Aperion Care Lakeshore
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 7200 North Sheridan Road, Chicago, Illinois 60626
- CMS Provider Number
- 145244
- Inspections on file
- 57
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 6 (1 serious)
Citation history
Health deficiencies cited at Aperion Care Lakeshore during CMS and state inspections, most recent first.
A resident with hemiplegia, impaired mobility, incontinence, and moderate cognitive impairment, who was care planned as totally dependent for toileting hygiene and to be checked and changed every 2–3 hours and PRN, was not changed for an extended period. Documentation showed only one toileting hygiene entry during the night and none for the day shift, the resident reported not being changed since the prior evening, and observation confirmed a urine-filled brief late the following morning. An LPN acknowledged the brief had not been changed that shift, a CNA stated residents are supposed to be checked at least every two hours, and the DON stated residents should be changed at least twice per shift and more often as needed, demonstrating a failure to follow the resident’s care plan and facility incontinence policy.
A resident with schizophrenia, anxiety, gait abnormalities, and a history of exit-seeking repeatedly eloped after staff failed to consistently identify and manage elopement risk. Despite an initial assessment labeling the resident as an elopement risk and an order for a wander guard, subsequent assessments incorrectly documented no elopement risk, exit-seeking episodes were not always followed by reassessment or care plan updates, and nursing staff documented that the wander guard was not in place over multiple days without correcting or reporting it. On one occasion, an LPN medicated the resident with Haldol after an attempted elopement but did not escalate the behavior; the resident later left the building and returned from the hospital with open areas on both feet. After a period on a locked unit without elopements, the resident was moved to an unsecured unit where residents knew the elevator code, had no wander guard in place, and was allowed by an LPN to leave the floor unsupervised to use vending machines. A receptionist, unaware the individual was a resident or an elopement risk, buzzed him out the front door, and the resident was later found at a hospital with a head injury and oral trauma. Staff interviews confirmed widespread lack of awareness of which residents were elopement risks, inconsistent use and monitoring of wander guards, and unrestricted resident access to elevator codes and the front exit.
Multiple residents were exposed to and bitten by bedbugs, leading to room relocations and discomfort. Staff interviews revealed confusion about pest control responsibilities, and observations showed untreated, cluttered rooms with bedbug activity confirmed by pest control reports. The facility's lack of clear communication and delayed treatment resulted in prolonged exposure for residents.
A resident with a history of aggressive behavior and severe mental illness entered a lounge area in an agitated state and made forceful contact with another resident, causing a fall and resulting in a fractured orbital wall. Despite care plans addressing both residents' risks, the facility failed to prevent the incident, and staff confirmed the aggressive contact led to the injury.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with multiple risk factors developed a large, unstageable pressure ulcer after staff failed to complete accurate skin assessments, maintain physician-ordered wound dressings, and document or implement appropriate interventions. Nursing documentation was inconsistent, and direct observation confirmed the wound was left uncovered, contrary to orders and facility policy.
A resident with severe cognitive impairment and a history of falls was not consistently supervised or provided with required fall prevention interventions, such as non-skid footwear and accessible call lights. Despite being identified as a fall risk, the resident experienced multiple falls, including one resulting in a head laceration requiring sutures. Staff interviews and documentation revealed lapses in supervision, inconsistent implementation of care plan interventions, and inaccurate fall risk assessments.
A resident with a history of falls, dementia, and impaired mobility was not accurately assessed for fall risk, despite documented needs for supervision and assistance. The fall risk assessment incorrectly indicated no risk, even though the resident required help with walking and had experienced a recent fall resulting in injury. Staff interviews and facility records confirmed the assessment was not completed properly, leading to a lack of appropriate fall prevention interventions.
A resident with a history of falls, dementia, and impaired cognition was not consistently provided with required fall prevention interventions, such as non-skid footwear and adequate supervision, as outlined in the care plan. Multiple falls occurred, and staff interviews revealed lapses in monitoring and inconsistent application of care plan measures, including the resident being found barefoot and unable to access or use the call light.
A resident with severe cognitive impairment and a history of falls was not assessed by PT in a timely manner after a fall, despite recommendations and orders from the IDT and nursing staff. The PT evaluation occurred several days after the incident, during which the resident continued to display mobility and safety concerns. Facility staff acknowledged the delay and that it did not meet policy expectations.
A resident with failure to thrive and dysphagia did not receive the prescribed pureed diet with required supplements, instead being served a mechanical soft meal without whole milk, ice cream, or pudding. Staff confirmed the meal ticket and tray did not match the physician's orders, and facility policy requiring compliance with diet orders was not followed.
