Aperion Care Forest Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Forest Park, Illinois.
- Location
- 8200 West Roosevelt Road, Forest Park, Illinois 60130
- CMS Provider Number
- 145969
- Inspections on file
- 66
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Aperion Care Forest Park during CMS and state inspections, most recent first.
The facility failed to maintain a safe, clean, comfortable, and homelike environment by not ensuring adequate supplies of clean washcloths, towels, bed linens, and blankets, by not providing proper overbed lighting for both sides of a semi-private room, and by not preparing a fully made bed with mattress and linens for a resident transferred to a new room. A resident with paraplegia reported delays in wound care due to lack of clean linens and refusal to be cleaned with stained or cut-up rags, while another resident with psoriasis and psoriatic arthritis reported insufficient washcloths to perform hygiene needed for frequent topical medication applications and observed a CNA cutting a diaper to use for cleaning. Surveyors found linen carts on multiple floors either empty or with very limited linens, staff acknowledged frequent linen shortages, and one unit had no blankets available when requested by a family member. A medically complex resident transferred to another floor found no mattress initially and then only a stained fitted sheet on the bed for several hours, with staff on both sending and receiving units unaware or uncoordinated about the transfer and room readiness, and another resident’s side of a shared room lacked an overbed light while the roommate’s side had one.
A resident with multiple chronic conditions, including visual impairment and diabetes, repeatedly reported that another resident was entering her room, harassing her, and threatening to have people beat her up, including a specific threat not to come to the dining room or she would be harmed. An LPN documented the resident’s complaints of harassment and fear of being attacked, and an RN and CNA confirmed being informed of the situation by the resident and her upset family members. Despite the facility’s abuse policy defining mental and verbal abuse to include harassment and threats, and requiring review of resident-to-resident altercations as potential abuse and timely reporting to the Department of Public Health, the administrator/abuse coordinator stated that he did not consider the incident abuse, did not complete a formal investigation, and did not submit a reportable, relying only on informal staff statements instead.
A resident with multiple chronic conditions reported that another resident repeatedly harassed and threatened her, including entering her room, bothering her, and telling her he would have people beat her up. Nursing documentation noted the resident’s complaints of harassment and fear of being attacked, and family members reported receiving distressed calls and being told that the other resident pushed the door open and threatened to "f her up" if she came to the dining room. The alleged aggressor acknowledged a verbal altercation but denied making threats. Despite these allegations and a policy that requires all resident-to-resident altercations and abuse allegations to be documented and investigated, the administrator/abuse coordinator did not initiate or document an abuse investigation and only recorded a discussion about moving the resident to another floor.
A resident with hemiplegia, hemiparesis, cerebral infarction, and COPD, who was cognitively intact and on Medicaid, received a dental exam from an outside provider that resulted in a written referral for multiple tooth extractions, but there was no documentation that the extractions or any further dental services were ever completed. The contracted dental provider confirmed that the last notes were from 2024, that the resident was not enrolled in the dental program, and that no follow-up requests came from the facility or family. Facility staff, including Social Services and the DON, stated that residents should receive at least yearly dental services and that the facility was responsible for scheduling care, yet the resident had no dental services for an entire year and the facility lacked a clear dental services policy, relying instead on an undated statement that residents would be seen on an as-needed basis.
Two residents with moderately impaired cognition and multiple comorbidities, both care planned as high fall risk with interventions requiring a working and reachable call light, were found lying in bed with their call lights on the floor and not within reach. One resident reported not knowing where the call device was, and a CNA confirmed both devices were on the floor. This occurred despite facility policies and CNA job duties requiring that call lights be kept easily accessible at all times and used as part of the fall prevention program.
A resident with hypertension, alcohol dependence, osteoarthritis, and moderately impaired cognition experienced multiple unwitnessed falls over a two‑month period. The care plan identified fall risk and included dated interventions such as encouraging rest, obtaining labs, resident education on call light use and bed positioning, labs to rule out UTI and high ammonia levels, and referral to therapy. However, the care plan was not updated after one of the documented falls, despite facility policies and staff expectations that each fall be addressed in the care plan with investigation and new or revised interventions as appropriate.
A bedbound resident who required extensive assistance for ADLs and transfers was later found with a swollen, deformed right wrist and was grimacing in pain. The resident was sent to the hospital, where EMS reported a fall the prior day, the resident stated she remembered falling, and imaging showed comminuted fractures of the distal radius and ulna with displacement, along with a hematoma on the right side of the head. The facility’s investigation relied on limited staff statements, accepted an explanation that the resident hit an arm on a side rail and that the fracture was pathological, and did not obtain statements from all staff on the unit or reconcile the hospital findings and fall report. Despite policy requirements for thorough investigation of injuries of unknown source based on known facts, the facility concluded the injury was a pathological fracture without supporting documentation, resulting in a failure to properly investigate a potential abuse-related injury.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, resulting in an unsafe environment for residents.
A resident remained on a sunken, deflated mattress after reporting the issue to both the Maintenance Director and an LPN. The LPN did not document or escalate the concern, and the Director of Nursing was unaware of the problem. No record of the complaint was found in facility logs, and the facility could not provide a relevant policy, resulting in the resident's comfort needs not being met.
A resident with multiple complex medical conditions and high fall risk was injured during incontinence care when a single aide, instead of the required two-person assist, failed to ensure both bed rails were up. The resident slid off the bed and sustained fractures to both legs, with staff interviews revealing inconsistent adherence to the care plan and inadequate supervision.
A resident with complex medical conditions, including end stage renal disease and dependence on dialysis, experienced low blood pressure prior to a scheduled dialysis session. An LPN administered Midodrine based on a standing order but did not notify the RN or physician of the hypotensive episode, and there was no documentation of the medication being given or of communication with clinical staff. The lack of notification and documentation resulted in a failure to meet professional standards of care.
A resident with insulin-dependent diabetes was found unresponsive with severe hypoglycemia. Despite clear protocols and the availability of emergency medication, nursing staff did not administer treatment or notify the appropriate medical personnel before EMS arrived. The resident was transported to the hospital for further care.
A resident was administered insulin 70/30 intramuscularly three times daily instead of the prescribed subcutaneous once-daily dose, after an LPN changed the order without proper clarification. Multiple nurses administered the incorrect doses, leading to the resident developing severe hypoglycemia and becoming unresponsive, requiring emergency intervention.
A resident with diabetes was found nonresponsive with a critically low blood sugar level. An LPN checked the blood sugar but did not initiate treatment for hypoglycemia or notify the nurse practitioner, despite emergency medication being available on the unit. The nursing supervisor was not contacted, and EMS found the resident untreated upon arrival. Facility policies requiring immediate intervention and notification were not followed.
A resident with diabetes was administered intermediate-acting insulin intramuscularly and at an increased frequency, contrary to physician orders and professional standards. Multiple nurses gave the insulin incorrectly, and the resident received two doses close together, leading to severe hypoglycemia. Staff failed to recognize and treat the hypoglycemic event in a timely manner, and emergency services found the resident unresponsive with critically low blood sugar.
A resident experienced an unwitnessed fall resulting in a fracture and was sent to the ER, but the POA was not promptly notified despite having a working phone number. The LPN documented only one unsuccessful attempt to contact the POA, and no further efforts or alternative methods were recorded, contrary to facility policy requiring timely family notification after significant changes in condition.
A resident admitted with a stage 2 sacral pressure ulcer did not have treatment orders initiated until four days after admission, despite facility policy requiring prompt initiation and documentation of physician-ordered wound care. The resident, who had multiple chronic conditions and was dependent on staff, was observed with a protective dressing, but timely wound care orders were not transcribed as required.
A resident with multiple chronic conditions was not administered her scheduled medications after admission because two LPNs failed to complete the admission assessment and enter medication orders. As a result, essential medications for hypertension, diabetes, COPD, and other conditions were missed, contrary to facility policy requiring prompt transcription and administration of physician orders.
The facility failed to discard expired food products and maintain temperature logs for resident refrigerators, affecting all residents receiving food and four specific residents. Expired food items were found in the kitchen, and several residents' refrigerators lacked temperature logs, with one refrigerator's temperature below the normal range. Staff acknowledged the oversight and the need for daily monitoring.
The facility failed to ensure call lights were within reach for five residents, affecting their ability to request assistance. Observations showed call lights placed behind dressers, on the floor, or otherwise out of reach. Residents had various medical conditions, including diabetes, osteoarthritis, and hemiparesis, necessitating accessible call lights. Staff confirmed call lights should be within reach, but this was not consistently done.
The facility failed to follow manufacturer's guidelines for low air loss mattresses, affecting residents with pressure ulcers. Observations showed improper linen layering on mattresses, contrary to recommendations, and issues with mattress functionality and settings. The facility lacked a policy on proper mattress use, contributing to these deficiencies.
The facility failed to implement fall prevention measures for residents at risk, as observed during a survey. Residents were found with call lights out of reach and beds in high positions, contrary to care plans. Additionally, a resident's care plan was not updated within the required timeframe after a fall.
The facility failed to ensure proper medication management and storage, with an unlocked medication cart, expired and improperly labeled insulin, and personal food in a medication refrigerator. Additionally, a resident had medications at their bedside without a physician's order for self-administration. The DON confirmed the necessity of proper labeling, storage, and physician orders for bedside medications.
A resident experienced verbal abuse from a former roommate, who accused her of theft and used profanities. Despite being moved to a different room, the abusive resident continued to harass her. The facility's staff, including the social worker, did not adequately address the situation, leading to a deficiency in protecting the resident from abuse.
The facility failed to maintain residents' dignity by not knocking on doors before entering rooms. During rounds, a Wound Care Coordinator entered the rooms of three residents without knocking, despite care plans emphasizing respect and dignity. The facility's policy requires knocking and requesting permission before entry, which was not followed.
A facility failed to provide adequate nail care to a resident dependent on staff for ADLs. The resident was observed with long, dirty fingernails, despite facility policies requiring CNAs and nurses to maintain nail hygiene. The resident had multiple diagnoses, including Type 2 Diabetes Mellitus, and was admitted with a self-care and mobility performance deficit.
