Aperion Care Elgin
Inspection history, citations, penalties and survey trends for this long-term care facility in Elgin, Illinois.
- Location
- 134 North Mclean Boulevard, Elgin, Illinois 60121
- CMS Provider Number
- 145740
- Inspections on file
- 30
- Latest survey
- November 30, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Aperion Care Elgin during CMS and state inspections, most recent first.
A resident reported repeated verbal and mental abuse by a CNA, including inappropriate comments, threatening behavior, and the use of profanity. Despite prior instructions for the staff to avoid the resident's unit, the staff members were present in the area, leading to further confrontation and the use of abusive language, as confirmed by a video recording and staff interviews.
Surveyors observed multiple failures in sanitary food handling, including improper dish machine sanitizer levels, uncovered beverages during meal tray transport, and a cook preparing food with soiled gloves. These actions were not in accordance with facility policy or professional standards and affected all residents receiving meals from the kitchen.
The facility failed to follow its Water Management Plan for Legionella, did not ensure proper use of personal protective equipment during laundry handling, and did not enforce infection control practices such as hand hygiene, contact isolation, and disinfection of medical devices between residents. These deficiencies were observed in multiple areas, including resident care, therapy, and medication administration, affecting all residents in the facility.
A resident with multiple sclerosis and moderate cognitive impairment, requiring moderate staff assistance for grooming, was not provided with necessary help for shaving, oral care, or washing. Over several days, the resident was observed with unshaven facial hair, matted hair, and reported not being offered showers or grooming assistance, despite facility policies and care plans indicating these needs.
A resident with multiple medical conditions and identified nutritional risks did not receive a required quarterly nutrition assessment, as documented in the facility's records. The resident experienced a steady weight loss over several months, reported feeling he was losing weight, and was observed eating without staff assistance despite being legally blind. Facility staff confirmed that the assessment was overdue and that the dietitian only evaluates residents with significant weight loss, contrary to policy requirements.
A resident with a midline IV catheter for antibiotic therapy was found to have a soiled gauze dressing under a transparent dressing, with no care plan in place and no documentation of required monitoring or dressing changes. The facility did not follow its own protocols for IV site care, including regular assessment, documentation, and dressing changes.
A resident's family member left a purse containing a firearm in a room, and staff secured the purse after being notified by the family member. However, staff and administration did not report the presence of the firearm to law enforcement or the state survey agency as required by policy and state law, only doing so after being questioned by a surveyor. The resident involved was severely cognitively impaired and unable to participate in the investigation.
A resident with severe cognitive impairment had a purse containing a firearm left at their bedside by a family member. The facility administrator was notified but did not document, investigate, or report the incident as required by facility policy and state regulations. No investigation records or preventative measures were provided, despite the facility's policy mandating such actions.
The facility failed to conduct care plan conferences with residents and their representatives, as required. This deficiency affected all six residents reviewed, with no care plan meetings held quarterly or following significant changes in residents' conditions. The DON confirmed the absence of a care plan coordinator, and the facility lacked a policy to ensure these meetings occurred.
A facility failed to schedule neuropsychological testing for a resident with severe cognitive impairment and epilepsy, as ordered by a neurologist. Despite the neurologist's order, the necessary appointment was not made, and staff confirmed the oversight. The facility's policy requires physician orders to be confirmed and completed by a licensed nurse, which was not followed in this instance.
A resident with severe cognitive impairment and epilepsy did not receive a scheduled ophthalmology appointment as ordered by a neurologist. Despite the neurologist's recommendation for a neuro-ophthalmology referral due to visual impairment concerns, the facility failed to make the appointment, as confirmed by the DON. This oversight occurred despite the facility's policy on processing physician orders.
A resident with multiple neurological and psychological conditions did not receive an MRI as ordered by their neurologist. The MRI was supposed to be scheduled around mid-July, but the facility failed to document or schedule it. The neurologist noted the oversight during a follow-up visit in late November, and the MRI was only completed at the end of December after being reordered. The facility's policy for confirming physician orders was not followed, resulting in the delay.
A resident with severe cognitive impairment and multiple diagnoses had a scheduled neurology appointment, but the facility failed to arrange transportation. The Transportation Coordinator was not informed of the appointment by the nurse, leading to the resident not being included on the transportation list, risking a missed appointment.