The facility did not conduct a thorough investigation or determine the root cause of an altercation between two residents, resulting in conflicting accounts about whether the incident was accidental or intentional. One resident, who was cognitively intact, reported being repeatedly punched and injured, while staff and documentation provided inconsistent descriptions. The facility's final report concluded the event was accidental without fully reconciling these differences or following abuse prevention policy requirements.
Two residents were involved in a physical altercation in a common area, resulting in one resident sustaining a large bruise, a bump on the head, and pain after being struck multiple times by another agitated resident with a psychiatric history. Staff and medical records confirmed the incident, and the facility's abuse prevention policy was not followed.
The facility did not update or revise care plans for two residents after significant events, including an abuse incident and changes in community access needs. One resident's care plan was not updated to address abuse risk after an altercation, and both residents had expired or outdated care plan goals for community access and abuse/neglect. Staff confirmed that care plans were not revised as required following these events.
A resident with severe morbid obesity and osteoarthritis fell out of bed and sustained a right femur fracture due to the facility's failure to maintain safety precautions. The resident required maximum assistance with bed mobility and was totally dependent on staff for ADL care. A CNA observed the resident sleeping near the edge of the bed but did not reposition them or check for incontinence. Later, the resident fell, claiming the CNA pushed them, which the CNA denied. The facility's failure to follow the care plan and provide adequate supervision contributed to the fall.
The facility failed to provide bedtime snacks to residents who wanted to eat outside of scheduled meal times, affecting all 235 residents on oral diets. Observations showed that snacks were scarce, with one resident keeping pizza in bed to eat when hungry. The Food Service Director confirmed snacks were mainly for those on a specific list, and documentation showed a 14.5-hour gap between dinner and breakfast, exceeding policy limits.
The facility failed to ensure proper medication management and storage, affecting multiple residents. Loose pills were found in medication carts, and several medications lacked open and expiration dates or were expired. The medication refrigerator was improperly maintained, with temperatures exceeding the recommended range, and there was confusion about temperature log documentation. These deficiencies indicate a failure to adhere to the facility's medication storage policy.
The facility failed to manage personal refrigerators for residents, resulting in expired food and inadequate temperature monitoring. Two residents with medical conditions had expired milk in their refrigerators, which lacked thermometers and temperature logs. Housekeeping staff did not maintain cleanliness or perform required checks, and there was confusion about responsibility for monitoring. This non-compliance with facility policy potentially affected all residents with personal refrigerators.
A facility failed to ensure staff wore appropriate PPE while providing care to a resident with Enhanced Barrier Precautions (EBP). A CNA was observed providing perineal care without PPE, and the Infection Preventionist was unaware of the resident's need for EBP. This oversight could affect all residents on the second floor.
The facility failed to cover the catheter drainage bags of two residents, compromising their dignity. One resident was observed in bed with an uncovered catheter bag, while another was in a wheelchair with a similar issue. Both residents have cognitive impairments and specific medical conditions. Staff acknowledged the importance of privacy bags for dignity, but the facility did not adhere to this practice.
The facility failed to ensure call lights were within reach for two residents, one with Cerebral Palsy and another with Cerebral Infarction. Despite care plans encouraging the use of call devices, the call lights were inaccessible, violating the facility's policy. Staff confirmed the deficiency, acknowledging the need for accessible call systems.
The facility failed to obtain and document Advanced Directives for two residents, one with cognitive impairments and another cognitively intact, upon their admission. Despite having medical conditions requiring clear directives, their records lacked physician orders for code status, which should have been documented by the admitting nurse. This oversight was identified during a survey, highlighting a lapse in following the facility's policy on Advanced Directives.
A resident was found with old food and a meal tray in her bed, which she consumed intermittently due to a lack of snacks. The CNA assigned to her placed the meal tray on the bed due to a shortage of staff and the absence of a bedside table. The LPN and Housekeeping Director acknowledged the unsanitary conditions and the need for proper food removal and availability of bedside tables.
A facility failed to complete a new PASARR for a resident with multiple mental health diagnoses upon admission. The resident, who was receiving medication for Bipolar Disorder, did not have a Level 1 or Level 2 PASARR in the facility's system. The oversight occurred because the resident was admitted before the facility started using the Maximus system for monitoring PASARR screenings.
A resident, who is cognitively intact and dependent on staff for showers due to multiple health conditions, did not receive her scheduled showers for over a month. Despite having a care plan for showers twice a week, documentation showed only one shower was given in January, with inadequate bed baths provided instead. The facility's ADON confirmed the expectation for scheduled showers, but the lack of documentation for missed showers indicates non-compliance with the care plan.
