Aperion Care International
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 4815 South Western Ave, Chicago, Illinois 60609
- CMS Provider Number
- 146001
- Inspections on file
- 66
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Aperion Care International during CMS and state inspections, most recent first.
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.
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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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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