Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aperion Care International during CMS and state inspections, most recent first.
A resident with multiple comorbidities, including type 2 DM, CHF, venous insufficiency, and a facility-acquired diabetic/vascular ulcer on the left heel, was placed under Enhanced Barrier Precautions (EBP) with posted signage requiring staff to wear gloves and a gown for wound care. During an observed dressing change, an LPN performed hand hygiene, donned gloves, removed a soiled dressing, cleansed the wound with Dakin’s solution, applied honey and silver alginate, and redressed the wound without wearing a gown, contrary to the posted EBP instructions and the facility’s written EBP policy. The DON and IP confirmed that residents with chronic wounds are to be cared for under EBP and that staff are expected to wear both gown and gloves during high-contact care activities such as wound care.
A resident with mobility limitations and osteoporosis was transferred by CNAs into a wheelchair without leg rests, and an OT then transported the resident down the hallway while instructing the resident to hold her legs up. During transport, the resident’s leg dropped under the wheelchair, a popping sound was heard, and the resident immediately reported severe pain. The OT stopped, retrieved and applied the leg rests, and continued to move the resident, after which a physician assessment and subsequent hospital evaluation confirmed a closed fracture of the left tibia. Staff interviews revealed inconsistent practices and understanding regarding when leg rests are required, conflicting statements about whether leg rests were in place at the time of the incident, and acknowledgment that there was no facility policy for accident hazards, supervision, or wheelchair use, despite restorative documentation indicating that this resident required a wheelchair with leg rests.
A cognitively intact resident lying in bed was physically assaulted by a neighboring resident with dementia and a documented potential for aggressive behavior, who entered the room, attempted to pull down bed covers and move the bedside table, and then punched the resident in the face. The injured resident reported crying, calling for help, and contacting a family member, who later stated that the resident was screaming and that staff were not immediately present at the nurse’s station. Staff interviews and records showed that the aggressor had dementia, memory problems, and a care plan directing staff to observe his location and aggression level, yet he was able to access the adjacent room, located directly across from the nurse’s station. CNAs described hearing calls for help, finding the aggressor standing by the victim’s bed while the victim held her flushed face, and noted that residents with dementia were monitored at varying intervals. The administrator, serving as abuse coordinator, acknowledged that the facility lacked a supervision/monitoring policy despite a written abuse-prevention policy requiring protection of residents from abuse and ensuring staff knowledge of individual care needs.
Two residents engaged in a verbal altercation involving threats and foul language, with staff needing to intervene and separate them. The incident was triggered by ongoing disputes over housekeeping and disturbances, and both residents had documented behavioral and mental health concerns. Despite care plan interventions, the facility did not prevent the escalation of verbal abuse.
A resident with severe cognitive impairment and a history of dementia developed significant swelling in the left hand. An LPN observed the change and obtained a STAT x-ray order, but the radiology company was unable to perform the x-ray within the facility's required 4-hour window. Despite multiple follow-ups, the x-ray was delayed until the next day, and the resident was ultimately sent to the hospital, where a finger fracture was diagnosed. Staff interviews confirmed that the delay exceeded policy expectations and that the physician was not notified of the delay as required.
A resident with severe cognitive impairment, incontinence, and a history of falls sustained a femur fracture after an unwitnessed fall while attempting to access the bathroom unassisted. Staff assigned to the resident were unaware of the fall risk status, did not review the fall binder, and failed to provide or document required incontinence and toileting care during the shift, contrary to facility policy.
Two residents engaged in a physical altercation after a disagreement over food, resulting in one resident sustaining a laceration above the eye. Both residents were cognitively intact and were sent to the hospital following the incident. The facility's staff did not witness the altercation, highlighting a failure to maintain a secure environment as per the facility's abuse prevention policy.
A resident with a history of mobility issues experienced an unwitnessed fall and complained of leg pain. Despite an x-ray being ordered, it was not conducted, and the resident was not sent to the hospital until the next day, resulting in a delayed diagnosis of a hip fracture. The facility's policy for emergency care was not followed, leading to the resident undergoing surgery days later.
A resident with multiple medical conditions missed a podiatry appointment due to the facility's failure to provide an escort. Despite being prepared for the appointment, the resident was informed that no escort was available, resulting in the missed appointment. The breakdown in communication and staffing coordination among facility staff led to this deficiency.
A facility failed to protect resident confidentiality when two staff members left computers unattended with sensitive information visible. This breach involved two residents and potentially affected 46 others. The facility's policy requires securing computers to maintain privacy, which was not followed.
The facility failed to provide pressure-relieving cushions for residents at risk of pressure ulcers, as required by their care plans. Observations revealed that several residents were seated in wheelchairs without the necessary cushions, despite their documented risk levels and the facility's policy mandating such interventions.
The facility failed to implement fall prevention measures as outlined in care plans and facility policy for three residents. Observations revealed residents wearing smooth-bottomed socks instead of required non-skid socks, increasing fall risk. A CNA acknowledged the oversight, and the ADON corrected misinformation provided by a restorative nurse. Records showed residents were at risk for falls, with care plans specifying the need for appropriate footwear. The facility's fall prevention program mandates proper fitting shoes or non-skid footwear to ensure safety.
The facility did not include abuse prevention strategies in the care plans of four residents identified as at risk for abuse. Despite their vulnerability due to conditions like cognitive impairment and physical disabilities, the care plans lacked specific goals and approaches to prevent abuse, contrary to the facility's policy.
The facility experienced staffing shortages, resulting in delayed care and medication administration. A resident reported waiting two hours for assistance, and an LPN struggled to complete medication rounds on time due to insufficient staff. A CNA was left to care for over 70 residents alone, leading to unsafe conditions. The Director of Nursing acknowledged the impact of these shortages on resident care.
A deficiency was identified in a LTC facility where medications were not administered as ordered by the prescriber, affecting six residents. An LPN, who was a wound nurse, administered medications outside the prescribed time frame due to a shortage of nurses. Additionally, several medications were not signed off as administered in the MAR for multiple residents. The facility's policy requires medications to be given within one hour before or after the scheduled time, which was not consistently followed, leading to late administration and lack of documentation.
A resident in a wheelchair was hit in the back by another resident after a minor collision in the dining room. The incident was witnessed by a CNA, who separated the residents and reported the event. The facility's staff acknowledged the incident as physical abuse, but the report highlights a failure to protect the resident from such abuse, as affirmed in the facility's policy.
A resident with a history of hemiplegia and frequent incontinence experienced delays in receiving incontinence care, waiting up to three hours for assistance. The CNA responsible prioritized other tasks, such as assisting fall-risk residents and dining observations, over the resident's care. The facility's policy requires two-hourly checks, which were not followed in this instance.