A facility failed to adhere to a physician's order for oxygen administration for a resident, who was observed receiving oxygen at 1L/min instead of the prescribed 2L/min. The LPN confirmed the discrepancy, and the DON emphasized the importance of following physician's orders and posting oxygen use signage. The resident's medical history includes metabolic encephalopathy, respiratory failure with hypoxia, and other conditions. Facility policy requires accurate entry and confirmation of physician orders.
A facility failed to discontinue Olanzapine 2.5 mg for a resident, despite a pharmacist's recommendation to minimize somnolence. The medication continued to be administered daily for several months, contrary to the physician's agreement to discontinue it. The DON and assistant director of nursing were responsible for following up on pharmacy recommendations but did not ensure the medication was discontinued.
The facility failed to follow infection control practices for two residents, with nebulizer masks left exposed instead of stored properly. Additionally, staff did not adhere to Enhanced Barrier Precaution protocols during wound care, as they were not wearing the required PPE. These deficiencies were observed during a review of the Infection Control Program.
The facility failed to report the final written report of abuse investigations to the state department within the required timeframe for nine residents. The Assistant Administrator sent the reports to an incorrect fax number, which was a result of submitting reports via different methods depending on his location. This error violated the facility's policy, which requires timely reporting of investigation results and corrective actions to the Department of Public Health.
A facility failed to protect residents from abuse and did not report incidents promptly. One resident with cognitive impairment had feces thrown at them by another resident, and the incident was not reported immediately. In another case, two residents argued over TV volume, resulting in one resident being slapped. The facility's policy requires immediate reporting of abuse, but this was not followed, leading to a deficiency in care standards.
A resident with moderate cognitive impairment reported an incident where another resident allegedly threw feces at them. The incident was not reported to the state surveying agency until eight days later, despite facility policy requiring immediate reporting of abuse allegations. Staff interviews indicated a delay in reporting due to a lack of initial details.
A facility failed to send a copy of an involuntary discharge notice to the ombudsman for a resident with a history of dementia and psychiatric disorders. The resident exhibited aggressive behavior, leading to multiple hospital transfers and an eventual involuntary discharge due to safety concerns. The facility did not notify the resident's representative or revise the care plan to address the behavior, and staff were not trained to manage such situations.
A facility failed to provide individualized and person-centered care for a resident with mental disorders, leading to unmanaged aggressive behaviors. Despite documented incidents, the care plan was not updated, and staff were untrained in handling such behaviors. The facility's policies on behavioral health services were not adequately followed, resulting in a deficiency in care.
A resident with a history of falls and multiple medical conditions, including dementia and blindness, experienced a fall resulting in injury due to the facility's failure to implement adequate fall prevention measures. Despite being identified as at risk, the resident's walker was out of reach, and staff noted the resident's tendency to get up unassisted. The facility's fall prevention program and care plan interventions were not effectively executed, contributing to the incident.
Two residents in an LTC facility experienced ongoing conflicts due to incompatibility, with one resident expressing distress over the other's behavior and belongings. Despite staff awareness, including a CNA and the DON, no action was taken to separate them until a surveyor's involvement, highlighting a deficiency in upholding resident rights and addressing complaints.
The facility failed to maintain a clean environment for residents, with observations of debris and food particles in rooms and the dining area. Housekeeping staff were insufficiently assigned, with only one housekeeper per floor, leading to inadequate cleaning. Residents expressed concerns about room cleanliness, and the facility's policy on maintaining a sanitary environment was not met due to staffing shortages.
A resident with multiple diagnoses, including dementia and hypertensive heart disease, experienced a delay in receiving a urinalysis after a fall. The urinalysis, ordered on August 3, was not completed until August 21, revealing a urinary tract infection. The facility's policy on laboratory testing errors was not followed, as confirmed by the Regional Nurse.
Staff members were observed using personal cell phones while monitoring residents, violating facility policy and resident rights. CNAs were seen talking and laughing with earpieces and looking at phone screens during care activities. Residents reported frequent staff phone use during care, meals, and other interactions, which was confirmed by staff interviews. The facility's policy prohibits phone use during work hours except in break rooms, but this was not followed, leading to a breach of resident dignity.
A resident with a history of substance abuse was administered Narcan for a suspected overdose, but the facility failed to provide continuous monitoring for potential recurrence of opioid toxicity symptoms. The staff did not follow SAMHSA recommendations for post-Narcan administration, and there was no written policy or adequate training for handling such incidents. Interviews revealed inconsistencies in staff understanding and execution of overdose protocols.
The facility failed to maintain a clean and homelike environment, with observations of sticky floors, dirty dining rooms, and unclean nourishment rooms. Despite being informed, the administrator did not ensure immediate corrective action, as the areas remained dirty upon subsequent inspections.
The facility failed to provide sufficient nursing staff on the third and fourth floors, affecting 147 residents. On one occasion, the fourth floor had only one CNA for 76 residents, leading to inadequate care. Residents reported not receiving timely assistance, with one resident left unchanged overnight. Staff members, including the ADON and DON, were unaware of the staffing shortages, indicating a lack of communication and oversight. The facility's assessment document did not specify the number of staff needed, contributing to the deficiencies.
The facility failed to conduct a comprehensive assessment to determine necessary staffing levels, leading to inadequate care for residents. The assessment document lacked specific staffing numbers, resulting in insufficient staff on the dementia unit. Staff shortages were observed, with CNAs working double shifts and being pulled from other floors. Management was unaware of the impact on resident care, and there was no staffing policy in place. This deficiency affected the care provided to residents, particularly those requiring substantial assistance.
The facility failed to provide scheduled showers and timely incontinence care for three residents who require substantial assistance. Despite being cognitively intact, the residents reported not receiving their showers due to staff being busy. Documentation was incomplete, making it unclear if care was provided. The DON acknowledged the lack of documentation and emphasized the need for staff to document all care and notify nurses of refusals.
Two residents in an LTC facility experienced significant distress due to a failure in maintaining a consistent supply of prescribed medications. One resident with chronic pain did not receive Norco for three days, while another with anxiety missed doses of lorazepam. Staff acknowledged delays in reordering medications, leading to unnecessary pain and agitation for the residents.
A resident with a history of seizures did not receive their prescribed anticonvulsant medication, levetiracetam, for two days after returning from a hospital stay for status epilepticus. The facility failed to promptly reconcile hospital discharge orders, resulting in missed doses. The resident reported the issue, and the DON confirmed the delay in entering the medication order into the system.
The facility failed to provide a safe environment by not adequately assessing, monitoring, or supervising residents at risk for falls. This resulted in four residents experiencing falls and sustaining significant injuries, including lacerations and femur fractures, due to the lack of necessary interventions and supervision.
The facility failed to accurately transcribe a physician's order for pain medication and did not follow its medication administration policy by not clarifying the dosage for a resident. An LPN administered an incorrect dose of acetaminophen, and the DON and ADON confirmed that the order should have been clarified earlier.
A resident with cognitive impairment was assaulted by his roommate, also cognitively impaired, with a metal rod, resulting in significant facial injuries. The incident was witnessed by a CNA who intervened and called for assistance. The victim was hospitalized, and the aggressor was sent to a psychiatric hospital. The facility's abuse policy did not address resident-to-resident abuse, and the investigation found no antecedent factors for the assault.
A resident with a DNR order was found unresponsive in the bathroom. Despite the DNR status, an LPN initiated CPR, and the DON continued compressions until the LPN Manager verified the DNR and stopped the resuscitation efforts. The facility's failure to verify the resident's code status before initiating CPR led to this deficiency.
Failure to Maintain Adequate Linens, Room Readiness, and Lighting for Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not maintaining an adequate supply of clean bed and bath linens, not ensuring adequate lighting in resident rooms, and not providing a properly made bed with a mattress and linens for a resident who was transferred to a new room. Multiple residents reported and surveyors observed a lack of clean washcloths, towels, and blankets across several floors. One resident with paraplegia and a coccyx wound stated that there were no rags or towels available, causing delays in wound dressing changes and in getting out of bed, and reported that staff sometimes brought stained or cut-up rags that appeared to be used for cleaning toilets or furniture. Another resident with psoriasis and psoriatic arthritis reported that there were not enough washcloths to clean his armpits, abdominal folds, and groin so he could apply ordered topical medications multiple times daily, and stated that a CNA had cut a diaper into pieces to use for cleaning residents. Surveyors’ observations in the laundry department and on the resident units confirmed that the supply of clean linens was very limited. In the laundry area, only 15 clean towels, 6 clean washcloths, and 4 cut-up towels mixed in with clean rags were found, and the Housekeeping/Laundry Supervisor acknowledged that the cut towels were supposed to be used as dust rags and that the facility had recently started doing its own laundry without having a total inventory of washcloths and towels. On multiple floors, linen carts were found with either no clean washcloths and towels or very small quantities, and there were no additional carts or storage rooms with more linens. Staff, including an LPN and a CNA, reported that the facility frequently ran out of linen several times a week and that there were no blankets available on at least one unit when a family member requested a blanket for a resident. Morning meeting minutes documented that the facility was getting low on washcloths and that more linen was needed. The deficiency also includes failure to ensure adequate lighting and a properly prepared room for a transferred resident. One resident’s room lacked an overbed or reading light on her side of the room, while her roommate had an overbed light and cabinetry; the Maintenance Director confirmed that when single rooms were converted back to double occupancy, the second side was never remodeled to include an overbed light. Another resident with multiple serious medical conditions, including chronic respiratory failure, ESRD on dialysis, CHF, and moderate cognitive impairment, was transferred to a new room after breakfast and reported that there was initially no mattress on the bed and that, after a mattress was brought, the bed remained unmade without a flat sheet, blanket, or pillows for several hours. Surveyors observed only a stained fitted sheet on the bed and no bed linens on the nearby linen cart. Multiple staff members, including the RN on the receiving unit, the nurse manager, the ADON, and the SSD, gave inconsistent accounts and demonstrated lack of awareness or coordination regarding the transfer, and it was later confirmed that it took from mid-morning until mid-afternoon for the resident’s bed to be fully made with complete bed linen. Facility records, including resident rights policies, job descriptions for CNAs, laundry aides, and the Administrator, and the state Ombudsman resident rights booklet, describe expectations that residents receive care in a safe, clean, comfortable, and homelike environment and that staff ensure residents’ comfort, hygiene, and adequate laundry services. Despite these written expectations, the documented observations, interviews, and record reviews show that residents experienced shortages of basic linens needed for hygiene, bathing, and comfort, lacked appropriate room lighting on one side of a semi-private room, and that a newly transferred resident was placed in a room without a ready, fully made bed for an extended period of time.