A resident with a tracheostomy experienced acute respiratory distress due to the facility's failure to provide appropriate emergency tracheostomy supplies and adequately trained staff. The resident was admitted with a size 6 cuffed trach tube, but during an emergency, the facility lacked the correct emergency tracheostomy exchange kits, and available supplies were expired or incorrect. Nurses were not trained to change trach tubes, leading to the resident's hospitalization for acute hypoxemic respiratory failure.
The facility failed to discard expired food items and did not ensure the dishwashing machine was sanitizing properly. Expired Worcestershire sauces were found in dry storage, and the dishwashing machine failed sanitization tests with no log entries for the observed date.
The facility failed to assess and monitor residents for self-administration and storage of medications, resulting in four residents having unauthorized access to various medications without physician orders or care plans.
The facility failed to assess and care plan residents that smoke per facility policy and did not ensure smoking materials were kept in the designated secure location. Five residents were found with unsupervised access to smoking materials, contrary to their care plans and smoking safety risk assessments.
The facility failed to verify the accuracy of controlled medication counting logs and did not dispose of controlled medications per policy for four residents. Medications were missing or improperly logged, and controlled drug administration sheets were not in the appropriate binders.
The facility failed to provide timely incontinence care to a resident, resulting in soaked clothing and potential skin breakdown. Additionally, another resident's indwelling catheter bag was observed on the floor without a privacy bag, contrary to facility policy.
The facility failed to follow its oxygen and respiratory equipment changing/cleaning policy for three residents. One resident had a nasal cannula on the floor and a dirty humidifier, another had a nasal cannula hanging from a drawer knob, and a third had a nebulizer mask on the floor. Staff confirmed that the equipment should be changed weekly and stored properly, which was not done.
The facility failed to monitor and document behaviors and to develop and update care plans with interventions for residents with known behaviors related to mental disorders. One resident exhibited paranoia and refusal to eat, while another frequently urinated on the floor. Staff interviews confirmed the lack of documentation and appropriate care plan updates for these behaviors.
An LPN failed to administer insulin correctly to two residents, resulting in a 12% medication error rate. The LPN did not prime the insulin pens or hold the dose knob in and count to five before removing the needle, contrary to the manufacturer's instructions.
The facility failed to administer the correct doses of insulin to two residents and scheduled pain medication to another. An LPN forgot to administer a resident's scheduled Tramadol, and another LPN did not properly prime insulin pens or ensure correct dosing for two residents. The DON confirmed the absence of a medication administration policy.
The facility failed to dispose of expired medications for two residents. Expired Vancomycin, Lorazepam, and Scopolamine were found in the medication storage room, and the Medication Record Reports did not show orders for some of these medications. The Director of Nursing confirmed that expired medications should be removed and returned to the pharmacy for disposal.
A resident with a history of alcohol use, chronic pain syndrome, and repeated falls was involved in a serious accident after signing out of the facility without proper assessment for safe independent community access. Despite being hit by a car the previous day and presenting with alcohol on his breath, the resident was allowed to leave unsupervised. The facility lacked documentation of a physician's order for alcohol consumption or independent community access. Staff were aware of the resident's risky behavior but did not take appropriate actions, leading to the resident being found injured and requiring hospitalization.
Failure to Prevent Verbal and Mental Abuse of a Resident
Penalty
Summary
A deficiency occurred when a resident reported experiencing verbal and mental abuse from a Certified Nursing Assistant (CNA) and another staff member. The resident alleged that the CNA entered his room uninvited in a threatening manner, made inappropriate comments such as calling him 'Honey Bunny,' and referenced her father purchasing her a gun. The resident also described an incident where the CNA performed a 'hoola dance' in the hallway while pointing at him. These concerns were reported to the facility administrator, who instructed the involved staff to avoid working near the resident's unit. Despite these instructions, the resident encountered the same staff members in his hallway and reported the incident to the nurse on duty, requesting confirmation from the administrator that the staff should not be present. The resident recorded the interaction, which captured him repeatedly stating that the staff were not to be on his unit and requesting administrative intervention. The video also recorded a female voice off-camera using profanity directed at the resident as the staff walked away. Multiple staff interviews confirmed that the staff lingered in the area for several minutes after being told to leave, and there was an argument between the resident and the CNA. Facility records and emails documented the resident's repeated complaints about the CNA's behavior, including previous incidents of the CNA entering his room without permission and making inappropriate comments. The facility's abuse prevention policy defines verbal abuse as a form of mental abuse, including the use of oral or gestured communication within hearing distance of residents. The investigation concluded that profanity was used in the shared environment between the CNA and the resident, and the staff member was ultimately terminated for customer service reasons.