The facility failed to perform criminal background checks for new residents within 24 hours of admission, affecting four residents and potentially impacting all 192 residents. The Admissions Director admitted to not conducting checks on weekends, leading to delays. The facility's policy mandates these checks to ensure resident and staff safety.
The facility failed to properly label and store medications, maintain sanitary conditions, discard expired medications, and account for narcotics, affecting 22 residents and potentially impacting all residents receiving medications from the medication carts.
The facility failed to ensure proper labeling, dating, and sealing of food items, discarding expired food, and maintaining sanitation in the kitchen. Observations included undated food items, incomplete temperature logs, personal food in storage areas, inadequate sanitation solutions, and improper hand hygiene and glove use by dietary staff. These deficiencies put the health and safety of 185 residents at risk.
The facility failed to ensure there was no accumulation of lint at the bottom of the lint compartment in dryer #1, posing a fire hazard. The Housekeeping Director and Laundry staff indicated that maintenance is responsible for this area, but the Maintenance Director acknowledged the lint accumulation as a fire hazard. Job descriptions and facility guidelines require daily lint removal, which was not followed.
The facility failed to set low air loss mattresses at the correct weight settings for five residents, all of whom were at risk for or had existing pressure ulcers. The incorrect settings were observed during a surveyor's visit, despite care plans and facility policies indicating the need for accurate settings to prevent and heal pressure ulcers.
The facility failed to ensure proper respiratory care for four residents, including not securing a nebulizer mask in a bag when not in use and not dating oxygen tubing as required by policy. Residents had various diagnoses requiring respiratory support, and the facility's lapses in protocol posed potential health risks.
The facility failed to ensure dumpsters were closed and free from overflowing trash, potentially affecting all 192 residents. Observations revealed one dumpster lid open and another unable to close due to overflowing trash. The Housekeeping Director confirmed the lids should remain closed for rodent and animal control, and it is their responsibility along with the Maintenance Director to check the area. Facility guidelines require outdoor trash receptacles to be covered and the area kept free of litter.
The facility failed to ensure staff performed hand hygiene between residents during meal tray pass, leading to potential spread of infectious microorganisms. Staff members, including CNAs and dietary aides, were observed not using hand sanitizer or washing hands between handling meal trays and interacting with different residents. This deficiency affected nine residents with various medical conditions.
The facility failed to ensure that a resident's call light was accessible, leaving it on the floor and out of reach. The resident, with multiple medical conditions and cognitive impairments, was unable to call for assistance. An LPN acknowledged the issue and corrected it by placing the call light within reach. The ADON and the resident's care plan emphasized the importance of call light accessibility.
The facility failed to ensure residents received necessary assistance with shaving, affecting three residents who were left with unshaved facial hair despite their requests and care plans indicating a need for help. Staff interviews confirmed that CNAs are responsible for this task, but they did not fulfill their duties, compromising the residents' comfort and dignity.
The facility failed to ensure that an adaptive device (splint/palm grip) was in place for a resident with a contracted hand, despite physician orders and care plan requirements. The device was found on the resident's bedside dresser instead of being applied, leading to potential worsening of the contracture and a wound caused by the resident digging her nails into her hand.
The facility failed to properly log personal refrigerator temperatures for two residents, leading to multiple missing entries in the temperature logs. Staff interviews revealed confusion about who was responsible for this task, resulting in inconsistent monitoring.
The facility failed to post accurate and consistent daily nursing staffing information, affecting all 192 residents. The posted information was outdated and inaccurate, and the responsible receptionist admitted to not ensuring daily updates. Additionally, the posted document showed an incorrect census and lacked specific unit details.
A resident fell four times in 26 days, sustaining fractures, due to the facility's failure to develop and implement individualized fall prevention interventions. The IDT focused on medical responses rather than proactive strategies, and the care plan lacked specific interventions for the falls.
A facility failed to provide timely incontinence care for a dependent resident, resulting in the resident being left in a saturated brief with dark-colored urine and stool. The resident's care plan and facility policy required checks every 2-3 hours, but staff did not adhere to these guidelines, posing a risk for skin breakdown and other complications.
A resident with multiple diagnoses was not properly assessed for a newly identified skin alteration. The initial assessment by an agency LPN identified the wound as a skin tear without a head-to-toe assessment. The wound was later found to be an unstageable pressure wound, and no specific dressing order was documented, indicating a lapse in proper wound care and documentation.
Failure to Use Required PPE During Wound Care Under Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to follow its Enhanced Barrier Precautions (EBP) policy requiring both gown and gloves during high-contact resident care activities, specifically wound care. One resident was admitted with multiple diagnoses including hemiplegia following cerebral infarction, asthma, type 2 diabetes mellitus, congestive heart failure, venous insufficiency, hypertension, coronary artery disease, myocardial infarction, osteoarthritis, nephrotic syndrome, and lumbar spinal stenosis. The resident’s MDS showed intact cognition. The resident had a facility-acquired diabetic/vascular ulcer on the left heel, first identified in February, with documented measurements and characteristics including pink/red non-granulating tissue and necrotic tissue with scant serosanguinous exudate. The resident’s room and bed area displayed EBP signage stating that staff must wear gloves and a gown for wound care involving any skin opening requiring a dressing. During an observed wound care procedure performed by an LPN identified as the wound care nurse, the nurse washed her hands and donned gloves but did not wear a gown at any point during the treatment, despite the posted EBP requirements. The nurse removed a dressing with brownish drainage from the resident’s left heel, cleansed the wound with Dakin’s solution, applied honey and silver alginate, and covered it with a dry dressing, all without a gown. The DON and the Infection Preventionist later stated that residents with wounds or indwelling medical devices are placed under EBP and that staff are expected to wear both gloves and a gown during high-contact activities such as wound care to prevent cross contamination and possible transmission of organisms. Facility policy on Enhanced Barrier Precautions, dated 5/7/24, specifies that for residents with chronic wounds, staff must don gown and gloves during high-contact care activities, including wound care for any chronic skin opening requiring a dressing. Records showed the LPN was assigned to multiple rooms and 16 residents with skin impairments, underscoring that the observed noncompliance occurred in the context of established facility expectations and written policy for PPE use during wound care.