A resident at high risk for pressure ulcers was found lying on a low air loss mattress with multiple linens, contrary to guidelines. Staff confirmed the resident should have had only a flat sheet and a mattress pad or incontinence brief. This improper setup compromised the mattress's effectiveness in preventing and treating pressure ulcers.
The facility failed to supervise two residents at risk for falls in the dining room, despite their high fall risk scores and cognitive impairments. Staff present did not provide continuous supervision, and there was no formal policy on supervision, only an expectation of frequent monitoring. This lack of supervision violated the residents' rights to safety.
A resident with asthma and heart disease did not have their nebulizer mask changed weekly as required by facility policy. The mask, dated from June, was observed in use, and staff interviews confirmed the oversight. The facility's guidelines emphasize weekly changes to prevent infection, but this was not followed.
A facility failed to maintain accurate narcotic counts and documentation, affecting a resident receiving Tramadol. During a medication cart review, it was found that the shift change controlled substance inventory count sheet was missing, and there was a discrepancy in the narcotic count. An LPN admitted to administering a Tramadol tablet without signing the Controlled Drug Administration Record. The DON confirmed that facility policy requires accurate documentation and reporting of discrepancies.
A resident with a history of falls and multiple diagnoses, including Parkinson's and dementia, fell while attempting to pick up an item from the floor, resulting in cervical fractures. The resident's care plan included interventions like a sticky pad for the wheelchair and reminders to lock the wheelchair, but it was unclear if the wheelchair was locked at the time of the fall. Staff noted the resident's non-compliance with safety instructions, contributing to the incident.
The facility failed to maintain a pest-free environment, with roaches reported in several residents' rooms, affecting three residents directly and potentially impacting all 242 residents. Despite multiple complaints and documented infestations in various facility areas, the issue persisted, indicating a failure to adhere to the facility's pest control policy.
The facility failed to prevent residents from smoking indoors, posing a fire hazard. Two residents with mental health issues and nicotine dependence were observed smoking inside, despite policies requiring outdoor smoking and supervision. The facility's measures, such as searching visitor bags and testing residents, were insufficient to stop indoor smoking.
The facility did not conduct care plan meetings for three cognitively intact residents, as required. Clinical records lacked documentation of such meetings, and residents confirmed they were not informed or involved in care planning. Staff interviews revealed confusion and lack of coordination in scheduling and documenting these meetings, contrary to facility policy.
The facility failed to provide comprehensive bladder function assessments and care planning for residents with indwelling urinary catheters, and did not address a resident's urinalysis results, leading to untreated dysuria and burning upon urination for several weeks.
The facility failed to provide mail services to residents on Saturdays, affecting all 213 residents. Mail delivered on weekends is not sorted and distributed until Monday, and residents reported that their mail is sometimes opened when they receive it.
The facility failed to ensure adequate staffing, affecting all 213 residents. Frequent call-offs, especially on weekends, made it challenging for staff to complete their jobs. The facility was short-staffed on multiple occasions between October and December 2023. Additionally, maintenance issues were delayed until weekdays, leading to resident complaints.
The facility failed to properly label and date food items, store scoops correctly, follow manufacturer's guidelines for food storage, and sanitize cooking equipment as required. These deficiencies were observed during a kitchen tour and confirmed by the cook and food service director, potentially affecting all 209 residents.
The facility failed to ensure that dumpster lids were covered to prevent pests, insects, and rodents. During an observation, it was noted that two out of four dumpster lids were fully opened. Both the Former Food Service Manager and Housekeeping Director acknowledged that the lids should be shut to prevent rodents and garbage from flying outside. Despite these instructions, a surveyor observed two dumpster lids wide open later in the day. The facility's kitchen policy mandates that outdoor trash receptacles be kept covered and the surrounding area kept free of litter.
The facility failed to ensure medications were properly labeled when opened and did not remove discontinued medications from the medication cart. Several medications, including inhalers and insulin, were found opened and undated, and discontinued medications were not removed as required, affecting nine residents.
The facility failed to properly clean and disinfect multi-use devices between resident use, did not post required Enhanced Barrier Precaution signage, and did not ensure PPE was accessible and used when providing care to residents on Enhanced Barrier Precautions. These deficiencies were confirmed through observations and staff interviews.
The facility failed to document whether residents received influenza and pneumococcal immunizations and did not provide or document education on the benefits and side effects of these immunizations for several residents. Additionally, some residents were not assessed for eligibility and offered the immunizations as required by the facility's policy.
The facility failed to document COVID-19 immunization records and education for several residents, despite having a policy in place. The Assistant Director of Nursing admitted that the immunization tracker was not updated and that education was not documented in the electronic health records.