Failure to Maintain Sanitary Food Handling and Meal Service Practices
Penalty
Summary
The facility failed to follow sanitary practices in the kitchen and during meal service, affecting all residents who received food prepared in the facility kitchen. During an initial kitchen tour, a dietary aide was observed using a dish machine with chlorine sanitizer levels above the posted guidance range. The aide had not tested the machine prior to use, and there was confusion among staff regarding the correct sanitizer concentration, with posted guidance indicating 50-100 ppm but test results showing 200 ppm. The dish machine service representative later confirmed that the correct test strips should register between 50-100 ppm, and the facility's policy required staff to check sanitizer levels before use and not proceed if out of range. During meal service, trays prepared in the main dining room were transported to resident rooms on a cart with uncovered juice and water cups. The cart was stationed in a hallway with staff, visitors, and residents passing by. When questioned, a staff member assisting with tray delivery was unaware of the reason for the uncovered beverages. Facility policy required all foods to be covered during transport to control the spread of infectious disease, but this was not followed for several residents who received uncovered drinks. Additionally, a cook was observed preparing a meal while wearing gloves soiled with pureed food and gravy. Without changing gloves, the cook handled a hamburger bun and added toppings, directly violating sanitary food handling practices. The unsanitary practice was observed and reported to the dietary manager, and the facility menu confirmed the food items being prepared at the time.
Widespread Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to implement and document its Water Management Plan for Legionella as required by its own policies. The Maintenance Director did not monitor or document water temperatures in accordance with the plan, only checking a limited number of locations and failing to log hot water tank temperatures. There was no documentation of control measures or monitoring activities prior to a specific date, and the required weekly flushing and cleaning of eye wash stations was not performed as outlined in the facility's risk assessment and water management guidelines. Laundry staff did not adhere to the facility's linen handling policy, as soiled laundry was handled without the use of required personal protective equipment such as aprons or gowns. The staff member responsible for laundry confirmed that only gloves were used, and no aprons or gowns were available in the laundry room, contrary to policy requirements for handling potentially contaminated linens. Multiple infection control breaches were observed during resident care and medication administration. A resident on contact isolation for ESBL in urine was allowed to participate in group activities and therapy without appropriate precautions, and therapy staff were unaware of the resident's isolation status. Hand hygiene was not performed by staff between glove changes or after providing care, and medical devices such as blood pressure monitors were not disinfected between uses on different residents. These lapses occurred despite facility policies requiring hand hygiene and equipment disinfection between resident contacts.
Failure to Provide Required Grooming Assistance to Resident Needing Moderate Support
Penalty
Summary
The facility failed to provide necessary assistance with grooming and personal hygiene for a resident who required moderate staff support due to multiple sclerosis, weakness, and moderate cognitive impairment. The resident's care plan and MDS indicated a need for moderate assistance with grooming, and her condition could fluctuate throughout the day. Despite these documented needs, observations over several days revealed that the resident had not received help with shaving, oral care, or washing her face and hands. The resident reported not being offered a shower or grooming assistance, and staff interviews confirmed that grooming care was expected on non-shower days, but there was no documentation of refusals except for one instance where a bed bath was provided instead of a shower. Physical observations showed the resident had visible whiskers on her chin and upper lip, stringy and matted hair, and a shiny face, indicating a lack of grooming. The resident stated she was not allowed to have a razor and had not been offered shaving assistance. Staff interviews revealed inconsistent accounts regarding when grooming and showers were provided, and documentation did not support claims of frequent refusals. Facility policies required regular assessment and assistance with shaving and grooming, but these were not followed as documented in the resident's records and observed condition.