Failure to Report and Investigate Alleged Resident-to-Resident Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse policy by not reporting and fully investigating an allegation of resident-to-resident verbal/mental abuse. One resident (R7), who has multiple medical conditions including blindness in the left eye, hypertension, diabetes with proliferative diabetic retinopathy, hyperlipidemia, and a history of falls, reported that another resident (R16) was harassing and threatening her. A progress note dated 2/16/2026 by an LPN (V47) documented that R7 complained of being harassed by another patient, requested to be taken to her room, and stated she heard that other patients might attack her if she was seen in the dayroom the next day. The note further documented that R16 came to R7’s room, continued to bother and harass her despite being asked to leave, and that R7 was crying and called her family, who came to the facility, creating an intense situation. On subsequent interviews, R7 stated that R16 repeatedly came to her room, harassed her, told her he would get people to beat her up, and interfered with her wig. R16 acknowledged an altercation with R7 but denied threatening her, stating he told her to stop messing with people and that if she put her hands on him, he would do the same. A family member (V48) reported that R7 called her crying about R16, and that when the family came to the facility, they were told that R16 had gone to R7’s room, pushed her door open, and told R7 she better not come to the dining room or he would “f her up.” A CNA (V45) confirmed receiving a phone call from an upset family member stating that R16 had said something to R7, and an RN (V18) reported being called to the floor because R7’s family was present after R7 reported that R16 had threatened her. Despite these reports and the facility’s written abuse policy defining mental and verbal abuse to include harassment and threats, and specifying that resident-to-resident altercations should be reviewed as potential abuse and reported to the Department of Public Health within required time frames, the administrator (V1), who is the abuse coordinator, stated that he did not have any investigation or reportable for the incidents involving R7 and R16 because he did not consider it abuse. When asked if he conducted any investigation to determine whether abuse occurred, he stated that staff statements were his investigation and confirmed that no formal investigation or reportable was completed. This failure to treat the resident’s allegations and the documented threats as a reportable abuse allegation and to conduct a thorough investigation constitutes the cited deficiency.
Failure to Investigate Alleged Resident-to-Resident Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse policy by not initiating and thoroughly investigating an allegation of resident-to-resident verbal/mental abuse. One resident (R7), who has multiple medical conditions including blindness in the left eye, hypertension, diabetes with proliferative diabetic retinopathy, hyperlipidemia, and a history of falls, reported that another resident (R16) was harassing her. On observation, R7 was awake and alert in the dining room and stated that R16 came to her room, harassed her, told her he would get people to beat her up, and interfered with her wig. A nursing progress note dated 2/16/2026 by an LPN documented that R7 complained of being harassed by another resident, requested to be taken to her room, and reported hearing that other residents might attack her if she was seen in the dayroom. The note further described that R16 came to R7’s room, continued to bother and harass her despite being asked to leave, and that R7 was crying and called her family, who came to the facility, with the situation becoming intense. Interviews with involved parties provided differing accounts of the altercation but consistently indicated a conflict between the two residents that included alleged threats. R16 stated he recalled an altercation with R7, claiming he told her to stop messing with people, that she became rude and cursed at him, and that he cursed back. He denied threatening her but admitted telling R7 and her sister that if R7 put her hands on him first, he would do the same. A family member (V48) reported that R7 called her crying and said that R16 went to R7’s room, pushed the door open, and told R7 she better not come to the dining room or he would “f her up.” A CNA (V45) stated she was present on the unit but did not witness the incident; she answered a phone call from a very upset family member stating that R16 had said something to R7. An RN (V18) reported being called to the floor because R7’s family was present, and was informed that R7 said R16 came to her room and threatened her; V18 told the family the facility was going to investigate and notified the DON and the administrator. Despite these allegations and the facility’s written abuse policy, the administrator (V1), who is the abuse coordinator, did not initiate an investigation at the time of the incident. When the surveyor requested the investigation, V1 stated that he did not conduct any investigation because he did not consider the situation to be abuse, explaining that not every disagreement is abuse and giving his own example of what he considered verbal abuse. The facility’s abuse prevention and reporting policy, however, defines mental and verbal abuse to include harassing and threatening residents and specifies that resident-to-resident altercations should be reviewed as potential abuse and that all incidents will be documented and investigated when abuse, neglect, exploitation, mistreatment, or misappropriation is alleged or suspected. There was no documentation that anyone formally interviewed R7 or R16 regarding the incident, and V1 only documented speaking to R7 about moving her to another floor, demonstrating that the required internal investigation of the alleged resident-to-resident verbal/mental abuse was not carried out in accordance with facility policy.
Failure to Arrange Recommended Dental Extractions and Ongoing Dental Care
Penalty
Summary
Failure to obtain routine and emergency dental services occurred when a cognitively intact resident, admitted in 2020 and discharged in 2026 with diagnoses including hemiplegia, hemiparesis, cerebral infarction, and COPD, did not receive recommended dental treatment or ongoing dental care. A dental exam performed by an outside provider in April 2024 documented a referral for extraction of teeth #3, 8, 9, and 14, and the associated patient referral form specified extractions of those teeth. No additional dental service notes or documentation of completed extractions were found in the facility records after that visit. Email correspondence from the contracted dental provider in February 2026 confirmed that the last notes for this resident were from 2024 and that the resident was not enrolled in the dental program, meaning she would not be seen regularly unless the facility or family submitted a request. Interviews with facility staff further showed that the facility did not follow through on arranging the recommended extractions or ensuring ongoing dental services. The dental provider’s clinical support stated that after the April 2024 exam and recommendation for extractions, they never heard anything further and that it was the facility’s responsibility to take the referral to an outside dental office and schedule care. The Social Services Director stated the resident was on Medicaid and should be scheduled to see a dentist at least yearly, with nursing notifying Social Services when appointments were needed. The DON acknowledged that if the last dental service was in 2024, the resident did not receive dental services for the entire year of 2025. The Assistant Administrator reported that the facility had no dental services policy and procedure regarding frequency of services, and an undated facility document stated residents would be seen on an as-needed basis, while residents’ rights materials stated the facility must provide services to keep residents’ physical and mental health at their highest practicable levels.
Failure to Keep Call Lights Within Reach for Two High Fall-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that call light devices were placed within reach for two residents who were care planned to have accessible call lights as part of their fall prevention interventions. One resident had diagnoses including pulmonary embolism, Type 2 DM, and COPD, with a BIMS score of 11 indicating moderately impaired cognition and requiring substantial/maximal assistance with multiple ADLs. This resident’s care plan for fall risk specified that a working and reachable call light must be ensured and that the resident’s call light should be within reach with encouragement to use it for assistance. The resident was also listed on the unit’s high fall-risk list and enrolled in a falling leaf program with an intervention to educate on calling for assistance prior to transfers. The second resident had diagnoses including hypertension, Type 2 DM, and osteoarthritis, with a BIMS score of 9 indicating moderately impaired cognition and requiring partial/moderate assistance with toileting and bathing. This resident’s fall risk care plan also required a working and reachable call light and personal items within reach, and directed staff to ensure the call light was within reach and to encourage its use for assistance. During a surveyor observation with a CNA, both residents were found lying in bed and unable to access their call devices; one resident stated he did not know where his call device was, and the CNA found both residents’ call lights on the floor, not within their reach. Facility policies and the CNA job description required that residents with the ability to use a call device have the nurse call light system available at all times and within easy accessibility, and that staff answer call lights and provide for resident comfort and safety, but these requirements were not met for the two residents at the time of observation.
Failure to Update Fall Risk Care Plan After Each Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to update a resident’s care plan after each fall, as required by facility policy and staff expectations. The resident had diagnoses including hypertension, alcohol dependence, and osteoarthritis, and a BIMS score of 8 indicating moderately impaired cognition. Progress notes documented multiple unwitnessed falls during a two‑month period, specifically on 11/04/2025, 11/05/2025, 11/27/2025, 11/30/2025, 12/05/2025, and 12/07/2025. The comprehensive care plan, dated 01/21/2026, identified the resident as being at risk for falls and injury related to falls, with risk factors such as need for assistance with ADLs, possible medication side effects, chronic pain, and osteoarthritis. The care plan included dated interventions tied to several of the fall events, such as encouraging rest during fatigue, obtaining labs, resident education on using the call light and proper bed positioning, labs to rule out UTI, referral to therapy, and labs to rule out high ammonia levels. Despite these documented falls and the facility’s Fall Prevention Program and Restorative Nursing Program requirements that care plans address each fall and that interventions be changed with each fall as appropriate, the care plan was not updated following the fall that occurred on 11/30/2025. Interviews with the MDS Coordinator/LPN, the Restorative Director, and the DON confirmed that the facility’s expectation is that the care plan be updated with each fall, that each fall be treated as needing a new intervention, and that the IDT investigate to determine root cause and adjust interventions accordingly. When shown the care plan and the sequence of falls, these staff acknowledged that the care plan should have been updated to address the 11/30/2025 fall but was not, resulting in a failure to follow the facility’s own fall prevention and care planning guidelines.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse prohibition policy by not conducting a thorough investigation into an injury of unknown origin for one resident. The resident was bedbound for the past 3–4 years, required extensive assistance with turning in bed, was dependent on staff for all transfers via mechanical lift, and only got out of bed on dialysis days. On the day of the incident, the RN documented that the resident’s right arm appeared normal at the beginning of the shift and at medication pass, but later that day the restorative aide observed the resident grimacing, not eating well, and noted swelling and deformity of the right wrist with the resident unable to move fingers. The resident was subsequently sent to the hospital. At the hospital, EMS reported that the resident had a fall the previous day and that imaging showed distal radius and ulna fractures. The resident stated she remembered falling the previous day. The emergency room exam documented a small hematoma on the right lateral head and swelling with obvious deformity of the right wrist. X‑rays showed mildly comminuted fractures of the distal radius and ulna with displacement and soft tissue swelling. The orthopedic surgeon noted an unclear, unwitnessed mechanism of injury given the resident’s bedbound status and also noted the head injury and wrist deformity. There was no documentation in the hospital record that the right arm injury was due to a pathological fracture or that the resident had osteoporosis in the right arm. The facility’s internal investigation was limited to statements from the RN, restorative aide, and one CNA, and did not include statements from all staff who worked on the resident’s unit in the days preceding the incident. The investigation concluded that the right arm injury was a pathological fracture, despite the absence of supporting hospital documentation and the presence of a head hematoma in the hospital record. The administrator stated the resident injured the arm on the side rail, and the DON reported that a roommate said the resident hit her arm on the side rail while rolling up the top sheet. The DON also stated she believed the fracture was pathological based on the resident’s comorbidities and referenced a phone call to the hospital, but could not identify whom she spoke with. The facility’s abuse prevention and reporting policy defines injuries of unknown source and requires that final investigation reports be based on known facts; however, the investigation did not fully explore or reconcile the conflicting accounts of a fall, the head hematoma, and the mechanism of injury, resulting in a failure to conduct a thorough investigation of an injury of unknown origin.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Provide Timely Replacement of Defective Mattress
Penalty
Summary
A deficiency occurred when a resident was left to lie on a sunken, deflated mattress despite having reported the issue to both the Maintenance Director and an LPN. The resident, who is oriented and able to communicate needs, stated that he had informed the Maintenance Director about the mattress, who confirmed the mattress was deflated on one side and promised replacement. The resident also told the LPN about the problem, but the LPN did not document the concern or report it in the maintenance log, as the resident indicated he had already notified maintenance and was waiting for resolution. The Director of Nursing was unaware of the issue and stated that staff are expected to document such complaints in the facility work order system, which is checked daily by maintenance. However, no record of the mattress concern was found in the facility's grievance binder or work order logs. Additionally, the facility administrator stated that if a concern is reported directly to maintenance, it is not expected to be entered into the maintenance logbook, but the resident's needs should be met as soon as possible depending on the situation. The facility was unable to provide a policy regarding furniture or equipment. The lack of documentation and follow-through resulted in the resident continuing to use an uncomfortable, sunken mattress for an extended period.