A resident with multiple medical conditions was observed with a half-filled urinary bag visible from the hallway, causing discomfort. An LPN and the DON acknowledged that urinary bags should be kept in privacy bags, as per facility policy, to avoid dignity issues.
The facility failed to ensure the call light was within reach for three residents, compromising their ability to call for assistance. One resident's call button did not light up when pressed, another did not know the location of the call light, and a third had the call light left on the floor by a CNA. The DON confirmed the expectation for call light accessibility and prompt reporting of defects.
The facility failed to update the PASARR Level II screening for a resident with Bipolar Disorder and other diagnoses after a significant change in mental health status, relying on an outdated OBRA screen from 1998. The Assistant Administrator admitted to not updating screenings for long-term residents, contrary to the facility's policy requiring annual and significant change updates.
The facility failed to initiate a new Level I PASARR screen for a resident with known mental illness, despite the resident's active diagnoses of anxiety, depression, and bipolar disease. The Assistant Administrator acknowledged that Level II PASARR screenings were not performed for residents admitted before the new PASARR system was implemented, and there was uncertainty about who was responsible for referring residents for Level II screenings if they developed psychiatric conditions after admission.
The facility failed to include Advance Directives in the care plans of three residents, despite having full code status orders. The Assistant Director of Social Services confirmed that all residents should have such care plans, but a review of the EHRs revealed the care plans were missing.
The facility failed to update a resident's care plan to reflect their Do Not Resuscitate (DNR) status as ordered by the physician, instead documenting the status as Full Code. Staff acknowledged the oversight, which could lead to inappropriate treatment against the resident's wishes.
The facility failed to provide adequate fingernail care for a dependent resident who requires assistance with ADLs. Despite the resident's request for nail care, the CNA responsible admitted it had been approximately four weeks since the nails were last cut. Observations revealed the resident's nails were overgrown, yellow, and dirty. The DON confirmed that staff are expected to perform ADL care as needed or requested, and it is unacceptable for residents' nails to be unkempt and dirty.
A resident with COPD was found lying flat in bed with labored breathing and without oxygen infusing. The nasal cannula tubing was dirty and not replaced as required, and the oxygen concentrator was set incorrectly and noted to be broken. The CNA admitted to removing the oxygen tubing for shaving and not replacing it properly, while the LPN confirmed the head of the bed should have been elevated and the tubing changed earlier.
Failure to Provide Timely Incontinence and Toileting Care
Penalty
Summary
The deficiency involves the facility’s failure to provide required assistance with activities of daily living, specifically toileting hygiene and incontinence care, for one resident. The resident had diagnoses including hemiplegia and hemiparesis, muscle disorders, hypertension, history of falling, and vitamin D deficiency, and had a Brief Interview of Mental Status score of 10, indicating moderate cognitive impairment. The resident’s MDS Section GG documented that toileting hygiene required a code of 01 (dependent), meaning staff must perform all of the effort. The resident’s care plan, initiated for bladder and bowel incontinence related to impaired mobility, directed staff to check and change the resident every 2–3 hours and as needed. Facility policy on incontinence care required incontinent residents to be checked periodically in accordance with assessed incontinent episodes or every two hours and to receive perineal and genital care after each episode. Record review showed a toileting hygiene task documented at 12:14 a.m. on a specific date, with no toileting hygiene time recorded for the 7:00 a.m.–3:00 p.m. shift that same day. Late in the morning, the resident reported not having been changed since 8:30 p.m. the previous evening. Observation shortly thereafter revealed the resident’s incontinence brief contained a dark yellow liquid substance in both the front and back. An LPN confirmed that the brief did not appear to have been changed during the current shift and appeared filled with urine. A CNA stated that residents are checked every two hours or more frequently for incontinence care, that the resident was not in her assignment, but that the resident should have been changed at least once that shift and more often if necessary. The DON stated residents should be changed at least twice a shift, at the beginning and end of the shift, and more frequently if necessary. These observations and interviews showed that the resident was not checked and changed in accordance with the care plan, facility policy, and stated practice.