Failure to Complete Required Quarterly Nutrition Assessment
Penalty
Summary
The facility failed to follow its policy to complete quarterly nutritional assessments for a resident with multiple medical conditions, including polyosteoarthritis, legal blindness, vitamin D deficiency, chronic gastritis, and nicotine dependence. The resident was cognitively intact and had a care plan identifying several nutritional risks, with a goal to maintain stable weight. Despite this, the electronic medical record showed that the last nutrition assessment by the Dietary Manager was completed in late October, and no further assessments were documented for nearly six months. The resident's weight steadily declined over this period, with a loss of over 11 pounds. During interviews, the Dietary Manager confirmed that quarterly nutrition assessments are required for residents not seen by the dietitian, and the Director of Nursing stated that the dietitian only evaluates residents with significant weight loss. The resident reported feeling that he was losing weight and was observed eating unassisted, dropping food onto his lap and tray without staff assistance. The facility's policy requires quarterly documentation and assessment in accordance with the MDS schedule, but this was not followed for the resident in question.
Failure to Monitor and Maintain Midline IV Catheter
Penalty
Summary
The facility failed to properly monitor and care for a midline peripheral intravenous catheter for a resident who was admitted with multiple diagnoses, including a lumbar vertebra fracture, dependence on renal dialysis, and gait abnormalities. The resident was receiving intravenous antibiotics and had a midline catheter inserted, but the transparent dressing covering the site was observed to have a gauze dressing underneath that was stained with dried blood and obscured the insertion site. The Director of Nursing confirmed the presence of the soiled gauze and acknowledged that the dressing should have been changed according to protocol. There was no care plan in place for the resident's midline intravenous line, and there was no documentation that the circumference of the resident's arm was being measured as required. Additionally, prior to a certain date, there was no evidence in the Medication Administration Record or Treatment Administration Record that the midline line was being flushed or monitored every shift. The facility's own policy required regular dressing changes, monitoring for infection and bleeding, and measurement of arm circumference, none of which were consistently documented or performed.
Failure to Timely Report Firearm Incident to Authorities
Penalty
Summary
The facility failed to report a suspicion of a crime involving a firearm being brought into the facility by a visitor, in violation of both facility policy and state law. A resident's daughter, who possessed a concealed carry license, left her purse containing a firearm in the resident's room after a visit. Upon realizing this at home, she called the facility and informed a nurse that her purse, which contained a firearm, needed to be secured. The nurse retrieved the purse and handed it to the Social Services Director, who then secured it in a locked office and notified the Administrator by text message. The Administrator later placed the purse in the facility safe. Despite being informed that a firearm was present in the facility, neither the nurse, the Social Services Director, nor the Administrator contacted local law enforcement or the Illinois Department of Public Health (IDPH) as required by facility policy and state law. The facility's policy mandates that law enforcement and the Department of Public Health be notified within 24 hours when there is a reasonable suspicion that a crime has been committed in the facility by a non-resident. The Administrator only reported the incident to law enforcement and IDPH after being questioned by a surveyor, well after the required reporting timeframe had passed. The resident involved was severely cognitively impaired, required extensive assistance with activities of daily living, and was unable to be interviewed due to hospitalization. The roommate of the resident was also immobile and unaware of the incident. Facility records and interviews confirmed that the firearm was not discovered or reported to authorities in a timely manner, as required by both facility policy and the Illinois Concealed Carry Firearms Act.
Failure to Investigate Firearm Incident in Accordance with Policy
Penalty
Summary
The facility failed to investigate an incident involving the presence of a firearm in accordance with its own policy and state regulations. A resident, who was severely cognitively impaired and dependent on staff for most activities of daily living, had a purse containing a firearm left at their bedside by a family member. The facility administrator was notified of the incident but did not initiate an investigation, document the occurrence, or report it to law enforcement or the Department of Public Health at the time. The administrator stated that he did not believe there was malicious intent and therefore did not follow the required procedures. The facility's policy required all incidents to be documented and investigated, including interviews with involved parties and submission of a final written report to the Department of Public Health within five working days. Despite these requirements, the administrator did not provide any investigation records, a timeline of events, interviews, or preventative measures related to the firearm incident. Additionally, there was no documentation of following state police guidelines for firearm safety, and the facility had signage indicating firearms were banned on the premises.