Resident Fracture Due to Wheelchair Transport Without Leg Rests
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety and adequate supervision during wheelchair transport, specifically by transporting the resident without leg rests, resulting in a left leg fracture. The resident had diagnoses including other specified disorders of muscle, right-sided sciatica, unilateral primary osteoarthritis of the right knee, and age-related osteoporosis without current pathological fracture, with documented limitations in mobility and a care plan focus on gait abnormalities and fall risk. The resident’s MDS showed intact cognition (BIMS score 15), and the care plan noted she was able to self-propel short distances in the hall without leg rests, but also identified her as chair-bound on the fall risk assessment. Therapy orders for both PT and OT included wheelchair management and training. On the day of the incident, CNAs transferred the resident from bed to a wheelchair via mechanical lift, and the wheelchair leg rests were not applied. The leg rests were reportedly on the resident’s table. The occupational therapist arrived to take the resident to therapy, did not apply the leg rests, and instructed the resident to hold her legs up while being pushed in the hallway. While being pushed, the resident’s left leg dropped and rolled or flexed backward under the wheelchair, and she heard and reported a popping sound. The resident yelled for the therapist to stop, stating that her leg was under the wheelchair and that her leg was broken. The therapist then stopped, returned to the room to retrieve and apply the leg rests, and continued to transport the resident down the hallway. The therapist informed the physician at the nursing station, who assessed the resident’s leg, noted pain on palpation and with testing, and ordered x‑rays and limited weight bearing of the left lower extremity. The resident reported severe pain (9/10) and remained in the wheelchair until CNAs later transferred her back to bed via mechanical lift. The resident and her family declined x‑rays at the facility and requested transfer to the hospital emergency room, where she was diagnosed with a closed nondisplaced fracture of the medial malleolus of the left tibia. Interviews with the resident and her family member consistently described that the leg rests were not on the wheelchair at the time of the incident and that the therapist continued to attempt therapy despite the resident’s pain. Multiple staff interviews revealed inconsistent understanding and practices regarding leg rest use and documentation. CNAs and nurses stated that residents who cannot self-propel or cannot move their legs require leg rests to prevent injury, and that leg rests should be applied when residents are transferred to wheelchairs and transported. The restorative director stated that the resident was capable of self-propelling and did not require leg rests before or after the incident, yet the restorative log she developed documented that the resident required a wheelchair with leg rests. The DON acknowledged that if a resident requires leg rests out of necessity and they are not used, an accident can happen, and described that staff might push residents with legs held up rather than using leg rests. The administrator and DON both stated there was no facility policy for Accident/Hazards/Supervision or wheelchair use, and the administrator confirmed that incidents are handled on a case-by-case basis without a specific policy, while also confirming there was no video footage available for review of the incident. Staff interviews further showed confusion about whether physician orders were required for leg rests or self-propelling and indicated reliance on restorative logs and in-services for guidance. One LPN reported being told by the therapist that the resident’s leg had dropped and twisted while being transported and that leg rests were on at the time she was notified, while the resident and other staff stated leg rests were not applied at the time of the incident. Another CNA stated that everyone knew the resident required leg rests because she could not move her legs and recalled an in-service to apply leg rests as soon as residents were placed in wheelchairs. Overall, the documented events and interviews show that the resident was transported in a wheelchair without leg rests, contrary to staff statements about safe practice and restorative documentation, and that this failure resulted in the resident sustaining a left leg fracture.
Failure to Prevent Resident-on-Resident Physical Abuse and Inadequate Supervision of a Dementia Resident
Penalty
Summary
The deficiency involves the facility’s failure to prevent and protect a cognitively intact resident (R1) from physical abuse by another resident (R2) who had dementia and a documented potential for aggressive behavior. R1 reported that while she was lying in bed in the evening, an unknown male, later identified as R2, entered her room, came directly to her side of the bed, and attempted to pull her sheets down. R1 stated that R2 then moved toward the front of her bed, tried to move her bedside table, and when she resisted by holding onto the table, he punched her in the face. R1 described crying, calling for help, and contacting her family member (V3) immediately after the incident. The surveyor observed a red bruise under R1’s left eye, and R1 reported facial swelling earlier, pain treated with medication and an ice pack, and significant emotional distress, including uncertainty about feeling safe in the facility. R1’s family member (V3) corroborated R1’s account, stating that R1 called him crying and saying she had been hit, and that she described an unknown male entering her room, attempting to pull down her blanket, trying to move the bedside table, and then punching her in the face when he could not move it. V3 reported that R1 was screaming for help and that he had to call the front desk to alert staff that R1 was being attacked. When V3 arrived at the facility, he initially could not locate staff at the nurse’s station and subsequently filed a police report. V3 stated that R2 could have seriously harmed R1 and emphasized that staff were responsible for ensuring R1’s safety and monitoring R2 and other residents. R2’s records documented diagnoses including unspecified dementia, suicidal ideations, and major depressive disorder, with an MDS indicating memory problems and inability to complete the BIMS. R2’s care plan identified a potential for aggressive behavior related to dementia and directed staff to observe his location and changes in aggression level and to remove him from areas when aggression increased. Staff interviews revealed that R2’s room was directly next to R1’s and both rooms were across from the nurse’s station. A CNA (V5) stated she had checked R2 about ten minutes before the incident and found him asleep, and that she later heard a call for help, entered R1’s room, and saw R2 standing by R1’s bed while R1 held her face, which was flushed red. Another CNA (V6) reported hearing R2 yell for help, entering R1’s room, and finding R2 at the foot of R1’s bed while R1 was hysterical and asking for him to be removed. The administrator (V1), who served as abuse coordinator, stated that the facility did not have a supervision/monitoring policy, despite facility policy stating a commitment to protect residents from abuse and to ensure staff have knowledge of individual resident care needs. These circumstances reflect a failure to adequately supervise and monitor R2, a resident with dementia and potential for aggression, resulting in physical abuse of R1. Additional documentation showed that R1’s MDS reflected a BIMS score of 13/15, indicating she was cognitively intact, with diagnoses including bilateral sensorineural hearing loss, rheumatoid arthritis, gait abnormalities, and vitamin D deficiency. A progress note for R1 recorded that a CNA informed the nurse that R1 had been hit in the face by another resident, and that the nurse found R1 in bed crying, with redness to the left cheek and flushed face and neck. A corresponding progress note for R2 recorded that staff were informed R2 had hit another resident in the face. Staff interviews indicated that residents with dementia were generally monitored every 15 minutes according to one CNA, while another nurse stated residents with dementia were monitored every two hours, and that R2 could easily access R1’s room due to their proximity. The combination of R2’s known dementia and potential for aggression, the lack of a facility supervision/monitoring policy, and inconsistent descriptions of monitoring practices contributed to the failure to prevent R2 from entering R1’s room and physically abusing her.