Failure to Provide Adequate Supervision During Incontinence Care Results in Resident Fractures
Penalty
Summary
A deficiency occurred when staff failed to ensure the safety of a dependent resident during incontinence care, resulting in the resident sustaining fractures to both legs. The resident, an elderly female with multiple complex medical conditions including end stage renal disease, chronic respiratory failure, stroke, and dependence on renal dialysis and supplemental oxygen, was identified as being at high risk for falls. Her care plan specified that she required substantial to maximal assistance for bed mobility and transfers, including the use of a mechanical lift and the presence of two staff members for certain activities. The care plan also indicated that bed rails should be used for safety during care. On the day of the incident, the resident was being changed in bed by a single aide, contrary to the care plan's requirement for two-person assistance. Multiple staff interviews confirmed that the aide did not ensure both bed rails were up, which was necessary for the resident's safety due to her poor trunk control and inability to maintain balance. During the care, the resident rolled or slid off the bed and landed on her knees. The aide did not immediately call for help but left the resident to seek assistance, and the resident remained on the floor until additional staff arrived to help her back into bed. The resident complained of pain, and subsequent assessment and hospital evaluation revealed fractures to her left tibia and right femur. Staff interviews revealed inconsistent knowledge of the resident's care requirements, with some aides unaware that two-person assistance was needed. The incident highlighted lapses in following the resident's individualized care plan, inadequate supervision, and failure to implement necessary safety interventions during incontinence care, directly leading to the resident's injuries.
Failure to Notify Physician and Document Care for Hypotensive Resident Prior to Dialysis
Penalty
Summary
A deficiency occurred when a resident with multiple complex diagnoses, including end stage renal disease, hypertensive heart and kidney disease, and dependence on dialysis, did not receive care in accordance with professional standards. The resident's care plan included interventions to maintain hemodynamic stability, such as administering medications as ordered, monitoring vital signs, and notifying the physician of any abnormalities. On the day in question, the resident exhibited low blood pressure prior to dialysis, which was noted by the LPN on duty. The LPN administered Midodrine, an anti-hypotensive medication, based on a standing order but did not notify the RN in charge or the physician about the resident's hypotensive state before sending the resident to dialysis. Interview and record review revealed that the LPN could not recall the exact blood pressure readings but confirmed they were below the resident's baseline. The LPN also stated that the resident's husband expressed concern about the low blood pressure, but the LPN reassured him and proceeded with the dialysis schedule. Documentation in the medication administration record did not show that Midodrine was administered on the date in question, and there was no record of communication with the RN or physician regarding the resident's condition prior to dialysis. The facility's communication report to the dialysis center noted the low blood pressure but did not indicate that anti-hypotensive medication had been given. Further review with the Director of Nursing confirmed that nurses are expected to assess vital signs, review medication administration, and communicate any significant changes in condition to the physician. However, the decision to notify the physician was left to nursing judgment. The lack of documentation and failure to notify the appropriate clinical staff or physician of the resident's low blood pressure prior to dialysis constituted a failure to meet accepted standards of clinical practice and professional standards of quality.
Failure to Administer Emergency Hypoglycemia Treatment and Follow Protocols
Penalty
Summary
A deficiency occurred when facility staff failed to follow physician orders and hypoglycemia guidelines in the care of a resident with diabetes. The resident, who had a history of insulin-dependent diabetes and was using a continuous blood glucose monitoring system, was found unresponsive with a critically low blood sugar level of 29. Despite the presence of emergency medication (baqsimi nasal glucagon) in the unit's emergency kit and clear facility protocols for treating severe hypoglycemia, no treatment was initiated by the nursing staff prior to the arrival of emergency medical services (EMS). The LPN on duty was notified by a CNA that the resident did not look right and, upon assessment, found the resident nonresponsive with a low blood sugar reading. The LPN was alone on the unit at the time and did not administer any medication to address the hypoglycemia, nor did she call for assistance from the nursing supervisor, who was available in the facility. The emergency medication in the crash cart was not used, and documentation confirmed that no medication was removed from the emergency kit during the incident. The nurse practitioner was not notified of the resident's condition, and the nursing supervisor was not made aware of the situation until days later. EMS arrived to find the resident unresponsive and diaphoretic, with a Glasgow Coma Score of 3 and a blood glucose reading that had been critically low for several hours according to the continuous glucose monitor. The resident was transported to the hospital, where she was admitted for hypoglycemia. Facility records and interviews confirmed that staff did not follow established protocols for the immediate treatment of severe hypoglycemia, including the administration of emergency medication and timely notification of medical providers.
Failure to Clarify and Follow Insulin Orders Results in Severe Hypoglycemia
Penalty
Summary
A significant medication error occurred when a resident was administered insulin 70/30 in a manner inconsistent with professional standards and the physician's original orders. The resident had previously received 20 units of insulin 70/30 subcutaneously once daily prior to admission. However, the order was changed to 20 units intramuscularly three times a day without proper clarification with the physician. The nurse practitioner was not informed of this change and stated that insulin 70/30 should not be administered intramuscularly or given three times daily, as it is an intermediate-acting insulin intended for subcutaneous administration once daily. The assistant director of nursing confirmed that nurses are expected to review discharge paperwork and clarify any questionable physician orders before implementation. Despite this expectation, the order was changed by an LPN, and six nurses subsequently administered the insulin intramuscularly, resulting in the resident receiving nine doses in this manner. On one occasion, two doses were administered within a short time frame, further deviating from safe medication practices. The facility's records and interviews indicated that the nurses did not verify the appropriateness of the route or frequency of administration, nor did they clarify the order with the prescribing provider. As a result of these actions, the resident experienced severe hypoglycemia, with a blood glucose level dropping to 29, and was found unresponsive for an unknown period. Emergency medical services were called, and the resident required advanced intervention, including intraosseous access and administration of dextrose. The incident was confirmed through onsite observations, interviews, and record reviews, and was determined to be a significant medication error due to failure to follow professional standards and verify medication orders.
Failure to Treat and Notify for Severe Hypoglycemia
Penalty
Summary
The facility failed to follow its physician and family notification policy and did not notify the attending physician or nurse practitioner of a resident experiencing severe hypoglycemia, nor did it obtain emergent treatment orders. A resident with diabetes was found nonresponsive with a blood sugar level of 29. The LPN on duty checked the resident's blood sugar but did not initiate any treatment for hypoglycemia prior to the arrival of emergency medical services (EMS). The LPN did not administer any medication to treat the low blood sugar, despite the availability of baqsimi (nasal glucagon) in the emergency kit on the unit. Documentation showed that the emergency medication was not removed from the kit, and the nurse did not respond when asked if any medication was given. The assistant director of nursing confirmed that staff are expected to try nursing interventions, call the nurse practitioner on call, and follow orders given, including administering glucose from the emergency kit if the resident is not alert. The nursing supervisor, who was on duty, was not contacted for assistance and only learned of the incident days later. The nurse practitioner stated that they were not notified of the resident's critical condition and would have expected immediate treatment for hypoglycemia while waiting for EMS. EMS records indicated that the resident's blood sugar had been critically low for several hours before their arrival, and no treatment had been initiated by facility staff prior to EMS intervention. Facility policies required immediate removal of medication from the emergency drug kit if needed and consultation with the physician or nurse practitioner in the event of a significant change in condition. The hypoglycemia guidelines specified contacting the physician if blood sugar is below 60 and preparing glucagon from the emergency kit if the resident is unable to swallow. These procedures were not followed, as evidenced by the lack of treatment and notification in this incident.