Failure to Conduct Care Plan Conferences
Penalty
Summary
The facility failed to hold care plan conferences with residents and their representatives, and did not invite them to participate in the care planning process. This deficiency was identified for all six residents reviewed in the sample. The facility's documentation showed that care plan meetings were not held quarterly or following significant changes in residents' conditions, as required. For instance, one resident with severe cognitive impairment had not had a care plan meeting documented since September 2024, despite multiple MDS assessments being completed afterward. Another resident, who was transitioned to hospice care, had not had a care plan meeting since September 2024, even though several MDS assessments were completed subsequently. Similarly, a resident with multiple diagnoses, including heart failure and psychosis, had only one documented care plan meeting since 2018, despite numerous MDS assessments. The lack of care plan meetings was consistent across all reviewed residents, indicating a systemic issue within the facility. The Director of Nursing acknowledged that the facility did not have a care plan coordinator and that no staff member was assigned to ensure care plans were conducted. The facility's admission packet stated that care planning conferences should involve residents and their families, but this was not being implemented. The facility administrator confirmed the absence of a policy regarding care plan meetings and the lack of a care plan coordinator, contributing to the deficiency.
Failure to Schedule Neuropsychological Testing as Ordered
Penalty
Summary
The facility failed to schedule neuropsychological testing for a resident as ordered by the neurology physician. The resident, who was admitted with multiple diagnoses including severe cognitive impairment, epilepsy, and mild vascular dementia, was seen by a neurologist who ordered neuropsychological testing to better understand the resident's brain function and aid in care planning. Despite the neurologist's order, the facility did not make the necessary appointment for the neuropsychological testing. The resident's electronic medical record and Minimum Data Set indicated severe cognitive impairment and a need for assistance with activities of daily living. Interviews with facility staff, including the Director of Nursing, confirmed that the neuropsychological testing was not scheduled. The facility's policy on processing physician orders requires that orders be confirmed and completed by a licensed nurse, but this was not adhered to in this case, leading to the deficiency.
Failure to Schedule Ophthalmology Appointment for Resident
Penalty
Summary
The facility failed to schedule an ophthalmology appointment for a resident as ordered by the neurologist. The resident, who was admitted with multiple diagnoses including severe cognitive impairment, epilepsy, and vascular dementia, was seen by a neurologist who recommended an ophthalmology referral due to visual impairment concerns. Despite this order being documented in the resident's medical records, the facility did not make the necessary appointment, as confirmed by the Director of Nursing. The resident's medical history includes significant cognitive and physical impairments, requiring assistance with daily activities and supervision. The neurologist's notes indicated the resident's cognitive challenges and the need for a neuro-ophthalmology referral, which was not acted upon by the facility. The facility's policy on processing physician orders was not followed, leading to the oversight in scheduling the required ophthalmology appointment.
Failure to Schedule MRI as Ordered by Neurologist
Penalty
Summary
The facility failed to ensure a resident received an MRI as ordered by the neurologist. The resident, who was admitted with multiple diagnoses including epilepsy, cognitive impairment, and other neurological and psychological conditions, was supposed to have an MRI scheduled around July 15, 2024, as per the neurologist's discharge instructions. However, the facility did not have documentation to show that the MRI was scheduled as ordered. The neurologist noted during a follow-up visit on November 25, 2024, that the MRI had not been completed, despite it being ordered previously. The Director of Nursing confirmed that the MRI was supposed to be completed before the resident's next visit on November 25, 2024, but it was not done until December 30, 2024, after the neurologist ordered it again. The facility's policy requires a licensed nurse to check and confirm any orders following a physician visit, but this process was not followed, leading to the delay in the MRI procedure.
Failure to Arrange Transportation for Resident's Medical Appointment
Penalty
Summary
The facility failed to ensure transportation arrangements were made for a resident with a scheduled physician follow-up appointment. The resident, who was admitted with multiple diagnoses including severe cognitive impairment, required assistance with various activities of daily living. The resident had a scheduled neurology appointment on March 17, 2025, which was documented by the neurologist. However, the facility's Transportation Log did not include this appointment, indicating that transportation had not been arranged. The Transportation Coordinator stated that it was the nurse's responsibility to inform them of appointments so that transportation could be arranged. In this case, the nurse did not communicate the resident's appointment to the Transportation Coordinator, resulting in the resident not being included on the transportation list. Consequently, the resident was at risk of missing the scheduled neurology appointment due to the lack of transportation arrangements.