Failure to Prevent Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to prevent and protect a resident from verbal abuse by another resident, resulting in a verbal altercation between two residents. On the morning of 06/14/2025, both residents were involved in a heated argument in their shared room, during which they screamed and used foul language toward each other. One resident threatened physical harm, stating, "I am going to f*ck you up," but did not become physically aggressive. Staff intervened and separated the residents, with one being removed from the room. Interviews and record reviews revealed that the altercation was triggered by ongoing disputes, including complaints about housekeeping services and disturbances caused by early morning phone calls. One resident, who has a history of adjustment disorder with anxiety and depression but is cognitively intact, reported feeling stressed and tense during the incident. The other resident, who has impaired cognitive function and diagnoses including dementia and major depressive disorder, reported feeling nervous and needing sleep, and had previously informed a nurse about the disturbances. Behavior notes and care plans for both residents documented their risk for abuse or neglect, with interventions such as providing reassurance and observing the resident when in the company of peers. Despite these interventions, the facility did not prevent the escalation of verbal abuse between the residents, as evidenced by staff and resident interviews and documentation of the incident.
Failure to Provide Timely STAT X-Ray Services for Resident with Hand Injury
Penalty
Summary
The facility failed to provide timely radiology services for a resident who was identified with swelling in the left hand. The resident, who had diagnoses including dementia, major depressive disorder, and severe cognitive impairment, was observed by an LPN to have +3 pitting edema and swelling in the left hand. A STAT x-ray and doppler were ordered by the nurse practitioner, and the orders were placed as required. However, the radiology company was unable to perform the STAT x-ray within the expected timeframe due to high volume, and the x-ray was not completed until the following day. During this period, staff communicated with the radiology company multiple times to follow up on the status of the STAT x-ray, but no estimated time of arrival could be provided. The facility's policy and agreement with the radiology provider specified that STAT x-rays should be performed within 4 hours. Despite this, the x-ray was delayed, and the resident was eventually transferred to the hospital for further evaluation, where a small fracture of the left little finger was diagnosed. Interviews with facility staff, including the administrator, ADON, DON, and nurses, confirmed that STAT x-rays are expected to be completed within 4 to 6 hours, and that delays with the radiology company had been an ongoing issue. Documentation also revealed that the physician was not notified that the STAT x-ray was not completed within the required timeframe, contrary to facility policy, and the delay in obtaining the x-ray was not properly documented in the progress notes.
Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement fall prevention interventions for a resident identified as high risk for falls. The resident, who had a history of falls, dementia, severely impaired cognition, and was always incontinent, required substantial to maximal assistance with transfers, mobility, and toileting. On the night of the incident, the resident was found on the floor near the bathroom after an unwitnessed fall and was later diagnosed with a left femur fracture. The resident had been attempting to go to the bathroom unassisted. Certified Nursing Assistant (CNA) staff assigned to the resident's care during the shift reported being unfamiliar with the resident's fall risk status and did not review the fall binder that night. The CNA also could not recall if toileting or incontinence care was provided or documented for the resident during the shift. Review of CNA documentation for that shift showed no entries for bladder and bowel elimination or toilet transfers for the resident. The facility's policies required regular checks and care for incontinent residents and specific fall prevention interventions for those at high risk, including visual checks and assistance with care needs. Interviews with staff confirmed the importance of providing regular incontinence care and supervision to prevent residents from attempting unsafe self-transfers. The lack of staff awareness of the resident's fall risk, failure to provide and document required care, and absence of supervision contributed to the resident's ability to attempt to transfer independently, resulting in a fall and serious injury.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to ensure that two residents, R3 and R4, were free from physical abuse, resulting in R4 sustaining a laceration above the right eye. Both residents had intact cognition, as indicated by their BIMS scores of 15. The incident occurred when R4 offered R3 some pizza and garlic bread, which R3 refused. R4 then threw a piece of garlic bread at R3, missing him. R3 responded by taunting R4, which led to R4 rolling his wheelchair towards R3 and swinging his arms, hitting R3 in the chest and chin. R3 retaliated by hitting R4 back. The altercation was not witnessed by staff, but a nurse entered the room after hearing commotion and separated the two residents. Following the incident, both residents were sent to the hospital. R4 had a visible laceration above his right eye, while R3 did not have any reported injuries. Upon their return, R4 was moved to a different room. The facility's policy on abuse prevention and reporting emphasizes the residents' right to be free from abuse and the facility's commitment to preventing such occurrences. However, the incident between R3 and R4 indicates a failure in maintaining a secure environment for the residents, as no staff witnessed the altercation, and the response was reactive rather than preventive.
Failure to Provide Timely Emergency Care After Resident Fall
Penalty
Summary
The facility failed to provide timely emergency care for a resident who experienced an unwitnessed fall and subsequently complained of leg pain. The resident, who had a history of mobility issues and was diagnosed with a displaced intertrochanteric fracture of the right femur, reported the fall and pain to the nursing staff. Despite the resident's complaints, an x-ray was not conducted at the facility, and the resident was not sent to the hospital until the following day, resulting in a delay in diagnosing a hip fracture. The report details that the resident's fall occurred in the evening, and although an x-ray was ordered, it was not performed within the expected timeframe. The Assistant Director of Nursing (ADON) noted the resident's increased pain and swelling the next morning and subsequently arranged for the resident to be sent to the hospital. The facility's policy indicated that emergency medical services should be notified for assessment and transport if an incident occurs during certain hours, which was not adhered to in this case. The delay in care led to the resident undergoing surgery for the hip fracture several days later.
Failure to Provide Escort for Resident's Medical Appointment
Penalty
Summary
The facility failed to provide a resident escort for a podiatry appointment, affecting a resident who requires assistance due to multiple medical conditions. The resident, a male with diagnoses including hemiplegia, diabetes, and moderately impaired cognition, was unable to attend his scheduled appointment because no escort was available to accompany him. The resident expressed his frustration to the surveyor, stating that he missed his appointment because the facility did not have anyone to escort him. The Director of Nursing (DON) and other staff members were involved in the scheduling and coordination of transportation and escorts for medical appointments. The concierge, responsible for scheduling transportation and escorts, was unable to find an escort for the resident and communicated this issue during a morning meeting. However, the DON was not present at the meeting and did not receive a notification about the lack of an escort. The resident's nurse confirmed that the resident was prepared for the appointment but was informed that no escort was available when he was taken downstairs for transportation. The facility's process for scheduling transportation and escorts involves multiple staff members, including the concierge and scheduler, who coordinate with nursing personnel to ensure residents are accompanied to appointments as needed. Despite these procedures, the breakdown in communication and staffing resulted in the resident missing his podiatry appointment. The facility's job descriptions and assessment tools outline the responsibilities and staffing plans, but the failure to secure an escort for the resident highlights a gap in the execution of these plans.