Failure to Follow Professional Standards in Insulin Administration and Hypoglycemia Management
Penalty
Summary
A deficiency occurred when a resident with diabetes received insulin in a manner inconsistent with professional standards and physician orders. The resident was originally ordered to receive 20 units of Novolin 70/30 insulin subcutaneously once daily, but the order was changed to 20 units intramuscularly three times daily without proper clarification or documentation of the rationale. Multiple nurses administered the insulin intramuscularly, and the resident received two doses in close succession on the same day. The nurse practitioner was not aware of the change to three times daily dosing and stated that such a change would not have been made by them. On the day of the incident, the resident was found unresponsive and diaphoretic by staff, with a blood glucose reading of 29. The LPN on duty was informed by a CNA that the resident did not look right, and upon checking, found the resident to be non-responsive with low blood sugar. No treatment for hypoglycemia was initiated by the nurse prior to the arrival of emergency medical services. EMS records indicated that the resident's blood glucose had dropped to a low level in the afternoon and remained low for several hours until their arrival late in the evening. Facility guidelines required staff to contact a physician, take vital signs, and initiate interventions for hypoglycemia, including administration of glucagon if the resident was unable to swallow. These steps were not followed. The facility's documentation and interviews revealed a lack of adherence to professional standards regarding insulin administration, monitoring, and response to hypoglycemia, resulting in severe hypoglycemia for the resident.
Failure to Notify POA of Resident Fall with Injury
Penalty
Summary
The facility failed to notify a resident's Power of Attorney for Healthcare (POAH) of a significant change in condition following a fall with injury. The resident experienced an unwitnessed fall in his room while attempting to go to the bathroom independently, resulting in a left humeral fracture. The resident was sent to the emergency room for evaluation and returned to the facility with a sling and an orthopedic referral. Documentation by the LPN indicated that an attempt was made to contact the POAH, but the phone number was reportedly not in service. No further attempts to notify the POAH were documented in the medical record. The POAH later reported not being informed of the fall or the hospital transport until several days after the incident, despite having the same working phone number since the resident's admission. Interviews with facility staff confirmed that multiple attempts and alternative methods of notification, such as email or mail, should have been used if initial contact was unsuccessful. The facility's policy requires timely and effective communication with the physician and family or responsible party in the event of an accident resulting in injury and potential need for physician intervention.
Delay in Initiation of Pressure Ulcer Treatment Orders
Penalty
Summary
A deficiency was identified when the facility failed to initiate timely treatment orders for a resident admitted with a stage 2 sacral pressure ulcer. The resident, an elderly female with multiple comorbidities including chronic kidney disease, hypertension, type 2 diabetes, lymphedema, COPD, cellulitis, and morbid obesity, was observed to have a protective dressing in place and was dependent on staff for care. Staff interviews confirmed that the resident was admitted with several wounds, including the sacral pressure ulcer, and that a skin assessment was performed on admission. However, documentation revealed that although the wound assessment report on admission noted the presence of a stage 2 pressure ulcer, the treatment orders for wound care were not entered until four days after admission. The facility's policy requires that physician-ordered treatments be initiated and documented after each administration, but this was not followed in a timely manner for this resident. This lapse resulted in a delay in the initiation of appropriate pressure ulcer care.
Failure to Transcribe and Administer Admission Medications
Penalty
Summary
A deficiency occurred when a resident was not free from significant medication errors due to the facility's failure to ensure that admission medications were properly transcribed and administered. The resident, a female with multiple diagnoses including stage 2 pressure ulcer, chronic kidney disease, hypertension, type 2 diabetes, lymphedema, COPD, cellulitis, and morbid obesity, was admitted to the facility. On the day following her admission, it was discovered that the admission process had not been completed by the nursing staff. The night shift LPN did not perform the admission assessment or enter the admission orders, citing inexperience, and the day shift LPN refused to complete the admission and left the facility. As a result, there was a delay in entering the resident's admission orders, and her scheduled morning and afternoon medications were not administered. The resident's hospital discharge summary listed several critical medications for conditions such as hypertension, diabetes, COPD, and DVT prophylaxis. Review of the Medication Administration Record confirmed that none of the resident's daily medications, including amlodipine, furosemide, cetirizine, duloxetine, carvedilol, famotidine, fluticasone inhaler, heparin, hydralazine, and insulin lispro, were administered on the day in question. The facility's policy required careful review and transcription of physician orders upon admission, but this process was not followed, resulting in the resident missing essential medications.
Deficiencies in Food Safety and Refrigerator Monitoring
Penalty
Summary
The facility failed to ensure that food products were discarded before or on their expiration date, affecting all 196 residents receiving food from the kitchen. During an initial kitchen tour, it was observed that containers of flour, thickener, and sugar had outdated labels, and expired cartons of Mildly Thick - Nectar Consistency were found on the shelves. Additionally, individual packs of condiments with expired use-by dates were not removed. The cook acknowledged the oversight and the administrator confirmed the requirement to discard food on or before expiration dates. The facility also failed to maintain temperature logs for resident refrigerators, affecting four residents. During a facility tour, it was noted that several residents' refrigerators lacked temperature logs. One resident's refrigerator had a log last dated several days prior, and the temperature was found to be below the normal range. The housekeeper responsible for checking the logs was unaware of the lapse and the need to report temperature discrepancies. The Director of Nursing was informed of these findings, acknowledging the requirement for daily temperature checks and the need to discard improperly stored food.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that resident call lights were within reach, affecting five residents. Observations revealed that call lights were placed behind dressers, on the floor, or otherwise out of reach for residents R148, R11, R102, R191, and R261. These residents had various medical conditions, including type 2 diabetes, osteoarthritis, hemiparesis, and language barriers, which necessitated the need for accessible call lights to request assistance. Interviews with nursing staff confirmed that call lights should be within reach, but they were not consistently placed appropriately. Resident R148, who was alert and verbal, reported being unable to reach her call light, which was found behind a bedside dresser. Similarly, R11, who was in a wheelchair, could not access her call light, which was also behind a dresser. R102's call light was found under a wheelchair, and R191's call light was on a bedside dresser, out of reach due to a right arm flexion contracture. R261, who had a language barrier, was observed gesturing for assistance while his call light was on the floor. The facility's policy requires call lights to be within easy accessibility to residents, but this was not adhered to in these cases.
Improper Use of Low Air Loss Mattresses for Pressure Ulcer Management
Penalty
Summary
The facility failed to implement the manufacturer's recommendations for using low air loss mattresses for residents with multiple stage 4 and unstageable pressure ulcers. Observations revealed that residents were using low air loss mattresses with additional layers of linen, such as flat sheets and cloth pads, which is contrary to the manufacturer's guidelines. This was confirmed by the Director of Nursing and the Wound Care Physician, who both stated that only a flat sheet should be used over the mattress to ensure its effectiveness. The facility did not have a policy on the proper use of low air loss mattresses, which contributed to this oversight. Several residents were affected by this deficiency. One resident, admitted with multiple pressure ulcers and other serious health conditions, was observed with a low air loss mattress improperly covered with a flat sheet and cloth pad. The resident's care plan indicated a need for specific wound care interventions, but the improper use of the mattress could have impeded the intended pressure relief. Another resident with a tracheostomy and pressure ulcers on the sacrum and buttocks was also found to have a low air loss mattress with improper linen layering, which could compromise the mattress's function. Additionally, there were issues with the functionality and settings of the low air loss mattresses. One resident's mattress machine had no light indicators turned on, suggesting it might not have been functioning correctly. This was not noticed by the wound care team, who are responsible for checking the settings daily. Another resident's mattress settings were incorrect, and the resident lacked necessary heel protectors. These observations indicate a lack of adherence to proper procedures and oversight in the management of pressure ulcer prevention equipment.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement fall preventive measures for residents at risk of falls, as observed during a survey. Resident R191 was found lying in bed at a high position with the call light and bed control out of reach, contrary to the care plan that required these items to be within reach and the bed to be in the lowest position. This resident had a history of falls and was diagnosed with conditions such as non-traumatic intracerebral hemorrhage and hemiplegia, which increased the risk of falls. Similarly, Resident R261 was observed with a call light on the floor, despite the care plan indicating it should be within reach. This resident, who had a language barrier and was trying to gesture for assistance, had a recent unwitnessed fall. The care plan for this resident also included ensuring the call light was accessible and following the facility's fall protocol. Resident R147 was found with the bed in a high position and the call light on the floor, with only one floor mat instead of the required two. This resident had a history of falls and was at risk due to conditions like Parkinson's disease and dementia. Additionally, the facility failed to update Resident R148's care plan within 24 hours after a fall, as required by the facility's guidelines. The care plan was only updated on the day of the survey, despite the fall occurring weeks earlier.
Medication Management and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper medication management and storage, as observed during a survey. On the 4th floor, a medication cart was found unlocked and unattended with medications on top, which was acknowledged by an LPN as a risk since residents could easily access the medications. On the 3rd floor, several issues were identified with the medication cart and storage room, including expired insulin, insulin without open dates, and expired aspirin. Additionally, personal food was found stored in the medication refrigerator, which is against facility policy. Further observations on the 2nd floor revealed a Semaglutide pen injector without an open date and a refrigerator temperature log that had not been completed for several days. The LPN confirmed that open medications should be dated to track expiration, and refrigerator temperatures should be logged daily. The Director of Nursing was informed of these findings and confirmed the necessity of proper labeling and storage practices, including keeping medication carts locked and free from personal food items. A resident was found to have medications at their bedside without a physician's order permitting self-administration. The resident reported taking Geri-lanta and eye drops regularly, and an LPN confirmed awareness of the medications at the bedside but noted the absence of a proper order. The Director of Nursing stated that medications should not be at the bedside without a physician's order, assessment, and care plan, which was not in place for this resident.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to ensure a resident was free from verbal abuse, as evidenced by the interactions between two residents, R68 and R93. R68 reported that R93, who was her roommate in December, accused her of taking a blanket, slapped her twice, and scratched her on the nose. Despite being moved to another room on the same unit, R93 continued to verbally abuse R68 by yelling profanities at her. R68 expressed her concerns to the social worker, who dismissed the behavior as typical for R93. The facility's staff, including the Director of Nurses and the Administrator, were not fully aware of the ongoing issues between the residents until after the altercation on December 27, 2024. R93 has a history of confusion and aggression towards roommates, as noted by multiple staff members, including CNAs and the Director of Nurses. R93's care plan acknowledged her potential for physical and verbal aggression, yet the interventions in place were insufficient to prevent further incidents. R68, who is alert and oriented, has a care plan that emphasizes her right to be treated with respect and to feel safe in the facility. However, the facility's failure to adequately address and prevent the verbal abuse from R93 resulted in a deficiency in protecting R68 from abuse.