Repeated Elopements Due to Failed Elopement Risk Management and Wander Guard Oversight
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and elopement prevention for a cognitively intact resident with schizophrenia, depression, anxiety, gait abnormalities, obesity, and hypertension, who had a documented history of exit-seeking and elopement risk. As early as 4/23/25, nursing notes documented that the resident attempted to leave the building and had to be redirected. On 6/21/25, the resident left through the front lobby door and was redirected back, prompting an elopement risk assessment that identified the resident as at risk and led to an elopement care plan and an order for an electronic monitoring device (wander guard) on 6/25/25. Despite this, subsequent elopement risk assessments dated 6/23/25 and 9/25/25, completed by a social worker, incorrectly documented that the resident was not at risk for elopement, which the social worker later acknowledged as clinical errors. Exit-seeking behavior on 9/28/25 was documented, but no new elopement assessment or care plan update was completed, and the resident remained on an unsecured floor where residents could freely access the elevator without a code. On 10/12/25, the resident eloped again. Earlier that day, the resident attempted to leave through the front door but was stopped and given Haldol 5 mg by the LPN, who did not report the exit-seeking behavior because the resident had not yet left the facility. Later, the resident could not be located, and a code pink was called; the resident ultimately presented to a hospital stating he had left the nursing facility because he was hearing voices. Hospital documentation indicated the facility nurse reported that the resident had tried to elope earlier and had been medicated. When the resident returned to the facility that evening, open areas were noted on the soles of both feet. Although there was a physician order from 6/25/25 through 10/31/25 to check the electronic monitoring device placement and functionality every shift, the LPN documented "N" (no device in place) for multiple days in October and admitted that the device was not on the resident, that this was not reported to administration or a supervisor, and that the absence of the device was not corrected even after the 10/12/25 elopement. On 2/6/26, the resident eloped a third time, this time from a different unit. The resident had previously been on a secure locked unit (3 North) from 10/15/25 to 1/8/26 without elopements, but after a hospital stay was readmitted on 1/16/26 to an unsecured unit (3 South) where residents knew the elevator code. On the morning of 2/6/26, the LPN on 3 South saw the resident at the elevator stating he was going to the first-floor vending machine, and allowed him to leave the floor unsupervised, not knowing he was an elopement risk and unaware of any wander guard order or device. The resident, who knew the elevator code, reached the first floor, where the receptionist—who did not know the resident was an elopement risk and did not recognize him as a resident—buzzed him out the front door, believing he was staff. The receptionist later stated that the front door wander guard alarm did not sound and that the resident did not have an electronic monitoring device in place. The resident was later found at the hospital after having run, tripped, and fallen, sustaining a closed head injury, chipped and missing teeth, and a lower lip laceration requiring sutures. Throughout these events, staff on multiple units and at the front desk did not consistently know which residents were elopement risks, elopement assessments were inaccurately completed, the care plan was not consistently updated after exit-seeking or elopement events, and the physician order for the electronic monitoring device was discontinued without documented rationale, contributing to the resident’s repeated elopements and injuries. The Immediate Jeopardy was determined to have begun on 10/12/25, when the resident eloped and returned with bilateral foot injuries, and continued through the subsequent elopement on 2/6/26, during which the resident sustained a head injury and oral trauma. The facility’s own interviews and records showed that staff failed to consistently implement and monitor the ordered electronic monitoring device, failed to reassess and accurately document elopement risk after each incident or exit-seeking behavior, and allowed the resident to access unsecured exits and elevator codes despite a known history of elopement. The administrator acknowledged that the resident’s first documented elopement on 6/21/25 was not reported to the state agency and that no incident report or police notification occurred because there was no injury. The DON later confirmed that if a wander guard order exists and the device is not in place, nursing staff are responsible for immediately obtaining and applying a device and notifying leadership, which did not occur in this case. These combined failures in assessment, care planning, communication, and monitoring led to repeated unsupervised departures of the resident from the facility and associated injuries.
Removal Plan
- Reassess all residents for elopement risk and monitor elopement risk assessments to ensure residents are reassessed when there is a change in status.
- Review all resident care plans and revise as needed; review care plans with each change to the elopement assessment.
- Review and update the elopement binder at the front desk and on the units to ensure all residents at risk for elopement with wander guard are listed, including new admissions and re-admissions; review and update the binder with changes in resident status to ensure accuracy.
- Retrain all staff on elopement procedures, including Code Pink procedure, signs of elopement, the elopement policy, and how to identify residents at risk for elopement; retrain staff returning from leave prior to returning to work.
- Conduct Code Pink drills on all shifts to monitor staff response and identify opportunities for additional training; continue Code Pink drills.
- Conduct an ad hoc QAPI meeting with the Medical Director to discuss elopement events and facility follow up.
- Review the elopement policy with the IDT team.
- Update the elevator key code and install a new keypad; instruct staff to know the elevator key code and not disclose it to residents; change the elevator code routinely and remind staff not to disclose the code to residents.
- Audit residents who utilize wander guard and ensure each has a corresponding order to check the device each shift on the MAR and a reminder in the EMR; implement a functionality log to monitor device function and monitor for compliance.