Breach of Resident Confidentiality Due to Unattended Computers
Penalty
Summary
The facility failed to maintain the confidentiality of medical records for two residents, identified as R12 and R13, which potentially affected 46 residents across two floors. On separate occasions, surveyors observed unattended medication carts with open computers displaying sensitive resident information. Specifically, R12's Medication Administration Record (MAR) was visible on a computer left unattended by an LPN on the second floor, and R13's patient information was visible on a computer left unattended by an RN on the third floor. Both staff members acknowledged the breach of privacy when questioned by the surveyor. The Director of Nursing confirmed that the facility's policy requires staff to log off or secure computers when not in use to protect resident privacy. The facility's policy on Residents' Rights emphasizes the right to confidentiality of treatment and personal and clinical records. The failure to adhere to these policies was evident in the actions of the staff, who left computers with resident information accessible to unauthorized individuals, thereby compromising the privacy and confidentiality of the residents' medical records.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to implement pressure ulcer prevention interventions as outlined in the care plans for residents at risk for pressure ulcers. During observations, residents identified as R9, R10, R11, and R12 were seen sitting in wheelchairs without pressure-relieving cushions, despite their care plans specifying the need for such devices to prevent pressure ulcers. Certified Nurse Assistants (CNAs) and the Restorative Aide were notified of the absence of these cushions, and it was acknowledged that the residents should have had them to prevent pressure ulcers. The records for the residents involved indicate that they were at varying levels of risk for pressure ulcers, with diagnoses including dementia, generalized muscle weakness, protein-calorie malnutrition, and chronic kidney disease. The facility's policy on pressure ulcer prevention, revised in 2018, mandates the use of pressure-reducing pads in chairs for residents identified as being at moderate to high risk. Despite this policy, the necessary interventions were not implemented, leading to the deficiency noted in the report.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plans and did not adhere to the facility's fall prevention policy for three residents. On the specified date, a resident was observed in the dining room wearing smooth-bottomed socks instead of non-skid socks, which are required for fall prevention. A CNA acknowledged the oversight and indicated that the resident should have been wearing non-skid socks. Similarly, two other residents were observed in wheelchairs wearing smooth-bottomed socks, and a CNA confirmed the need for non-skid socks to prevent falls. The restorative nurse incorrectly stated that non-skid socks were not mandatory for residents in wheelchairs, which was later corrected by the Assistant Director of Nursing. The records for the residents involved indicated that they were at risk for falls, with care plans specifying the need for appropriate footwear to prevent falls. One resident had a history of unwitnessed falls, and another had a history of recurrent falls with poor safety awareness. The facility's fall prevention program, last reviewed in 2017, requires that residents have proper fitting shoes or non-skid footwear to ensure safety. The failure to follow these protocols contributed to the deficiency observed by the surveyors.
Failure to Include Abuse Prevention in Care Plans
Penalty
Summary
The facility failed to adhere to its abuse policy and procedure by not developing comprehensive person-centered care plans that include goals and approaches to prevent abuse for four residents. Each of these residents was identified as being at risk for abuse, yet their care plans did not reflect any specific strategies to mitigate this risk. The residents in question had various medical conditions, including severe cognitive impairment, major depressive disorder, and physical disabilities, which increased their vulnerability to abuse. Despite these risk factors, the care plans lacked the necessary interventions to prevent potential abuse. Interviews with the Assistant Administrator revealed that the facility considers all residents at risk for abuse due to their elderly and vulnerable status. The facility's policy mandates that staff identify residents with increased vulnerability and incorporate strategies to reduce the chances of abuse into their care plans. However, the facility did not follow through with this requirement, as evidenced by the absence of abuse prevention goals and approaches in the care plans of the reviewed residents.
Staffing Shortages Lead to Delayed Care and Medication Administration
Penalty
Summary
The facility failed to provide sufficient licensed nursing staff and certified nursing assistants (CNAs) on specific dates, which affected the care provided to residents. On one occasion, a resident reported waiting for two hours to be changed after using the call light, indicating a lack of timely assistance for activities of daily living (ADL) care. Observations revealed that the facility was not adequately staffed, with fewer nurses and CNAs than required, leading to delays in medication administration and care. Licensed Practical Nurse (LPN) V4 reported being one of only two nurses covering 68 residents on a unit, resulting in a delay in administering 9 AM medications. Similarly, CNA V5 described working a night shift with only one other CNA, who was later reassigned, leaving V5 to care for 70-72 residents alone. This situation was deemed unsafe, and V5 refused to work under such conditions. The staffing coordinator, V11, confirmed that the facility did not meet the minimum staffing requirements on the specified dates, which compromised the ability to provide adequate care. The Director of Nursing (DON), V2, acknowledged the staffing shortages and the potential impact on resident care, including delayed treatments and unmet ADL needs. Medication administration was also affected, with several instances of medications being given late or not documented as administered. The facility's assessment tool and personnel policy outlined the required staffing levels, which were not met, leading to deficiencies in care delivery.
Medication Administration Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the prescriber, affecting six residents. The deficiency was observed during a medication administration observation where a Licensed Practical Nurse (LPN), who was a wound nurse pulled to work on the floor due to a shortage of nurses, administered medications to residents outside the prescribed time frame. For instance, medications for one resident were scheduled for 9 am but were given at 11:25 am, and another resident's medications scheduled for 8 am and 9 am were administered at 11:52 am. This delay in medication administration was not in accordance with the facility's policy, which requires medications to be given within one hour before or after the scheduled time. The report also highlighted that several medications were not signed off as administered in the Medication Administration Record (MAR) for multiple residents. For example, one resident's MAR showed that medications scheduled at 9 pm were not signed as given, and another resident's MAR indicated that medications scheduled at 4 pm and 9 pm were not documented as administered. The Director of Nursing (DON) confirmed that medications should be given according to the physician's order and documented immediately after administration, as per standard nursing practice. The facility's medication administration policy emphasizes the 'Five Rights' of medication administration: right resident, right drug, right dose, right route, and right time. However, the observations and record reviews revealed that these standards were not consistently met, leading to late administration and lack of documentation. This failure to adhere to prescribed medication schedules and documentation protocols constitutes a significant deficiency in the facility's pharmaceutical services.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, affecting one of the five residents reviewed for abuse. On the day of the incident, a resident in a wheelchair bumped into another resident's wheelchair in the dining room. This led to the second resident hitting the first resident in the back. The incident was witnessed by a Certified Nursing Assistant (CNA) who separated the residents and reported the event. The resident who was hit could not recall the incident when asked later, and the facility's Social Service Director was on vacation at the time of the incident. The facility's staff, including the Assistant Director of Nursing (ADON) and the Nurse Manager, were informed of the incident, and it was documented in the facility's final incident report and the police report as a simple battery. The facility's abuse policy affirms the right of residents to be free from abuse, yet the incident occurred, indicating a failure to uphold this policy. The staff involved acknowledged that hitting is a form of physical abuse, but the report does not detail any immediate interventions or preventive measures taken at the time of the incident.
