similarly, R5, who also requires a mechanical lift for transfers, was found without a wheelchair in her room. R5 expressed willingness to get out of bed, but staff did not facilitate this. The documentation for R5 showed similar inconsistencies, with numerous entries marked as 'N/A' or blank, suggesting that R5 was also confined to bed for extended periods. The facility's failure to provide the necessary mobility devices and transfer assistance resulted in the involuntary seclusion of both residents. The facility's abuse prevention policy outlines the need to prevent unreasonable confinement or involuntary seclusion, yet the staff failed to adhere to these guidelines. The policy requires staff to identify residents with increased vulnerability and ensure their needs are met, but the lack of proper documentation and equipment provision indicates a significant oversight. The surveyor's findings highlight the facility's inability to meet the residents' care needs, as evidenced by the absence of wheelchairs and the failure to perform necessary transfers.
Deficiency in Colonoscopy Scheduling and Preparation
Penalty
Summary
The facility failed to ensure proper scheduling and preparation for a resident's colonoscopy, which was ordered due to significant weight loss. The colonoscopy was initially ordered in February, but due to various issues, it was not completed until late August. The facility did not have policies or procedures in place for scheduling colonoscopies or arranging transportation, leading to missed appointments and inadequate preparation. The resident's appointments were rescheduled multiple times due to transportation issues and poor bowel preparation, and the facility did not retain records of scheduled appointments or transportation arrangements. Additionally, the facility failed to follow physician orders for bowel preparation and dietary restrictions prior to the colonoscopy. The resident did not receive the required bowel prep medication or NPO/clear liquid diet orders before the scheduled procedures. Despite the colonoscopy being ordered months in advance, the facility did not ensure timely services or receive the diagnostic results in a timely manner. The lack of documentation and communication among staff contributed to the delays and deficiencies in care for the resident experiencing significant weight loss.
Failure to Post and Maintain Daily Nursing Staffing Information
Penalty
Summary
The facility failed to ensure that the Daily Nursing Staffing information was posted daily and that previous records were maintained, potentially affecting all 160 residents. On the morning of August 5, 2024, it was observed that there was no daily nursing staffing sheet posted by the reception area. The Lead Receptionist stated that they were unaware of the current location of the staffing sheet due to issues with the wall where it was previously posted. The Staffing Coordinator, responsible for the schedule, admitted to not having filled out the daily nursing staffing sheet for that day and revealed that they typically discard the sheets after use, unaware of the requirement to keep them. Further investigation revealed that the last recorded Daily Nursing Staffing sheet was from February 6, 2024, indicating a significant lapse in record-keeping. The Director of Nursing confirmed that staffing should be posted daily and retained in a binder. An email from the Administrator outlined the expectations for staffing postings, including the need to display current nurse staffing numbers, total FTE count, and daily facility census in a prominent location accessible to residents and visitors. It also specified that copies should be kept for three years after removal from the visible area.
Improper Food Labeling and Expired Items in Kitchen
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items in the kitchen, which could potentially affect all 157 residents receiving an oral diet. During an observation of the facility's walk-in freezer, several food items were found to be improperly labeled or expired. These included a bag of corn and a bag of chocolate chips, both opened with no open date, and a bag of peas that was exposed to air and had freezer burn. Additionally, a peach cobbler was found with an expiration date that had passed. The Dietary Cook confirmed that the facility's policy requires opened food to be labeled with an open date and expiration date to prevent residents from consuming expired food, which could make them sick. Further inspection of the facility's walk-in refrigerator revealed a plastic container of cucumbers that was opened without an open date or expiration date. The Dietary Supervisor reiterated the importance of labeling to ensure food safety and prevent illness. The facility's policy on labeling and dating foods, dated 2020, outlines the procedures for dating food items upon receipt and after opening, using the first in-first out method for storage. The job descriptions for the Dietary Manager and Cook emphasize the responsibility for maintaining quality nutritional services and following food service procedures in accordance with established policies.
Failure to Properly Close Dumpster Lids
Penalty
Summary
The facility failed to ensure that the dumpster lids were closed, which has the potential to affect all 160 residents residing at the facility. During an observation with the Dietary Supervisory, it was noted that two dumpster lids were open. The Dietary Supervisory acknowledged that housekeeping staff also use the dumpsters and admitted uncertainty about who left the lids open, but confirmed that they should be closed to prevent mice from entering. Further interviews with the Housekeeping Director confirmed that the dumpsters should be closed at all times when not in use to prevent rodent infestation and maintain infection control. The facility's policy on garbage and rubbish disposal, dated 2020, mandates that all outside dumpsters be maintained in a clean and sanitary condition, with garbage and rubbish containing food waste covered when not in immediate use to prevent access by vermin. Job descriptions for the Dietary Manager and Housekeeping Supervisor emphasize maintaining a clean, safe, and sanitary environment.