Failure to Provide Adequate Tracheostomy Care and Emergency Supplies
Penalty
Summary
The facility failed to ensure that emergency-sized tracheostomy tubes were available for a resident who required tracheostomy care, leading to acute respiratory distress and emergency hospitalization. The resident, who had a history of nontraumatic subarachnoid hemorrhage, ruptured aneurysm, and acute respiratory failure, was admitted with a size 6 cuffed trach tube. However, during an emergency, the facility lacked the appropriate emergency tracheostomy exchange kits, and the available supplies were either expired or incorrect in size. Licensed nurses at the facility were not adequately trained to change tracheostomy tubes, which contributed to the deficiency. One nurse was unable to reinsert a new trach tube when the resident's tube decannulated, and another nurse was not trained to change entire trach tubes during an emergency. This lack of training and preparedness resulted in the resident being transferred to the hospital for acute hypoxemic respiratory failure, where the trach tube was eventually replaced by emergency paramedics. The facility's policies and procedures did not clearly outline the responsibilities of licensed nurses in reinserting trach tubes, nor did they provide instructions on how to perform the procedure. The Director of Nursing confirmed that the facility expected nursing staff to ensure that residents with tracheostomies have the required emergency supplies at the bedside, including trach tubes of the same size and a downsized tube, along with an obturator. However, these expectations were not met, leading to the resident's hospitalization.
Expired Food and Dishwashing Machine Sanitization Issues
Penalty
Summary
The facility failed to discard expired food items from the dry storage and did not follow dishwashing machine operation guidelines. During an initial tour of the kitchen, two one-gallon Worcestershire sauces were found to be expired. The Dietary Manager acknowledged the expired items and stated they would be discarded. The facility's food storage guidelines require discarding food past its expiration date and food prepared in the facility after seven days of proper refrigeration. Additionally, the facility did not ensure the dishwashing machine was sanitizing properly. The Dietary Aide ran the dishwashing machine, and upon testing, the sanitization test strip showed no color change, indicating it was not sanitizing. The Dietary Manager confirmed the issue and noted that the dishwashing machine should have a chlorine-based sanitization agent between 50 and 100 ppm. The dishwashing sanitization log had no entry for the observed date, contrary to the facility's guidelines requiring checks before first use and twice daily recordings of sanitizer concentration.
Failure to Assess and Monitor Self-Administration of Medications
Penalty
Summary
The facility failed to assess residents for self-administration and storage of medication, as well as notifying and ordering medications for residents who were self-administering. This deficiency was observed in four residents. One resident had a bottle of generic day time severe cold and cough medicine on their bedside table without a physician's order or care plan allowing self-administration. Another resident had several bottles of medications, including iron, Vitamin C, fish oil, and apple cider vinegar tablets, without any orders for self-administration or storage at bedside. A third resident had a medicine cup with red liquid for wound healing that had been left since the previous night, also without an order for self-administration. The fourth resident had an unlabeled bottle of Milk of Magnesia on top of their drawer, which they used for constipation without a physician's order or assessment for self-administration. The Director of Nursing (DON) confirmed that only one resident in the facility was allowed to self-administer medications and that the residents in question were not supposed to self-administer. The DON stated that an assessment should be completed for residents who wish to self-administer medications, and this should be documented in their medical record with a care plan initiated. The DON also mentioned that medications should be stored in a locked space in the resident's room for safety and that nurses should monitor residents taking their medications. The facility's policy on self-administration of medication requires a written order from the attending physician for a resident to administer or retain any medication in their room. The policy also states that medications should be labeled and come from the pharmacy. For medications brought from outside, the nurse should inform the physician and obtain an order to administer. The facility failed to follow these guidelines, resulting in residents having unauthorized and potentially unsafe access to medications.
Failure to Adhere to Smoking Policies and Care Plans
Penalty
Summary
The facility failed to assess and care plan residents that smoke per facility policy and did not ensure smoking materials were kept in the designated secure location. This deficiency was observed in five residents. One resident was found with an opened pack of cigarettes and matches on his bedside table, despite his care plan stating that smoking materials should be kept in the social service office. Another resident admitted to having cigarettes and a lighter in his pocket. A third resident had a cigarette and lighter in an unlocked nightstand drawer, contrary to his smoking safety risk assessment. A fourth resident had a carton of cigarettes on his bedside table, but his care plan did not address his smoking habits or the storage of smoking materials. The fifth resident was observed multiple times with cigarettes and a lighter on her bedside table and dresser, and her record lacked a smoking assessment and care plan. The Social Services Director confirmed that residents who smoke should have a yearly smoking assessment and quarterly reviews, along with a care plan addressing whether they are allowed to have smoking materials in their rooms. However, the facility did not adhere to these policies, resulting in residents having unsupervised access to smoking materials. This lack of compliance with the facility's smoking policy and care plans posed potential safety hazards for the residents involved.