Delayed Incontinence Care for Resident
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, identified as R9, who required assistance with toileting. R9, who has a medical history including hemiplegia, diabetes, and frequent incontinence, reported waiting for two hours to be changed after a bowel movement. The resident expressed that this delay in care was a regular occurrence, often waiting two to three hours for assistance. During an observation, R9 was found with a soiled incontinence brief, and care was provided by a CNA only after the surveyor's presence. The CNA, identified as V7, acknowledged the delay, explaining that she was prioritizing other tasks such as assisting fall-risk residents and conducting dining observations, which took precedence over R9's incontinence care. The CNA admitted that this was the first time R9 received incontinence care during the shift, which began at 7 am. The Director of Nursing confirmed that the facility's policy requires rounding every two hours to ensure residents are clean and dry, but this was not adhered to in R9's case.
Failure to Perform Timely Criminal Background Checks for New Residents
Penalty
Summary
The facility failed to follow its abuse policy by not performing criminal background checks for new residents within 24 hours of admission. This deficiency affected four residents (R198, R199, R200, and R202) and had the potential to affect all 192 residents in the facility. The Admissions Director (V13) admitted that criminal background checks were not conducted on weekends, leading to delays beyond the 24-hour requirement. The purpose of these checks is to ensure the safety of residents and staff by identifying any potentially dangerous individuals in the facility. During the survey, it was confirmed that R198, R199, R200, and R202 had their criminal background checks initiated more than 24 hours after their admission dates. For instance, R198 was admitted on 4/27/24, but the background check was not initiated until 4/29/24. Similarly, R202 was admitted on 4/20/24, but the background check was not initiated until 4/24/24. These delays were acknowledged by V13 and confirmed through record reviews. The facility's policy titled 'Abuse Prevention and Reporting' mandates that criminal background checks be requested within 24 hours of a new resident's admission. The Administrator (V1) and the Regional VP of Operations (V3) both emphasized the importance of these checks for ensuring that residents are free from abuse and that no dangerous individuals are admitted to the facility. Despite this policy, the facility failed to comply, leading to the identified deficiency.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to label and store biologicals in accordance with pharmaceutical recommendations, maintain sanitary conditions for medication storage, discard expired medications, maintain appropriate storage temperatures, and account for and store narcotics safely. This deficiency affected 22 residents and had the potential to affect all residents receiving medications from the first, second, and third-floor medication carts. Specific observations included the absence of a thermometer in the medication storage fridge, unsecured controlled substances, and medications stored without proper labeling or beyond their expiration dates. Surveyors observed multiple instances where medications were not stored according to the manufacturer's guidelines. For example, insulin and ophthalmic solutions were found unrefrigerated despite instructions to refrigerate them. Additionally, several medications were found opened without an open date, and expired medications were not discarded. Loose pills were also found in medication cart drawers, and some controlled substances were not stored behind two locks as required. During narcotic reconciliation, discrepancies were found in the controlled drug administration records, with missing documentation and unaccounted-for tablets. Staff interviews revealed a lack of adherence to proper procedures for documenting and storing medications, including controlled substances. The facility's policies on medication storage and controlled substances were not followed, leading to these deficiencies in medication management and storage practices.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to ensure proper labeling, dating, and sealing of food items in the kitchen, as well as discarding expired food items. During a tour of the kitchen, the surveyor observed multiple instances of improperly stored food, including undated hamburgers, hotdogs, sliced ham, green gelatin, watermelon, and custard. Additionally, sandwiches, pudding, cottage cheese, and tuna sandwiches were found without proper dates. The walk-in cooler and freezer temperature logs were incomplete, and personal food items belonging to staff were found in the kitchen storage areas. The sanitation buckets were found with inadequate sanitation solution, and the test strips used to check the sanitation levels were not properly stored or verified for expiration. Furthermore, the dietary staff failed to follow proper hand hygiene and glove use protocols, leading to potential contamination of food items during preparation and serving. The surveyor observed a dietary aide using a piece of plastic wrap hanging from a pan to clean a probe thermometer between temperature checks of different food items, which is against the facility's policy for cleaning thermometers. Additionally, a dietary cook was seen handling various food items and kitchen equipment without changing gloves or washing hands, which could lead to cross-contamination. The dietary manager acknowledged the importance of following safe practices in the kitchen to avoid foodborne illnesses and maintain infection control but admitted that the staff did not consistently adhere to these practices. The facility's documentation and policies emphasize the importance of proper food storage, labeling, and sanitation practices to ensure food safety and prevent contamination. However, the observations made by the surveyor indicate that these policies were not being followed, putting the health and safety of the 185 residents receiving an oral diet at risk. The dietary manager confirmed that staff should be recording cooler and freezer temperatures twice a day, discarding expired foods immediately, and storing personal food items in designated areas. The facility's failure to adhere to these guidelines and procedures led to the identified deficiencies in the kitchen operations.
Failure to Remove Lint from Dryer Compartment
Penalty
Summary
The facility failed to ensure there was no accumulation of lint at the bottom of the lint compartment in dryer #1, which could pose a fire hazard. During an inspection, the Housekeeping Director opened the lint compartment and stated that the lint screen is cleaned daily. However, upon further inspection, there was an accumulation of lint at the bottom of the dryer. The Housekeeping Director indicated that maintenance is responsible for that area. The Laundry staff confirmed that the accumulation of lint could catch fire and mentioned that maintenance checks the washer and dryer once a week. The Maintenance Director also acknowledged that the lint accumulation was a fire hazard. The job descriptions for both the Laundry Aide and Maintenance Director include responsibilities for ensuring the safety and cleanliness of the laundry equipment. The Laundry Aide's job description specifies the removal of lint from equipment and maintaining a hazard-free work area. The Maintenance Director's job description includes supervising safety and fire protection programs and ensuring equipment is maintained for a safe environment. Additionally, the facility's laundry inspection guidelines require daily removal of accumulated lint from the lint compartment and tops of the units. The failure to adhere to these guidelines and job responsibilities led to the identified deficiency.