Failure to Knock on Residents' Doors Violates Dignity
Penalty
Summary
The facility failed to honor the residents' right to a dignified existence by not knocking on their doors before entering. During unit rounds, the Wound Care Coordinator, identified as V32, entered the rooms of three residents (R5, R62, and R207) without knocking. This action was observed on January 14, 2025, and confirmed through interviews with V32, who acknowledged the failure to knock and stated that she should have done so. Each of these residents had care plans emphasizing the need for respect, sensitivity, and dignity, which were not adhered to during these incidents. Resident R5 had a care plan revised in November 2024, highlighting the importance of treating the resident with respect and dignity. R5 was admitted with diagnoses including obstructive sleep apnea and age-related physical debility. Resident R62's care plan, initiated in November 2024, also emphasized dignity and respect, with diagnoses including Anxiety Disorder and Schizoaffective Disorder. Resident R207's care plan, revised in January 2025, similarly stressed dignity, with diagnoses including Kyphosis and Adult Failure to Thrive. The facility's policy on dignity, last reviewed in April 2018, explicitly stated the importance of knocking on doors and requesting permission before entering, which was not followed in these cases.
Failure to Provide Adequate Nail Care to a Dependent Resident
Penalty
Summary
The facility failed to provide adequate nail care to a resident who was dependent on staff for assistance with activities of daily living (ADLs). During an observation, the resident was found lying in bed with long and dirty fingernails, with black matter underneath them. The Director of Nursing and Assistant Director of Nursing confirmed that Certified Nursing Assistants (CNAs) and nurses are responsible for providing nail care, including cleaning and trimming, as part of the ADLs program. The resident, who was alert but confused, had been admitted with multiple diagnoses, including non-traumatic intracerebral hemorrhage, Type 2 Diabetes Mellitus, and adult failure to thrive. The comprehensive care plan indicated that the resident had a self-care and mobility performance deficit due to osteoarthritis and weakness, as well as impaired cognitive function. The facility's policy on nail care, revised in 2028, outlines specific guidelines for observing and maintaining the cleanliness and length of residents' nails, particularly after bathing. It specifies that licensed nurses are responsible for trimming the nails of diabetic residents. However, the observation revealed that these guidelines were not followed for the resident in question, leading to the deficiency. The failure to adhere to the facility's nail care policy resulted in the resident's nails being neglected, despite the established procedures intended to ensure proper grooming and hygiene as part of the ADLs program.
Failure to Follow Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to follow a physician's order for oxygen administration for a resident, identified as R53, who was observed in bed with oxygen administered via nasal cannula at 1 liter per minute. The physician's order specified that oxygen should be administered at 2 liters per minute and could be titrated up to 4 liters per minute to maintain oxygen saturation levels above 90%. This discrepancy was confirmed by a Licensed Practical Nurse (LPN), who acknowledged that the oxygen should have been set at 2 liters per minute. Additionally, the Director of Nursing (DON) stated that physician's orders should be followed and that signage indicating oxygen use should be posted by the resident's door. The resident's medical history includes diagnoses of metabolic encephalopathy, unspecified respiratory failure with hypoxia, shortness of breath, unspecified asthma, and unspecified heart failure. The facility's policy and procedure for processing physician orders emphasize the importance of entering and confirming orders accurately, including the route, dose, time, and frequency of treatments.
Failure to Discontinue Unnecessary Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary medication. Specifically, the facility did not discontinue Olanzapine 2.5 mg for a resident, despite a consult pharmacist's recommendation to discontinue the medication to minimize somnolence. The recommendation was agreed upon and signed by the physician on 10/1/2024. However, the medication continued to be administered daily from October 2024 through January 2025, as indicated by the medication administration records. The Director of Nursing (DON) and the assistant director of nursing were responsible for following up on pharmacy recommendations. Despite this responsibility, the Olanzapine was not discontinued as recommended. The facility's policy on psychotropic medication and gradual dose reduction, revised in 2018, emphasizes that psychotropic drugs should only be used when necessary and at the lowest therapeutic dose. The policy also requires the licensed pharmacist to review the resident's drug regimen monthly and report any irregularities to the DON, who should then notify the attending physician as necessary.
Infection Control Deficiencies in Nebulizer Use and EBP Protocols
Penalty
Summary
The facility failed to adhere to proper infection control practices for two residents, R83 and R261, who were part of a sample reviewed for the Infection Control Program. For R261, a nebulizer mask was found exposed on the floor instead of being stored in a plastic bag in the bedside drawer, as confirmed by the nursing supervisor. R261 was admitted with multiple diagnoses, including respiratory failure and diabetes, and had an active physician order for nebulizer treatment. Similarly, for R83, a nebulizer mask was observed uncovered and exposed, contrary to the facility's policy. R83 was readmitted with conditions such as chronic respiratory failure and had a tracheostomy, with an active order for nebulizer treatment. Additionally, the facility did not follow Enhanced Barrier Precaution (EBP) protocols during wound care for R83. Despite EBP signage, staff were observed not wearing the required personal protective equipment (PPE) such as gowns and masks during high-contact care activities. The wound care nurse and CNA were only wearing gloves, and the wound care physician was also not in full PPE while reviewing notes. The facility's policy mandates the use of PPE during high-contact care to prevent the transmission of multi-drug-resistant organisms, but this was not adhered to during the observed wound care session.
Failure to Report Abuse Investigations Timely
Penalty
Summary
The facility failed to adhere to its policy of reporting the final written report of abuse investigations to the state department within 5 working days for nine residents. The Assistant Administrator, identified as V3, admitted to sending the final investigation reports for these residents to an incorrect fax number. This error occurred for residents R1, R2, R3, R4, R5, R6, R7, R8, and R9. V3 explained that the method of submission, either via email or fax, depended on his location, which contributed to the mistake. The facility's abuse prevention and reporting policy, last revised on 10/24/22, mandates that the administrator or designee is responsible for forwarding the final written report of the investigation results and any corrective actions to the Department of Public Health within the specified timeframe. However, the confirmation pages showed that the reports were sent to a fax number ending in 7320 instead of the correct number ending in 3720, leading to the deficiency.
Failure to Protect Residents from Abuse and Timely Reporting
Penalty
Summary
The facility failed to protect residents from resident-to-resident physical abuse, affecting four residents. One resident, with moderate cognitive impairment and dependent on staff for personal care, reported an incident where another resident, who uses a colostomy bag, threw feces at them. This incident was not immediately reported to the state survey agency, and the affected resident was not sent to a doctor despite feces getting into their eye. The facility staff, including a nurse and a social worker, intervened to clean the resident and separate the involved parties, but the incident was not reported until days later. Another incident involved two residents with cognitive impairments arguing over television volume and lighting. One resident reported being slapped by the other, although staff did not witness the physical altercation. The residents were separated, and the aggressor was sent for a psychiatric evaluation. The facility's internal investigation confirmed the physical contact, but the incident was not immediately reported to the state survey agency. The facility's policy requires immediate reporting of abuse allegations to the Department of Public Health, but this was not adhered to in both incidents. The staff involved were aware of the incidents but failed to report them promptly, leading to a delay in addressing the abuse allegations. The facility's failure to protect residents from abuse and to report incidents in a timely manner constitutes a deficiency in their care standards.
Delayed Reporting of Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse involving two residents, R1 and R4, in a timely manner. R1, a resident with moderate cognitive impairment and various medical conditions, reported an incident where R4 allegedly threw feces at them. The incident occurred on 11/17/2024, but the facility did not report it to the state surveying agency until 11/25/2024, eight days later. The facility's policy requires that any allegation of abuse be reported immediately, but not more than two hours after the allegation is made. However, the facility delayed reporting because they were initially unaware that the feces had hit R1. Interviews with facility staff revealed that the Director of Nursing (DON) reported the incident to the Administrator on the day it occurred, but the Administrator did not report it to the state surveying agency until eight days later. The Assistant Administrator stated that the incident was not reported immediately because they did not have all the details until the following day. The facility's policy mandates that any resident-to-resident altercation resulting in physical injury, mental anguish, or pain must be reported according to regulations, which was not adhered to in this case.
Failure to Notify Ombudsman of Involuntary Discharge
Penalty
Summary
The facility failed to send a copy of the involuntary discharge notice to the ombudsman, affecting one resident reviewed for transfers and discharges. The resident, a female with a history of vascular dementia, schizophrenia, bipolar disorder, and schizoaffective disorder, exhibited aggressive and combative behavior that led to her being transferred to a hospital for psychiatric evaluation. Despite returning to the facility, her behavior continued to be unmanageable, resulting in an involuntary discharge notice being issued due to the safety concerns for individuals in the facility. The facility's records indicate that the resident was initially admitted without any significant behavioral issues until early November, when she began exhibiting aggression and combativeness. The facility attempted to manage her behavior by sending her to the hospital multiple times, but she was returned each time due to not meeting the criteria for admission. On the morning of the final incident, the resident's behavior escalated to the point where paramedics were called, and she was transferred to a hospital in another state. The facility determined that they could not safely manage her behavior and issued an involuntary discharge notice. Interviews with facility staff revealed that the resident's representative was not notified of the discharge due to a lack of contact information, and the ombudsman was only informed via phone without receiving a copy of the discharge notice. The facility's discharge planning policy emphasizes the importance of creating an individualized discharge care plan, but there was no documentation of a 30-day discharge notice or any prior notice to the resident, her representative, or the ombudsman. The facility acknowledged that they did not revise the care plan to address the resident's aggressive behavior, and staff were not trained to handle such situations.
Failure to Implement Individualized Behavioral Health Care
Penalty
Summary
The facility failed to implement individualized and person-centered care goals and services for a resident diagnosed with multiple mental disorders, including Vascular Dementia, Schizophrenia, Bipolar Disorder, and Schizoaffective Disorder. The resident, who was admitted to the facility with moderate cognitive impairment, exhibited maladaptive behaviors such as verbal and physical aggression, wandering, and socially inappropriate actions. Despite these behaviors being documented in progress notes, the facility did not update or revise the resident's care plan to address these issues effectively. Interviews with facility staff revealed a lack of communication and coordination in managing the resident's behavior. The social worker admitted to not having a behavior care plan for the resident, and the assistant administrator acknowledged the resident's aggressive behavior but stated that the facility could not provide interventions for her violent tendencies. The licensed practical nurse, who regularly cared for the resident, described incidents of aggression and noted that staff were not trained to handle such violent behaviors. The facility's policies on behavioral health services and comprehensive care plans were not adequately followed. The resident's care plans lacked specific interventions for managing her behavior, and there was no evidence of individualized, person-centered approaches being implemented. Additionally, the activity care plan did not include appropriate activities or therapy programs tailored to the resident's needs, further contributing to the deficiency in providing necessary behavioral health care and services.