Failure to Verify Controlled Medication Logs and Dispose of Medications Properly
Penalty
Summary
The facility failed to verify the accuracy of controlled medication counting logs and did not dispose of controlled medications per facility policy for four residents. Specifically, one resident's Pregabalin medication punch card had missing pills that were not logged in the control drug administration record, and there was no order for Pregabalin in the resident's medication review report. Another resident's Hydrocodone-APAP medication punch card had pill slots taped over with pills inside, contrary to the facility's policy for disposing of controlled medications. Additionally, two residents had their Lorazepam controlled drug administration record sheets wrapped around the medication bottles instead of being in the unit's narcotic control counting log binder, and one of these residents did not have an order for Lorazepam in their medication review report. During observations, the LPN and RN present were unsure why the controlled medication sheets were not in the appropriate binders and why the medications were not logged correctly. The Director of Nursing stated that she expected all controlled administration sheets to be kept in the medication cart's narcotic control sign-off binder and for nurses to verify the correct count during shift changes. The facility's policy on counting controlled substances emphasized the importance of verifying the accuracy of log sheets, ensuring the integrity of liquid medications, and properly disposing of controlled medications, which was not followed in these instances.
Failure to Provide Timely Incontinence Care and Proper Catheter Bag Positioning
Penalty
Summary
The facility failed to provide timely incontinence care to a resident dependent on toileting and failed to keep an indwelling catheter drainage bag off the floor. One resident was observed with a strong smell of urine, and upon further inspection, it was found that the resident's incontinent brief, shirt, and bed pad were soaked with urine. The resident's coccyx was red, indicating potential skin breakdown. The CNA provided incontinence care but did not apply barrier cream as required. The resident's care plan indicated the need for frequent checks and peri-care after each incontinence episode, which was not adhered to, leading to the observed condition. The DON confirmed that staff are expected to check for incontinence care at least every two hours to prevent skin breakdown and infection. Another resident was observed with an indwelling catheter bag on the floor without a privacy bag. The LPN acknowledged that the catheter bag should not be on the floor. The facility's urinary catheter care policy specifies that urinary drainage bags and tubing should be positioned to prevent contact with the floor, either directly or through a secondary containment device. This policy was not followed, leading to the observed deficiency.
Failure to Follow Respiratory Equipment Changing/Cleaning Policy
Penalty
Summary
The facility failed to follow its oxygen and respiratory equipment changing/cleaning policy for three residents. One resident, a [AGE] year-old male with moderately impaired cognition, was observed with his nasal cannula on the floor and a dirty humidifier, both without date/label. The resident mentioned that the staff did not care about changing the tubing, and he had filled the humidifier water chamber himself. A Licensed Practical Nurse (LPN) confirmed that the night shift is responsible for changing and labeling the tubing and filling the water reservoir, and that the oxygen tubing should be stored in a plastic bag. Another resident, a [AGE] year-old female with intact cognition, was observed with her nasal cannula hanging from a drawer knob instead of being stored in a plastic bag. The resident stated that she was not provided with a plastic bag for her nasal cannula. A third resident, a [AGE] year-old female with mild cognitive impairment, was observed with a nebulizer mask on the floor. An LPN confirmed that the nebulizer mask should be stored in a plastic bag and kept inside a drawer. The facility's policy requires weekly changes and proper storage of respiratory equipment, which was not followed in these cases.