Incorrect Mattress Settings for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to set the low air loss mattress at the correct weight settings for five residents, all of whom were at risk for or had existing pressure ulcers. For instance, one resident, who weighed 93.6 pounds, had their mattress set at 180 pounds. This resident had a stage 3 pressure ulcer and was at high risk for developing further pressure ulcers, as indicated by a Braden scale score of 12. Another resident, weighing 159.2 pounds, had their mattress set at 350 pounds. This resident also had a stage 3 pressure ulcer and was at risk for developing additional pressure ulcers, with a Braden scale score of 15. Both residents' care plans indicated the need for pressure-reducing devices for their beds, but the incorrect mattress settings were observed during the surveyor's visit. The facility's documentation and the manufacturer's manual both specify that the mattress settings should match the resident's weight to effectively reduce pressure and aid in the prevention and healing of pressure ulcers. However, the facility did not adhere to these guidelines, leading to the deficiency. The wound care nurse confirmed that the mattress settings should match the resident's weight to prevent and heal pressure ulcers. The facility's policy on pressure ulcer prevention also supports the use of specialty mattresses as clinically appropriate, but this was not followed in these cases.
Failure to Ensure Proper Respiratory Care
Penalty
Summary
The facility failed to ensure proper respiratory care for four residents, as observed by surveyors. For one resident, the nebulizer mask was not secured in a bag when not in use, which was confirmed by a Licensed Practical Nurse (LPN) who stated that the mask should be covered for sanitation purposes. Additionally, three residents had oxygen tubing that was not dated, contrary to the facility's policy. One resident's oxygen tubing was observed without a date on two separate occasions, and another resident's nasal cannula was found to be undated upon inspection by an LPN. The third resident's oxygen tubing was labeled with a date from two years prior, and the resident stated that the tubing is changed every couple of weeks, which contradicts the facility's policy of weekly changes. The residents involved had various diagnoses including Chronic Obstructive Pulmonary Disease (COPD), respiratory failure, and other conditions requiring respiratory support. The facility's policy mandates that nasal cannulas and other respiratory equipment be dated and changed regularly to minimize infection risk. However, the observations and staff interviews revealed that these protocols were not consistently followed, leading to potential risks for the residents' health and safety.
Improper Garbage Disposal
Penalty
Summary
The facility failed to ensure that the dumpsters were closed and free from overflowing trash, which has the potential to affect all 192 residents. On 4/28/2024, the surveyor, along with the Housekeeping Director, observed one dumpster lid open and another unable to close due to overflowing trash and boxes hanging outside. The Housekeeping Director confirmed that the lids should remain closed for rodent and animal control and that it is their responsibility, along with the Maintenance Director, to check the dumpster area. The facility's guidelines and procedures, dated 2020, require that outdoor trash receptacles be kept covered and the surrounding area kept free of litter. An in-service meeting on the same day reiterated the importance of keeping dumpster lids closed and breaking down boxes.
Failure to Perform Hand Hygiene During Meal Tray Pass
Penalty
Summary
The facility failed to ensure staff appropriately performed hand hygiene between residents during meal tray pass, leading to the potential spread of infectious microorganisms. On multiple occasions, staff members, including CNAs and dietary aides, were observed not using alcohol-based hand sanitizer or washing their hands between handling meal trays and interacting with different residents. This deficiency was noted during lunch tray distribution in the dining room and individual resident rooms, affecting nine residents in total. Staff members admitted to not consistently performing hand hygiene, citing forgetfulness as a reason for non-compliance. Specific instances included a dietary aide and CNAs passing meal trays to residents without performing hand hygiene before or after each interaction. For example, one CNA was observed delivering meal trays to several residents consecutively without sanitizing their hands in between. Another CNA admitted to repositioning a resident and adjusting their table without performing hand hygiene before moving on to serve another resident. These actions were observed and confirmed through staff interviews, where it was acknowledged that proper hand hygiene protocols were not followed. The residents affected by this deficiency had various medical conditions, including diabetes, chronic obstructive pulmonary disease, hypertension, and cognitive impairments. The facility's infection preventionist confirmed that staff should perform hand hygiene before and after patient contact to reduce contamination and the spread of germs. The facility's hand hygiene policy, dated 1/10/18, emphasizes the importance of hand hygiene as the single most important precaution to prevent infection transmission. Despite this policy, staff failed to adhere to the guidelines, resulting in the observed deficiencies.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that the call light was accessible for one resident (R18) who was reviewed for call lights. On 04/28/24 at 11:59am, R18 was observed lying in bed with the call light on the floor under the bed and out of reach. R18's medical history includes unspecified osteoarthritis, unspecified dementia, anemia, type 2 diabetes mellitus, chronic kidney disease, pressure ulcer of the sacral region unstageable, pressure-induced deep tissue damage of the right heel, and a stage 4 pressure ulcer at another site. R18's cognitive skills for daily decision-making are moderately impaired, and the resident has short and long-term memory problems, making it crucial for the call light to be within reach for assistance. V21, an LPN, acknowledged the call light was on the floor and out of reach, and subsequently clipped it to R18's bed sheet to make it accessible. R18's family member confirmed that R18 needs help with everything and requires the call light for assistance. The Assistant Director of Nursing (ADON) stated that call lights should be within the resident's reach to call for assistance. R18's care plan also specifies that the call light should be within reach to prevent falls and injuries. The facility's policy and residents' rights documents support the requirement for call lights to be accessible to residents at all times.
Failure to Assist Residents with Shaving
Penalty
Summary
The facility failed to ensure that residents who require assistance with activities of daily living (ADLs) received the necessary help, specifically with shaving facial hair. This deficiency affected three residents out of a sample of 88. On multiple occasions, residents R189 and R40 were observed with facial hair and expressed that they were not offered assistance with shaving. Both residents were cognitively intact and had care plans indicating they required assistance with personal hygiene, including shaving. Despite this, the staff did not offer or provide the necessary assistance, leading to discomfort and irritation for the residents due to unshaved facial hair. Resident R7, who has a severely impaired cognitive status, also reported not receiving assistance with shaving despite requesting it from the staff. R7's care plan and Minimum Data Set (MDS) indicated a need for setup or clean-up assistance with personal hygiene, including shaving. However, the staff failed to provide this assistance, leaving R7 with unshaved facial hair. The Certified Nursing Assistant (CNA) job description and facility policies clearly state that CNAs are responsible for assisting residents with shaving as part of their personal hygiene care. Interviews with staff members, including the Assistant Director of Nursing (ADON) and CNAs, confirmed that CNAs are responsible for shaving residents' facial hair upon request. Despite this, the staff did not fulfill their duties, resulting in the residents' unmet needs for personal hygiene. The facility's failure to adhere to its policies and provide necessary ADL assistance compromised the residents' comfort and dignity.