Improper Storage of Oxygen Tanks and Lancet Disposal
Penalty
Summary
The facility failed to ensure the proper storage of oxygen tanks for a resident diagnosed with primary generalized osteoarthritis, unspecified dementia, mood disturbance, and anxiety, who uses oxygen therapy for respiratory illness and conversational dyspnea. During an observation, an unsecured oxygen cylinder was found on the floor behind the resident's bed. A Licensed Practical Nurse (LPN) confirmed the improper storage and removed the tank, acknowledging the potential hazard of the tank tipping over and causing an explosion. The Director of Nursing later affirmed that all oxygen cylinders must be stored safely in a holder to prevent such hazards, as outlined in the facility's Oxygen Safety policy. Additionally, the facility failed to discard a lancet used for blood sugar monitoring for a resident with type 2 diabetes mellitus and cognitive impairments. A surveyor observed the lancet left on the resident's bedside drawer, which was confirmed by an LPN who stated that lancets should not be left in residents' rooms due to the risk of injury. The facility's job description for LPNs and the Medical Waste Disposal policy both emphasize the importance of following safety regulations and proper disposal of medical waste, including sharps like lancets.
Failure to Maintain Respiratory Equipment
Penalty
Summary
The facility failed to adhere to its policy regarding the maintenance and replacement of respiratory equipment, specifically nebulizer tubing and nasal cannulas. Observations revealed that the nebulizer tubing for a resident was not changed weekly as required, with the tubing label indicating it had not been replaced since 07/22/2024. The resident confirmed daily use of the nebulizer, and a Licensed Practical Nurse (LPN) admitted to being unaware of the tubing replacement schedule. Additionally, the facility did not ensure that nasal cannulas were properly stored when not in use, leading to potential contamination. Observations showed nasal cannulas on the floor or not contained in a plastic bag for several residents. Both the Director of Nursing (DON) and an Infection Preventionist confirmed that nasal cannulas should be stored in a plastic bag to prevent contamination, although the DON could not find this requirement in the facility's written policy. The facility's policy, dated 11/28/12, mandates that oxygen and nebulizer equipment be changed every seven days and as needed. However, the survey found that this policy was not consistently followed, as evidenced by undated and uncovered nasal cannulas and humidifier bottles. These deficiencies affected multiple residents, including those with chronic respiratory conditions, highlighting a lapse in infection control practices.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly manage and store medications, leading to several deficiencies. During an observation, a registered nurse found an expired Sodium chloride irrigation water bottle in the medication room, which should have been discarded as it was past its expiration date. Additionally, a resident's medication bottle containing Rosuvastatin tablets was found in a medication cart with a discard date that had already passed, indicating that the medication should have been removed and reordered from the pharmacy. Furthermore, loose pills were discovered in the medication carts, with nurses unable to identify them, highlighting a lack of proper labeling and storage. These deficiencies affected one resident directly and had the potential to impact all residents assigned to the medication carts and storage room. The resident involved had multiple diagnoses, including Type 2 Diabetes Mellitus, Chronic Kidney Disease, and Major Depressive Disorder, and had an active order for Rosuvastatin. The facility's policy on medication storage was not adhered to, as expired and improperly stored medications were not immediately removed and disposed of, posing a risk of medication errors.