Failure to Maintain Bedbug-Free Environment
Penalty
Summary
The facility failed to maintain an environment free of bedbugs, as evidenced by multiple residents being exposed to and bitten by bedbugs in their rooms. Several residents reported being relocated due to bedbug infestations, with some stating that the problem had persisted for weeks. Observations revealed rooms with 'Do Not Enter' tape on the doors, significant clutter, and plastic bags, making it difficult to treat the affected areas. Interviews with staff indicated confusion regarding responsibility for pest control, with the Maintenance Director, Housekeeping Director, and Assistant Administrator each providing inconsistent information about the bedbug situation and treatment efforts. The pest control company’s service report confirmed the presence of both live and dead bedbugs in several rooms, including those recently vacated by affected residents. Record review showed that residents were moved from infested rooms on various dates, and pest control documentation listed multiple rooms as having bedbug activity. The facility’s pest control policy assigns responsibility to the Environmental Services Director and requires prompt reporting and regular pest control measures. However, interviews and observations indicated a lack of clear communication and coordination among staff, resulting in delays in addressing the infestation and leaving residents exposed to bedbugs for extended periods. The affected rooms were not promptly treated due to clutter and personal belongings, further contributing to the ongoing issue.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to prevent and protect a resident from physical abuse, resulting in a significant injury. One resident, who was cognitively intact and required supervision or assistance for mobility, was identified as being at risk for abuse and had a care plan in place to ensure safe care. Another resident, with a history of severe mental illness, psychotic disorder, and aggressive behaviors, had documented episodes of verbal and physical aggression, including multiple hospitalizations for aggressive behavior and acute psychosis. Despite these known risks, the aggressive resident was able to enter a lounge area where the other resident was present. On the day of the incident, staff accounts and interviews revealed that the aggressive resident entered the lounge in an agitated state and made forceful physical contact with the other resident, who was in the process of standing up from a chair. This contact caused the resident to fall to the floor, resulting in visible injuries including swelling, abrasions, and ultimately a diagnosis of a closed fracture of the orbital wall. Multiple staff members, including a housekeeper and the Social Service Director, witnessed or responded to the incident, confirming that the aggressive resident's actions directly led to the injury. The facility's own incident report categorized the event as resident abuse. The injured resident was subsequently transferred to the hospital, where further evaluation confirmed significant facial injuries. The facility's documentation and staff interviews indicated that the aggressive resident had a known history of unpredictable and aggressive behaviors, and that there were care plans in place addressing these risks. However, the measures in place were insufficient to prevent the incident, and the facility was unable to provide video evidence due to non-functioning cameras. The failure to adequately supervise and separate residents with known aggressive tendencies from vulnerable residents led to the occurrence of physical abuse and injury.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Prevent and Manage Pressure Ulcer Development
Penalty
Summary
The facility failed to prevent the development of a significant pressure ulcer in a resident, failed to ensure wound dressings were maintained as ordered, and did not complete accurate or timely skin assessments. The resident, who had diagnoses including failure to thrive, dysphagia, and major depressive disorder, was initially documented as having intact skin. However, within a week, an unstageable pressure ulcer measuring 25x10 cm developed on the resident's sacrum. Despite the presence of risk factors such as hypertension, anemia, poor appetite, bowel and urinary incontinence, and malnutrition, not all risk factors or potential interventions were documented or addressed in the facility's investigation report. Nursing documentation was inconsistent and incomplete, with a weekly skin assessment incorrectly stating the resident's skin was intact even after the pressure ulcer had developed. No further weekly skin observations were recorded after this incorrect entry. Staff interviews revealed uncertainty about when the wound was discovered and acknowledged that the required weekly skin assessments and documentation were not completed as expected. The wound care nurse and DON confirmed that the skin assessment documentation was inaccurate and that the wound should have been described and monitored. Direct observation showed that the resident's wound was not covered with a dressing as ordered by the physician, and staff confirmed that a dressing should have been present. The wound care nurse and other staff stated that if a dressing is missing, it should be reported and reapplied, but this did not occur. The facility's own pressure ulcer policy outlines regular skin inspections, timely repositioning, and the use of pressure-reducing devices, but these measures were not consistently implemented or documented for this resident.