Failure to Monitor and Document Resident Behaviors
Penalty
Summary
The facility failed to monitor and document behaviors and to develop and update care plans with interventions for residents with known behaviors related to mental disorders. Resident R61, who was diagnosed with psychosis, paranoid delusions, and dementia, exhibited behaviors such as believing he was being poisoned and refusing to eat. Despite these behaviors, the last documented Behavior/Mood Charting assessment for R61 was on 12/06/2023. Additionally, R61's care plan did not include interventions recommended by his inpatient psychiatric hospital discharge report, such as maintaining focus on reality or addressing his diagnosis of Major Depressive Disorder (MDD) and schizoaffective disorder. Interviews with staff confirmed the lack of documentation and appropriate care plan updates for R61's behaviors. Resident R1, diagnosed with schizoaffective disorder bipolar type, insomnia, generalized anxiety disorder, and vascular dementia with behaviors, was found in bed with his pants unzipped and a strong foul urine smell in the room. R1's roommate reported that R1 frequently urinated on the floor. Despite these behaviors, there was no documentation of behavior episodes in R1's Electronic Medical Record (EMR), and his care plan did not address the behavior of urinating on the floor. Interviews with staff, including the Director of Nursing (DON), revealed that the facility did not have a policy for behavioral monitoring, and there were no orders for behavior monitoring every shift for R1 and R61. The facility's failure to document and address these behaviors in the care plans led to the identified deficiencies.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 12%. During medication administration, an LPN administered insulin to two residents without following proper procedures. Specifically, the LPN did not prime the insulin pens before administering the doses and did not continue to press down the pens after injecting the doses before removing the needles. This was observed during the administration of 11 units of Aspart insulin to one resident and 12 units of Humalog insulin and 2 units of Lyumjev insulin to another resident. The Medication Review Reports for both residents confirmed the orders for the insulin doses. The manufacturer's instructions for the insulin pens, revised in August 2023, clearly state the need to prime the pen before each injection and to hold the dose knob in and count to five before removing the needle. The LPN's failure to follow these instructions led to the medication errors observed during the survey.
Failure to Administer Correct Medication Doses
Penalty
Summary
The facility failed to administer the correct doses of insulin medications to two residents and scheduled pain medication to another resident. Specifically, an LPN signed off on a resident's scheduled 9 AM Tramadol medication but forgot to administer it. The medication punch card confirmed that the dose was not removed. The resident had an order for Tramadol HCI Oral Tablet 50 MG to be given once daily for chronic pain. Additionally, another LPN administered incorrect doses of insulin to two residents. The LPN did not prime the insulin pens before administering the doses and did not continue to press down the pens after injecting the doses before removing the needles. This resulted in the residents potentially receiving incorrect doses of insulin. The Director of Nursing confirmed that the facility did not have a medication administration policy but expected nurses to administer medications as ordered and sign them off in the Medication Administration Record once completed.
Failure to Dispose of Expired Medications
Penalty
Summary
The facility failed to dispose of expired medications for two residents. During an inspection of the medication storage room, it was found that the refrigerator contained two bottles of Vancomycin liquid solution for one resident with expiration labels dated 4/01/2024. Additionally, the Medication Record Report (MRR) for this resident did not show an order for Vancomycin. Another resident's hospice kit in the same refrigerator contained expired medications, including Lorazepam oral solution, Scopolamine gel, and Vancomycin liquid solution, with expiration dates ranging from 12/31/2023 to 3/02/2024. The MRR for this resident showed an order for Lorazepam but not for Scopolamine and Vancomycin. The Director of Nursing confirmed that expired and discontinued medications should be removed and returned to the pharmacy for disposal. The facility's policy on medication storage, revised on 7/02/2019, aims to ensure proper storage, labeling, and expiration dates of medications. However, the observation revealed that the policy was not followed, leading to the presence of expired medications in the storage room. This deficiency was identified through observation, interview, and record review, highlighting a lapse in the facility's adherence to its medication management protocols.
Failure to Ensure Resident Safety with Substance Use Disorder
Penalty
Summary
The facility failed to ensure the safety of a resident with substance use disorder, identified as R2, who was involved in a serious accident while out in the community. Despite being hit by a car the previous day and presenting with alcohol on his breath, R2 signed himself out of the facility without being assessed for safe independent community access. This failure resulted in R2 being found on the side of the road by a bystander and requiring hospitalization for multiple injuries, including fractures of the ribs and elevated blood alcohol levels. Records indicate that R2 had a history of alcohol use, chronic pain syndrome, repeated falls, and multiple injuries related to alcohol intoxication. Despite being cognitively intact, R2 required supervision for all activities of daily living. The facility lacked proper documentation to show that R2 had a physician's order to consume alcohol or to be safe in the community without supervision, especially after the recent accident. Staff members, including nurses and physicians, were aware of R2's alcohol use and risky behavior but failed to take appropriate actions to ensure his safety. The facility's policies regarding community access and substance abuse were not effectively implemented, leading to R2 being granted independent pass privileges without meeting the necessary criteria. The lack of proper assessments, documentation, and supervision ultimately contributed to the serious accident and subsequent hospitalization of R2.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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