Failure to Apply Adaptive Device for Resident with Contracted Hand
Penalty
Summary
The facility failed to ensure that an adaptive device (splint/palm grip) was in place for a resident with a contracted hand. On multiple occasions, the resident was observed without the splint/palm grip in either hand, despite having a physician's order for its use to prevent further contracture. The splint/palm grip was found on the resident's bedside dresser instead of being applied as required. A Licensed Practical Nurse (LPN) confirmed the order and placed the device in the resident's hand upon noticing the oversight. The resident's medical history includes unspecified osteoarthritis, dementia, anemia, type 2 diabetes mellitus, chronic kidney disease, and multiple pressure ulcers, indicating a high level of care needs and vulnerability to further complications from contractures. The resident's care plan and medication administration record both documented the necessity of the splint/palm grip to be applied daily. The restorative nurse confirmed that the device should be on the resident from 7:00 am to 3:00 pm every day. Additionally, a family member reported that the resident had caused a wound by digging her nails into her contracted hand, further emphasizing the importance of the splint/palm grip. The facility's policies and job descriptions also support the requirement for maintaining such devices to prevent further physical decline, yet these were not adhered to in this instance.
Failure to Log Refrigerator Temperatures
Penalty
Summary
The facility failed to properly log personal refrigerator temperatures for two residents, R22 and R87, who had personal refrigerators in their rooms. Observations revealed that the temperature logs for both residents' refrigerators had multiple missing entries throughout April 2024. Specifically, the logs for R87's refrigerator were missing entries on 04/02/24, 04/04/24, 04/07/24, 04/09/24, 04/11/24, 04/14/24, 04/17/24, 04/18/24, 04/21/24, 04/23/24, and 04/25/24. Similarly, R22's refrigerator temperature logs were missing entries on the same dates, plus an additional missing entry on 04/27/24. Both refrigerators were observed to have a temperature of 40 degrees Fahrenheit at the time of inspection, and R22's refrigerator contained various food items including sliced lunch meat and fruits. Interviews with staff revealed confusion and inconsistency regarding who was responsible for checking and recording the refrigerator temperatures. The housekeeper, V33, was unsure of their responsibility, while the ADON/LPN/IP, V19, stated that housekeeping staff were responsible. A CNA, V34, believed the maintenance department was responsible. The Housekeeping Director, V16, stated that they were checking the temperatures on certain days of the week but acknowledged that the task had not been formally reassigned under the new administration. The facility's policy indicated that the housekeeper should log the temperature daily, but this was not consistently followed, leading to the observed deficiencies.
Failure to Post Accurate Daily Nursing Staffing Information
Penalty
Summary
The facility failed to post the daily nursing staffing information accurately and consistently, affecting all 192 residents. On 4/28/24, the surveyor observed that the posted staffing information was dated 1/25/24, indicating it had not been updated for over three months. On 4/30/24, the surveyor noted that the staffing information posted was dated 4/29/24, and the current day's staffing information had not been posted. The receptionist, who is responsible for posting the daily staffing, admitted to not being sure why the information was outdated and committed to updating it daily moving forward. Additionally, the posted document on 4/30/24 showed an incorrect census and lacked specific unit details, further indicating inaccuracies in the staffing information provided to residents and staff.
Failure to Implement Individualized Fall Prevention Interventions
Penalty
Summary
The facility failed to develop and implement individualized fall prevention interventions for a resident who experienced multiple falls within a short period. The resident, who was cognitively intact with a BIMS score of 14, fell four times in 26 days, including two falls on the same day. The resident sustained fractures of the sacral spine and coccyx during one of these falls. Despite the resident's repeated falls and complaints of not receiving timely assistance to prevent these incidents, the facility's Interdisciplinary Team (IDT) primarily focused on medical responses rather than implementing effective fall prevention strategies. The resident's medical record documented several falls, with the IDT identifying root causes such as increased confusion, poor insight on functional ability, and altered mental status. However, the interventions suggested by the IDT were largely medical responses, such as sending the resident to the emergency room or administering medications, rather than proactive fall prevention measures. The resident's care plan did not document any specific fall interventions for the incidents on 3/5/2024 or 3/12/2024, indicating a lack of individualized and effective fall prevention strategies.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide adequate ADL care for a dependent resident (R3) who required assistance with bladder and bowel incontinence. On 4/12/2024, R3 was observed with a saturated brief containing dark-colored urine and dark brown stool, indicating that incontinence care had not been provided in a timely manner. The call light was not within reach, and the resident was unable to answer questions. The CNA assigned to R3 was on break, and another CNA admitted to not realizing R3 was assigned to them, resulting in R3 not being changed until the afternoon. The Assistant Director of Nursing (ADON) confirmed that residents should be checked every two hours for incontinence care, and failure to do so could lead to skin breakdown. The Wound Care Coordinator also noted that prolonged exposure to soiled briefs could result in moisture-associated skin damage and pressure ulcers. R3's medical record indicated severe cognitive impairment and complete dependence on staff for toileting hygiene. The care plan specified that incontinence care should be provided every 2-3 hours and as needed. The facility's incontinence care policy also required periodic checks every two hours. Despite these guidelines, the facility did not ensure that R3 received timely incontinence care, as evidenced by the observations and staff interviews. This failure to adhere to the care plan and policy resulted in R3 being left in a soiled brief for an extended period, posing a risk for skin breakdown and other complications.
Failure to Properly Assess and Document Wound Care
Penalty
Summary
The facility failed to properly assess and obtain a physician's order for a newly identified skin alteration for a resident (R2). R2, an elderly resident with multiple diagnoses including cerebral infarction, end-stage renal disease, type 2 diabetes, peripheral vascular disease, and idiopathic aseptic necrosis of both feet, was admitted to the facility on 2/24/2022. On 4/12/2024, the Assistant Director of Nursing (ADON) was informed by an LPN that R2 had a serious wound that required hospital attention. The initial assessment by an agency LPN identified the wound as a skin tear, but a head-to-toe assessment was not completed. The wound was later found to be more severe than initially documented, indicating a failure in proper wound assessment and documentation by the initial nurse (V8). The CNA who first noticed the wound reported it to the LPN, who then notified the physician and obtained an order for wound care, but did not document a detailed wound assessment or obtain a specific dressing order for the right hip wound. The wound was later assessed by another LPN (V11) who found it to be an unstageable pressure wound with significant necrosis, requiring specific treatment orders from the primary physician. However, no treatment order for the dressing was found in the physician's orders for the relevant period, indicating a lapse in proper documentation and follow-up care.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| California Terrace | 2.4 mi | ★★★★★ | 25 | 0 |
| Archer Heights Healthcare | 3 mi | ★★★★★ | 5 | 0 |
| Aspyre Of Bronzeville | 3.1 mi | ★★★★★ | 14 | 0 |
| Little Village Nrsg & Rhb Ctr | 3.4 mi | ★★★★★ | 6 | 0 |
| Kensington Place Nrsg & Rehab | 3.6 mi | ★★★★★ | 4 | 0 |
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