Failure to Provide Adequate Supervision and Fall Prevention for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and accident prevention for a resident with a known history of falls, severe cognitive impairment, and multiple diagnoses including dementia, schizophrenia, anxiety disorder, and major depressive disorder. The resident was assessed as a fall risk and had a care plan that included interventions such as ensuring the use of non-skid footwear, frequent rounding, and supervision during mobility and transfers. Despite these documented interventions, the resident experienced multiple falls, including an unwitnessed fall that resulted in a laceration to the left eyebrow requiring sutures and hospitalization. Direct observations and interviews revealed that the resident was often found without non-skid footwear, and staff acknowledged that the resident frequently removed the socks intended to prevent falls. The resident's call light was not consistently accessible or understood by the resident, who was severely cognitively impaired and unable to reliably request assistance. Staff interviews indicated that supervision was not constant, with staff present at the nurse's station only 'most of the time,' and monitoring was often limited to visual checks from a distance. The resident's care plan interventions, such as supervision and use of non-skid footwear, were not consistently implemented or maintained. Documentation and staff statements also indicated that fall risk assessments were not always completed accurately, and there was a lack of individualized or enhanced supervision for this high-risk, impulsive resident. The facility's fall prevention policy required ongoing assessment and implementation of safety interventions, but these measures were not effectively carried out for this resident, resulting in a preventable injury. The deficiency was further supported by the facility's own policies and staff acknowledgments that interventions were not always in place or effective.
Failure to Accurately Complete Fall Risk Assessment
Penalty
Summary
The facility failed to accurately complete fall risk assessments for a resident with multiple diagnoses, including repeated falls, dementia, schizophrenia, anxiety disorder, and major depressive disorder. The resident's care plans, revised on several occasions, documented a history of falls, impaired safety awareness, wandering, and the need for supervision and assistance with mobility and activities of daily living. Despite these documented risks and functional deficits, the resident's Fall Risk Assessment dated 2/12/25 indicated that the resident was 'Not at Risk for Falls,' and described the resident as chair bound with gait and balance marked as not applicable. The Minimum Data Set (MDS) for the resident showed a BIMS score of 00, indicating severely impaired cognition, and documented that the resident required partial/moderate assistance to walk 10 feet. The resident experienced an unwitnessed fall on 4/7/25, resulting in an injury that required hospital evaluation and sutures. Observations on 4/20/25 found the resident attempting to stand without footwear and unable to identify the call light, further demonstrating cognitive and functional impairments. Interviews with facility staff, including the ADON, MDS Coordinator, and DON, confirmed that the fall risk assessment was not completed accurately and emphasized the importance of proper assessment for implementing appropriate interventions. Facility policies required fall risk assessments to be performed at admission, quarterly, after significant changes, and after any fall incident, with interventions tailored to identified risks. The failure to accurately assess the resident's fall risk led to a lack of appropriate interventions, as documented in the facility's policies and staff interviews. The deficiency was identified through record review, staff interviews, and direct observation of the resident's condition and environment.
Failure to Implement Fall Prevention Care Plan for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement a comprehensive care plan for a resident with a history of repeated falls, dementia, schizophrenia, anxiety disorder, and major depressive disorder. The resident was assessed as being at risk for falls and included in the elopement prevention program, with care plan interventions specifying the use of non-skid footwear, frequent rounding to ensure the resident was wearing nonskid socks, supervision during mobility and transfers, and assistance with walking. Despite these documented interventions, the resident experienced multiple falls, both witnessed and unwitnessed, and was observed barefoot with non-skid socks found under the bed rather than being worn. Staff interviews revealed inconsistent implementation of the care plan interventions. Several staff members acknowledged that the resident was a fall risk and should always have non-skid socks on, but also noted that the resident often removed the socks or refused to wear shoes. There was also inconsistency in staff awareness and monitoring, with some staff stating that the resident was checked every 15 minutes or that the room was positioned for better observation, while others admitted that supervision was not constant. The resident's call light was not accessible or understood by the resident, further limiting the ability to request assistance. Facility policies required the development and consistent implementation of individualized care plans and fall prevention measures, including proper footwear and supervision. However, the care plan interventions were not reliably carried out, as evidenced by the resident's repeated falls, lack of non-skid footwear at the time of observation, and staff statements indicating lapses in supervision and intervention. The failure to consistently implement the care plan directly affected the resident's safety and well-being.
Delay in Physical Therapy Assessment Following Fall
Penalty
Summary
A resident with a history of repeated falls, dementia, schizophrenia, anxiety disorder, and major depressive disorder was not assessed by Physical Therapy (PT) in a timely manner following a fall. The resident's care plan identified significant risks for falls and wandering, and documented the need for supervision and assistance with mobility and transfers. Despite these risks and multiple falls, including an unwitnessed fall resulting in injury, there was a delay in PT evaluation after the most recent incident. Following a fall on 4/7/25, the Interdisciplinary Team (IDT) recommended a PT evaluation for an assistive device on 4/8/25, and a formal order for PT evaluation and treatment was placed on 4/11/25. However, the PT assessment did not occur until 4/17/25, which was 10 days after the fall, 9 days after the IDT recommendation, and 6 days after the order was placed. During this period, the resident continued to display impaired cognition and mobility, as observed by the surveyor, including being barefoot and unable to use the call light appropriately. Interviews with facility staff, including the PT Director and DON, confirmed that PT should have been notified and completed the evaluation as soon as possible. Both acknowledged that the delay was not in accordance with facility expectations or policy, and that timely notification and assessment are necessary. Facility policies require prompt assessment and intervention following falls, and the delay in PT evaluation was not consistent with these standards.