Failure to Implement Fall Prevention Measures for At-Risk Resident
Penalty
Summary
The facility failed to implement fall prevention interventions for a resident with a history of falls and multiple medical conditions, including dementia, hemiplegia, and blindness in one eye. The resident was identified as being at risk for falls, yet the facility's assessments were inconsistent, with one noting the resident was not at risk. The resident experienced falls on two occasions, with the most recent resulting in a laceration and hospital evaluation. Observations revealed that the resident's walker was out of reach, and staff noted the resident's tendency to get up unassisted, particularly at night when incontinence was an issue. Interviews with staff indicated that the resident required assistance with activities of daily living and was known to be non-compliant with using a walker and non-skid footwear. Despite being on a fall risk list, the resident was not consistently monitored or assisted, leading to the fall incident. Staff acknowledged the resident's confusion and impaired memory, which contributed to the resident's attempts to ambulate independently without proper support or footwear. The facility's documentation and interviews revealed that no new interventions were implemented following the resident's fall, despite the resident's known risk factors and history of falls. The facility's fall prevention program and care plan interventions, such as ensuring the resident wore appropriate footwear and had access to a call light, were not effectively executed. The lack of consistent supervision and failure to implement adequate fall prevention measures contributed to the resident's fall and subsequent injury.
Failure to Address Roommate Incompatibility
Penalty
Summary
The facility failed to ensure compatibility between two residents, R1 and R5, who shared a room, leading to a deficiency in honoring resident rights. Observations and interviews revealed ongoing conflicts between the two residents, with R1 expressing frustration over R5's belongings and behavior, including loud television noise and clutter. R1, who does not have cognitive impairments, reported feeling stressed and unable to sleep due to R5's actions, while R5, who is cognitively impaired, was unaware of the incidents but expressed willingness to change rooms. Staff, including a CNA and the Director of Nursing, acknowledged the ongoing disagreements and the need for a room change, but no action was taken until the surveyor's involvement. The facility's policy on resident rights emphasizes autonomy and choice, yet the inaction in addressing the incompatibility between R1 and R5 resulted in a failure to uphold these rights. Despite staff awareness of the situation, including reports from the CNA and Social Services, the issue persisted for 2.5 years without resolution. The Director of Nursing and Administrator were aware of minor disagreements but did not perceive the severity of the situation until it was brought to their attention during the survey. This lack of timely intervention highlights a deficiency in the facility's response to resident complaints and the enforcement of their own policies regarding resident rights.
Inadequate Housekeeping Leads to Unsanitary Conditions
Penalty
Summary
The facility failed to maintain a clean, sanitary environment in resident rooms and the dining room, affecting two of the three residents reviewed. Observations revealed that one resident's room had scattered debris, food particles on the floor, and a toilet with yellow liquid that appeared to be urine. The dining room was also found to have food and debris scattered on the floor, with dried food and sticky liquid spills. Interviews with housekeeping staff indicated that there was only one housekeeper assigned per floor, which was insufficient to maintain cleanliness. The housekeeping supervisor confirmed that each room should be cleaned daily, including under the beds, but staffing had been reduced from three housekeepers per floor to one. Another resident's room was observed to have garbage, debris, and dried food on the floor, with thick dust along the walls and under the bed. The resident expressed concerns about the cleanliness of the room, stating that the bed had never been moved for cleaning in the six months they had lived there. The administrator confirmed that there should be two housekeepers per residential floor, but staffing shortages were evident. The facility's housekeeping policy emphasized maintaining a sanitary environment, but the current staffing levels were inadequate to meet these standards.
Failure to Complete Timely Urinalysis for Resident
Penalty
Summary
The facility failed to ensure that a physician's order for a urinalysis was completed for a resident, identified as R2, who was reviewed for laboratory services. R2 was admitted with multiple diagnoses, including dementia, protein-calorie malnutrition, and hypertensive heart disease. After a fall on August 3, 2024, a urinalysis was ordered but not carried out. The physician's progress note on August 6, 2024, indicated that the urinalysis had not been completed, and staff were educated on monitoring and safety precautions. The urinalysis was not collected until August 21, 2024, revealing that R2 had a urinary tract infection. Subsequently, an antibiotic, Bactrim, was ordered on August 23, 2024, for treatment. The facility's policy on laboratory testing incident reporting outlines responsibilities for reporting and reviewing incidents associated with laboratory testing errors, such as improper transcription of orders and failure to notify the laboratory service. The Regional Nurse confirmed the delay in completing the urinalysis, acknowledging the failure to adhere to the physician's order.
Staff Cell Phone Use Violates Resident Dignity
Penalty
Summary
The facility failed to ensure that residents were treated in a dignified manner, as staff members were observed using personal cell phones while monitoring residents. This deficiency was identified through observations, interviews, and record reviews involving four residents. On multiple occasions, surveyors observed certified nursing assistants (CNAs) using cell phones inappropriately during work hours, including talking and laughing loudly with earpieces in, and looking at phone screens while collecting trays and monitoring residents in dining areas. Residents reported that staff frequently used cell phones while providing care, serving meals, and during other resident interactions, which was corroborated by staff interviews. The facility's policy, as outlined in the employee handbook, prohibits the use of personal cell phones during business hours except in designated break rooms. Despite this policy, staff members admitted to using their phones during work hours, with some citing emergencies as the reason. However, the facility's guidelines for resident rights emphasize the importance of promoting the exercise of rights for each resident, including privacy and confidentiality. The failure to adhere to these guidelines and policies resulted in a breach of resident rights, as staff were observed engaging in personal phone use while responsible for resident care.
Failure to Monitor Resident After Narcan Administration
Penalty
Summary
The facility failed to have a written policy to address the response to an opioid overdose and did not ensure that staff were trained and competent in monitoring a resident after the administration of Narcan medication. This deficiency was identified during the review of a case involving a resident who was administered Narcan for a suspected overdose. The staff did not provide continuous monitoring for potential recurrence of signs and symptoms of opioid toxicity for at least four hours after the administration of Narcan, as recommended by SAMHSA. The resident involved was a female with a history of substance abuse and several medical diagnoses, including schizoaffective disorder, bipolar disorder, and traumatic brain injury. On the day of the incident, the resident was found hard to arouse in her wheelchair, with normal vital signs but pinpoint pupils. Narcan was administered by an LPN, who noted that the resident became more responsive after the administration. However, the monitoring was insufficient, as the resident was not continuously observed for the recommended duration, and there was no documentation of a rapid drug test or further medical evaluation. Interviews with facility staff revealed inconsistencies in the understanding and execution of protocols for handling suspected overdoses. The LPN and RN involved in the incident did not conduct a rapid drug test, and there was no clear documentation of the monitoring process. The facility lacked a specific written policy for post-Narcan administration monitoring, and staff relied on their judgment without clear guidelines. The absence of a structured protocol and adequate training contributed to the deficiency in care provided to the resident.
Removal Plan
- R11 has been reassessed and shows no signs of active substance use.
- R11's care plan reviewed.
- All residents with a history of substance abuse have been reviewed by the Interdisciplinary Team for care plans and interventions.
- The facility has updated the substance use disorder policy to include post-Narcan administration monitoring, response to overdose, and when to indicate transfer.
- Nurses are being retrained and competencied on how to respond to emergencies related to substance use including administration and monitoring after giving Naloxone, administering Cardiopulmonary Resuscitation when appropriate, and hospital transfer. Nurses on vacation or Family Medical Leave will be inserviced and competencied before returning to work. New Nurses will be inserviced and competencied during New Employee Orientation, prior to working directly with residents. Agency Nurses will be provided inservice material in their Orientation Packet that they receive prior to their first scheduled shift.
- A Quality Assurance Performance Improvement meeting was held with the medical director to discuss the incident with R11, policy updates, and follow up.
- During the monthly Quality Assurance Meeting, Interdisciplinary Team will review ongoing training of nurses, review competencies and review any incidents of Narcan medication administration.
- The facility will monitor the next 5 uses of Narcan to ensure staff follow the updated facility policy on substance use.
- The facility will randomly competency 3 nurses a week for the next 12 weeks to ensure they are aware of the proper protocol for Narcan administration and substance use. Competencies will be added to Annual Nursing Competencies.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment, as observed during a survey. On the fourth floor, the hallway floors were sticky with black scuff marks, and there were stains in front of the soiled utility/biohazard room. The dining room walls were splattered with dark spots, and the floors were sticky with dried liquid spill stains. The baseboards were dirty, and similar conditions were noted in the elevator and third-floor nourishment room, where the refrigerator had ice buildup and unlabeled food items. The third-floor dining room had black crumbs on the floor, sticky cabinets, and peeling wallpaper. Further observations revealed that the second-floor nourishment room had a dirty ice machine and microwave, with greasy substances and residue on the kitchen counter. The third and fourth-floor microwaves were also dirty, with crusty paper towels and food splatters inside. The ice-cream room was found with food debris and dirty tables and chairs. Despite being informed of these issues, the facility's administrator acknowledged the unclean conditions but did not ensure immediate corrective action, as the areas remained dirty upon subsequent inspections.
Staffing Deficiencies Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents on the third and fourth floors, affecting 147 residents and potentially impacting all 209 residents in the facility. On the day of the survey, the third floor had 74 residents with only three nurses and four CNAs, instead of the usual five to six CNAs. The fourth floor, which houses residents with dementia, falls, and elopement risks, was also understaffed. The staffing issues were exacerbated by the absence of the scheduler, who was on vacation, and the facility's reliance on agency staff was not effectively managed. The facility's assessment document did not specify the number of staff needed to ensure sufficient care, listing overall staffing as "00" and activities of daily living as "sufficient." This lack of clarity contributed to the staffing deficiencies. On one occasion, the fourth floor had only one CNA for 76 residents, leading to inadequate care. Residents reported not receiving timely assistance, with one resident not being changed overnight, resulting in soiled conditions. Staff members, including the ADON and DON, were unaware of the staffing shortages, indicating a lack of communication and oversight. The report highlights specific instances where residents did not receive necessary care due to staffing shortages. One resident, who requires substantial assistance, was left unchanged overnight, while another resident expressed frustration over long wait times for assistance. Staff members working double shifts and being pulled from other floors further indicate the facility's struggle to maintain adequate staffing levels. The facility's administrator acknowledged the lack of a staffing policy and relied on a corporate-provided assessment that did not adequately address staffing needs.