Deficiencies in Refrigerator Temperature Logging and Maintenance
Penalty
Summary
The facility failed to properly log refrigerator temperatures for residents' personal refrigerators, affecting 10 residents. Observations revealed missing temperature log entries for specific dates, indicating a lack of daily monitoring as required by the facility's policy. Interviews with residents and staff confirmed that the temperature checks were not consistently performed, and some residents were unaware of the monitoring process. The facility's policy mandates daily temperature logging by housekeeping staff, but this was not adhered to, leading to incomplete records. Additionally, the facility failed to adequately maintain the freezers in residents' personal refrigerators for two residents. Observations showed ice buildup in the freezers, with one freezer door frozen shut, preventing access. Housekeeping staff stated that defrosting was done every 1.5 to 2 months or as needed, but the presence of ice buildup suggests this was not effectively managed. The housekeeping supervisor confirmed that maintaining cleanliness and defrosting were their responsibilities, but the process was not consistently executed. The deficiencies in temperature logging and freezer maintenance have the potential to affect the safety of personal food items for all residents reviewed. The facility's failure to ensure proper monitoring and maintenance of personal refrigerators could lead to spoiled food, posing a health risk to residents. Interviews with staff highlighted a lack of clarity regarding the frequency of defrosting and the importance of daily temperature checks, contributing to the observed deficiencies.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to update a resident's isolation status, leading to potential infection control issues. A resident with a history of methicillin-resistant Staphylococcus aureus (MRSA) and Clostridioides difficile (C. diff) was observed with outdated contact isolation orders, despite having completed antibiotics and not having an active infection. The infection preventionist acknowledged that the isolation orders should have been discontinued, emphasizing the importance of accurate records to prevent the spread of infections. Additionally, the facility did not adhere to proper infection control practices regarding the handling of clean linen. A clean linen cart was improperly brought into a resident's room, which was against the facility's policy to prevent contamination. The staff member responsible admitted the mistake, and the Director of Nursing and Infection Preventionist confirmed that such actions could lead to cross-contamination, as the cart should remain in the hallway and be covered. The facility also failed to ensure staff followed hand hygiene and personal protective equipment (PPE) protocols. Staff members were observed not sanitizing hands before donning gloves, handling items that had fallen on the floor, and performing resident care without appropriate PPE. These lapses in infection control practices were acknowledged by the staff involved, highlighting a lack of adherence to the facility's infection prevention and control policies.
Unsecured Handrail in Unit 2B
Penalty
Summary
The facility failed to ensure a handrail was firmly secured to the wall in Unit 2B, which has the potential to affect all residents in that unit. On August 5, 2024, at 10:45 am, it was observed that the handrail in Unit 2B was not fixed to the wall. This observation was confirmed by a Certified Nursing Assistant, who stated that the handrail had been in that condition for a long time. At 10:55 am, the Housekeeping Supervisor/Maintenance Director/Laundry Director also checked the handrail and confirmed it was not secured. Later, at 11:23 am, the same individual stated they were unaware of the issue and acknowledged the danger posed by an unsecured handrail. On August 6, 2024, at 3:30 pm, the Director of Nursing emphasized the importance of fixed handrails for resident safety, noting that residents rely on them for support while ambulating. An email correspondence with the Administrator on August 7, 2024, highlighted the need to ensure all handrails are properly secured to protect residents and visitors. The Residents' Rights for People in Long-Term Care Facilities document also underscores the facility's obligation to maintain a safe environment for residents.
Failure to Maintain Resident Dignity by Covering Catheter Bags
Penalty
Summary
The facility failed to ensure that indwelling catheter drainage bags were covered to maintain the dignity of residents. This deficiency affected two residents, R27 and R109, who were observed with their urinary drainage bags exposed. R109, who has a diagnosis of neurogenic bladder, was observed with an uncovered urinary drainage bag hanging on the bed frame, despite the presence of a black privacy bag intended for this purpose. A Licensed Practical Nurse (LPN) confirmed that the drainage bag should have been kept in the privacy bag to maintain the resident's dignity. The Director of Nursing (DON) also affirmed that the facility's expectation is for all urinary drainage bags to be kept in privacy bags. Similarly, R27's indwelling catheter bag was observed facing the door and not in a privacy bag. An LPN noted that a Certified Nurses Aide (CNA) might have emptied the bag and failed to return it to the privacy bag. The LPN then placed the catheter bag inside the privacy bag, acknowledging the importance of covering the bag for the resident's dignity. R27 has a diagnosis of female genital tract fistula and chronic kidney disease, with a severely impaired mental status. The facility's Dignity Policy emphasizes the importance of maintaining residents' dignity by covering urinary catheter bags, which was not adhered to in these instances.
Failure to Maintain Privacy of Electronic Health Records
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of electronic health records, which is a violation of HIPAA. During an observation, a surveyor noted that a medication administration record for a resident was left open and unattended on a laptop attached to a nursing cart. No staff were present near the cart at the time. A Licensed Practical Nurse (LPN) admitted to forgetting to close the laptop screen before leaving the area. The Director of Nursing (DON) confirmed that the facility's expectation is for staff to close or minimize the screen when stepping away from the computer to prevent unauthorized access to medical records.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for two residents, both of whom have intact cognition as indicated by their BIMS scores. One resident, who has multiple diagnoses including the absence of the right foot and severe protein-calorie malnutrition, reported that their bathroom door does not close, which compromises their privacy. This was confirmed by an LPN who acknowledged the issue and stated that the door should close for privacy. Another resident, with diagnoses including chronic obstructive pulmonary disease and end-stage renal disease, was observed to have a large brown stain on the ceiling above their bed and a hole in the floor tile at the foot of their bed. The LPN noted that the stain, caused by the air conditioning, poses a safety issue, and the hole in the floor could lead to accidents. The Maintenance Director confirmed that water sometimes stains the ceiling tiles when it rains and acknowledged the need to replace the floor tiles and fix the bathroom door hinge to ensure privacy and safety.