Inadequate Staffing Levels Due to Insufficient Facility Assessment
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary staffing levels to meet the day-to-day needs of its residents. This deficiency was identified during a survey when it was observed that the facility's assessment did not include a thorough evaluation of the overall number of staff required. The facility's assessment document, dated 01/16/24, listed the overall staffing number as '00' and described the staffing for activities of daily living as 'sufficient,' without providing specific numbers or a detailed analysis. This lack of detailed staffing information led to inadequate staffing levels, particularly on the fourth floor, which houses residents with dementia and high care needs. During the survey, it was noted that the fourth floor, with a census of 74 residents, was staffed with only three nurses and four CNAs, instead of the usual five to six CNAs. Staff interviews revealed that the facility was experiencing staffing shortages, with CNAs working double shifts and being pulled from other floors to cover gaps. On one occasion, only one CNA was available to care for 76 residents on the dementia unit during the night shift, which was insufficient to meet the residents' needs. This resulted in residents not receiving timely incontinence care and assistance with activities of daily living, as evidenced by the experiences of two residents who reported not receiving adequate care during the night. The facility's management, including the Assistant Director of Nursing (ADON), Director of Nursing (DON), and Assistant Administrator, were unaware of the staffing shortages and the impact on resident care. The staffing coordinator was on vacation, and the facility relied on agency staff to fill gaps, but this was not effectively managed. The facility's administrator admitted that there was no staffing policy in place, and the facility assessment from corporate was used without further elaboration on how it determined staffing needs. This lack of a structured staffing plan and oversight contributed to the deficiency in providing adequate care to the residents.
Failure to Provide Scheduled Showers and Incontinence Care
Penalty
Summary
The facility failed to provide adequate bathing and incontinence care for residents who require substantial assistance from staff. Three residents, all cognitively intact, reported not receiving their scheduled showers due to staff being too busy. The documentation for these residents' showers was incomplete, with several instances of missing records, making it unclear whether the showers were provided or not. The Director of Nursing (DON) acknowledged the lack of documentation and stated that staff are expected to document all care provided and notify nurses of any refusals. Resident R4, a female with medical conditions including diabetes and major depressive disorder, did not receive her scheduled showers twice a week as per her care plan. Similarly, Resident R8, a male with hemiplegia and diabetes, and Resident R10, a female with hemiplegia and hemiparesis, also reported not receiving their scheduled showers. The facility's policy requires documentation of bathing tasks and assistance provided, but the records for these residents were incomplete, indicating a failure to adhere to the policy and ensure proper hygiene and dignity for the residents.
Medication Supply Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure a consistent supply of prescribed medications for two residents, leading to significant discomfort and distress. One resident, diagnosed with chronic pain syndrome, paraplegia, and morbid obesity, did not receive his scheduled Norco medication for three days due to a delay in reordering from the pharmacy. The resident reported severe pain during this period, which was corroborated by the facility's staff, who acknowledged the medication was not ordered in time. The delay was exacerbated by a holiday and the need for a signed script for the controlled substance. Another resident, with diagnoses including major depressive disorder, generalized anxiety disorder, and insomnia, experienced similar issues with the availability of lorazepam. The resident missed several doses due to pharmacy delays, leading to increased anxiety and agitation. The facility staff confirmed that the medication was not available in the facility's stock and was awaiting delivery from the pharmacy. The resident's frustration was noted in therapy notes, and staff acknowledged the medication should have been reordered in time to prevent running out. Both cases highlight a breakdown in the facility's medication management system, where the responsibility for reordering medications was not effectively executed. The staff, including nurses and the Director of Nursing, recognized the lapses in ensuring timely medication orders, which resulted in residents experiencing unnecessary pain and anxiety. The facility's expectation to maintain a daily supply of prescribed medications was not met, leading to these deficiencies.
Failure to Administer Anticonvulsant Medication Post-Hospitalization
Penalty
Summary
The facility failed to ensure that a resident received their prescribed anticonvulsant medication, levetiracetam (Keppra), immediately following a hospitalization for status epilepticus. The resident, who is cognitively intact and has a history of seizures, was readmitted to the facility with hospital discharge orders for levetiracetam 1000mg to be taken at bedtime. However, the medication order was not entered into the facility's system until two days after the resident's return, resulting in missed doses on two consecutive nights. The resident reported not receiving his seizure medication on one of these nights, and the Director of Nursing confirmed that the medication reconciliation process was not completed promptly upon the resident's return from the hospital. The nurse responsible for the resident's care did not reconcile the hospital discharge orders with the facility's records immediately, leading to the oversight. The Nurse Practitioner was unaware of the missed doses and emphasized the importance of following hospital discharge orders to manage the resident's chronic seizure condition effectively.
Failure to Provide Adequate Fall Prevention and Supervision
Penalty
Summary
The facility failed to provide a safe environment by not adequately assessing, monitoring, or supervising residents at risk for falls. This deficiency was evident in the cases of four residents (R1, R3, R4, R5) who experienced falls resulting in significant injuries. For instance, R1, who had a history of falls and was on seizure precautions, fell and sustained a laceration to his left ear. Despite being listed on the fall intervention log, necessary interventions such as non-skid strips were not in place at the time of the incident. Additionally, R1 was not included in the fall leaf program, which was a critical oversight given his medical history and fall risk assessment indicating a high risk for falls. The incident led to R1 being hospitalized for a few days to receive stitches for his injury. The staff, including an LPN and a restorative nurse, acknowledged the oversight and the need to include R1 in the fall prevention program due to his frequent falls and medical conditions such as seizures and hemiplegia following a cerebral infarction. The facility's failure to implement and monitor the prescribed fall interventions contributed to R1's fall and subsequent hospitalization. Similarly, R3, who had dementia and a history of falls, was found on the toilet with a laceration to his left eyebrow after a fall. Despite being at high risk for falls, R3 was not adequately supervised, leading to his injury and hospitalization for stitches. The facility's fall risk assessment and care plan for R3 indicated the need for close monitoring, which was not effectively carried out. R4 and R5 also experienced falls resulting in severe injuries, including femur fractures, due to inadequate supervision and failure to follow the fall prevention program. R4 fell while unattended in the shower, and R5 fell while ambulating to the bathroom without assistance. Both residents had documented histories of falls and required assistance with activities of daily living, yet the necessary precautions and supervision were not provided. These incidents highlight the facility's systemic failure to adhere to its fall prevention program, resulting in significant harm to the residents.
Failure to Accurately Transcribe and Administer Pain Medication
Penalty
Summary
The facility failed to accurately transcribe a physician's order for pain medication and did not follow its medication administration policy by not clarifying the pain medication dosage for one resident. On 05/24/2024, a Licensed Practical Nurse (LPN) was observed preparing and administering acetaminophen to a resident. The electronic medication administration record (eMAR) showed an order for 625 mg of acetaminophen, but the LPN administered one 325 mg tablet and one half tablet of 325 mg (162.5 mg), totaling 487.5 mg. The LPN acknowledged the need to clarify the order with the physician because 625 mg is an uncommon dose. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the order should have been clarified earlier and that the LPN had administered only 325 mg of acetaminophen during the surveyor's observation. The resident's eMAR indicated that acetaminophen 625 mg had been administered on multiple dates in May 2024. The order was discontinued on 05/24/2024, and a new order for 650 mg of acetaminophen was issued. The facility's Medication Administration policy requires the safe, accurate, and effective administration of oral medications and mandates the review and confirmation of medication orders prior to administration. The failure to clarify the physician's order and the incorrect administration of the medication led to the deficiency.
Resident Assaulted by Roommate in LTC Facility
Penalty
Summary
The facility failed to protect a resident from physical abuse by his roommate, resulting in significant injuries. The incident involved a resident with cognitive impairment and dementia, who was assaulted by his roommate, also suffering from cognitive impairment and dementia, with a metal rod. The assault occurred without apparent provocation, leading to the victim being struck multiple times in the face, necessitating an emergency transfer to the hospital for treatment of facial lacerations and contusions. The incident was witnessed by a Certified Nurses Aide (CNA) who heard screaming and found the aggressor standing over the victim, hitting him. The CNA attempted to calm the aggressor and called for assistance from another CNA and a Licensed Practical Nurse (LPN). The staff provided first aid to the victim and managed to separate the aggressor, who was then monitored one-on-one in the dining room. The police and emergency services were called, and the victim was transported to the hospital, while the aggressor was sent to a psychiatric hospital. The facility's internal investigation revealed that the staff responded to the incident by providing immediate care and separating the residents. However, the facility's abuse policy did not specifically address resident-to-resident abuse, which may have contributed to the incident. The investigation could not determine any antecedent factors leading to the assault, and it was noted that the aggressor was experiencing a psychotic episode at the time of the incident.
Failure to Follow DNR Orders During Emergency Response
Penalty
Summary
The facility failed to adhere to a resident's advanced directives, specifically a Do Not Resuscitate (DNR) order, during an emergency situation. A resident with multiple serious health conditions, including chronic respiratory failure and heart issues, was found unresponsive in the bathroom by an LPN. Despite the resident's POLST form indicating a DNR status, the LPN initiated CPR and called a code blue. The Director of Nursing (DON) arrived and continued chest compressions until another LPN Manager checked the DNR binder and instructed them to stop CPR, realizing the resident's DNR status. The incident involved a lack of verification of the resident's code status before initiating life-saving measures, as outlined in the facility's Code Blue policy. The staff involved did not check for signs of life or verify the resident's advanced directives before starting CPR. The DON and LPN Manager were making rounds when they discovered the error, but CPR had already been performed for several minutes. The physician later suggested that the resident might have experienced a syncopal episode, leading to a fall and subsequent bleeding.
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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