Failure to Complete PASARR Assessment for New Psychiatric Diagnosis
Penalty
Summary
The facility failed to complete a new Pre-Admission Screen and Resident Review (PASARR) assessment for a resident after a new diagnosis of schizoaffective disorder was identified. The resident, who was initially admitted with no known mental health issues, was later diagnosed with schizoaffective disorder and major depression. Despite this significant change in the resident's mental health status, the facility did not conduct a new PASARR assessment as required. The Social Services Director confirmed that the admissions department is responsible for ensuring PASARR assessments are completed prior to admission, and the social services department is responsible for completing them if a new psychiatric diagnosis is made while the resident is in the facility. The director acknowledged that a new PASARR assessment should have been completed following the new diagnoses but was not. A review of the facility's policy and the Maximus system confirmed that no additional PASARR assessments had been conducted for the resident since their admission.
Failure to Provide Adequate ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for two residents, R45 and R74, which compromised their personal hygiene. R45, who has a diagnosis of hemiplegia, hemiparesis following cerebral infarction, dementia, atrial fibrillation, and hypertension, was observed with a wet bed and worn incontinence pad. Despite the care plan indicating the need for assistance after attempting tasks, R45 did not receive timely incontinence care. A Certified Nursing Assistant (CNA) admitted to not having provided the necessary care since starting her shift at 7:00 am, which was confirmed as unacceptable by the Director of Nursing (DON). The facility's policy requires incontinence care every two hours to prevent skin breakdown and maintain dignity, which was not adhered to in this case. R74, diagnosed with type 2 diabetes mellitus, peripheral vascular disease, and other conditions, was observed with unclean fingernails containing food debris. Despite being cognitively intact and expressing a desire for nail care, R74's nails were not cleaned or trimmed as required. A Licensed Practical Nurse (LPN) and a CNA confirmed that CNAs are responsible for maintaining residents' nail hygiene, including diabetic residents. The facility's policy mandates regular observation and maintenance of nail cleanliness, which was not followed, leading to the deficiency in R74's personal hygiene care.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the physician, affecting two residents. The Director of Nursing (DON) presented the medication administration records (MAR) for two residents, R32 and R81, which revealed missing entries of nurses' signatures or codes for several medications throughout August 2024. This indicates that the medications may not have been administered as prescribed, as there were blank spaces on the MAR where documentation should have been present. Resident R32, who has a BIMS score indicating intact cognition, has multiple diagnoses including congestive heart failure, diabetes, and renal disease. The MAR for R32 showed missing documentation for medications such as Carvedilol, Cephalexin, Atorvastatin, and others on specific dates and times. Similarly, Resident R81, also with intact cognition, has a range of medical conditions including rheumatoid arthritis and vascular dementia. The MAR for R81 also had missing entries for medications like Enoxaparin, Pantoprazole, and Vancomycin, among others. The facility's policy requires that the individual administering the medication records the administration on the MAR immediately after giving the medication. The DON confirmed that nurses are responsible for documenting medication administration and that blank spaces on the MAR suggest that the medication was not administered. The facility's policies and job descriptions for registered nurses and licensed practical nurses emphasize the importance of accurate documentation and medication administration as ordered by the physician.
Improper Reuse of Catheter Care Equipment
Penalty
Summary
The facility failed to ensure proper disposal of equipment used for catheter care, specifically a piston syringe, which was not discarded after use. This deficiency was observed in the case of a resident with an indwelling catheter due to neuromuscular dysfunction of the bladder. During an inspection, an unlabeled piston syringe was found in the resident's room, which was used for irrigating the Foley catheter. The Licensed Practice Nurse confirmed that the syringe was reused three times within 24 hours, once every shift, contrary to the facility's guidelines that require such equipment to be disposed of after a single use. The Director of Nursing and the Infection Preventionist both stated that reusing the piston syringe violated aseptic technique and increased the risk of bacterial growth, potentially leading to catheter-associated urinary tract infections. The resident's care plan highlighted the risk of complications due to the indwelling catheter and emphasized the need for maintaining a closed drainage system and proper catheter care. Despite these precautions, the facility's practice of reusing the piston syringe contradicted its own policy, which mandates that Foley catheter irrigation sets are for one-time use only.
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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