Failure to Provide Diet as Ordered by Physician and Dietician
Penalty
Summary
A deficiency occurred when a resident with diagnoses including failure to thrive, dysphagia, and major depressive disorder did not receive a diet in accordance with physician orders and dietician recommendations. The resident, who was cognitively intact, had an active physician order for a general diet with pureed texture, thin liquids, super cereal at breakfast, whole milk with meals, ice cream at lunch and dinner, and pudding with meals. However, during a meal observation, the resident was served a mechanical soft diet with chicken, mashed potatoes, fruit, and lemonade, and did not receive the required whole milk, ice cream, or pudding. The dietary slip accompanying the tray listed a regular diet with mechanical soft texture and did not reflect the current physician-ordered diet or supplements. Interviews with facility staff, including a CNA, LPN, Dietary Manager, Registered Dietician, and DON, confirmed that the meal ticket and tray did not match the resident's current dietary orders. The Dietary Manager and DON acknowledged that the tray should have included the specified supplements and that the facility should be following the active physician orders. The facility's policy requires compliance with physician diet orders and coordination between nursing and dietary staff, but this process was not followed, resulting in the resident not receiving the prescribed diet.
Failure to Thoroughly Investigate Resident Altercation and Determine Root Cause
Penalty
Summary
The facility failed to conduct a thorough investigation and determine the root cause of an altercation between two residents, resulting in a deficiency related to abuse prevention and response. The incident involved one resident who was agitated in a common area and another resident who was exiting the elevator. During the encounter, the agitated resident made contact with the other resident's forehead, causing the latter to fall and sustain injuries, including redness and a bruise on the forehead. The injured resident reported being repeatedly punched in the head and expressed that the incident was not accidental, while staff and documentation provided conflicting accounts, with some suggesting the event was accidental. The facility's investigation was insufficient, as it did not reconcile the differing accounts from the residents and staff, nor did it adequately address the injured resident's statements that the altercation was intentional and involved multiple blows. The facility's administrator concluded the incident was accidental without substantiating this determination through a comprehensive review of all available evidence, including interviews and medical records. The facility's abuse prevention policy requires a thorough investigation of any alleged abuse, including interviews with all involved parties and review of pertinent documentation, which was not fully executed in this case. Additionally, the facility's documentation and staff interviews revealed inconsistencies regarding the nature and severity of the incident. The injured resident was alert and oriented, with an intact cognitive status, and clearly described the event as intentional. Despite this, the facility's final report characterized the incident as an accident, which was incongruent with the findings and the resident's account. The failure to conduct a complete and objective investigation had the potential to affect all residents in the facility.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in a physical altercation between them. One resident, who was alert and oriented with a BIMS score indicating intact cognition, reported being struck multiple times in the head by another resident who was agitated and had a history of schizophrenia, anxiety disorder, and altered mental status. The incident occurred in a common area near the elevator, where the agitated resident made contact with the other resident's forehead, causing him to fall and sustain a large bruise on the forehead, a bump on the back of the head, and pain rated at 2 out of 10. Witnesses confirmed the injured resident was found on the floor and appeared hurt, while the aggressor was described as frequently agitated and difficult to redirect. Staff interviews and medical record reviews confirmed the sequence of events, with the injured resident stating he was repeatedly punched in the head and that the aggressor appeared to be holding a silver object, which he thought might be a knife. The aggressor's behavior was described as delusional and agitated, and he was not redirectable following the incident. The facility's abuse prevention policy states that residents have the right to be free from abuse, defined as the willful infliction of injury or pain, which was not upheld in this case.
Failure to Revise Care Plans After Abuse Incident and Community Access Changes
Penalty
Summary
The facility failed to revise and update comprehensive care plans for two residents following significant events related to abuse and community access. For one resident, after an altercation with another resident that resulted in a large bruise on the forehead and a report of being repeatedly punched, the care plan was not updated to address the risk for abuse or to reflect the incident. The Director of Nursing confirmed that the care plan did not include any information about abuse, despite the resident having an intact cognitive status as determined by a BIMS score of 13. Additionally, the same resident's care plan for supervised community access had an expired goal target date and was not updated in a timely manner, as acknowledged by the Social Service Director. For another resident, the care plan included expired goal target dates for both community access and abuse/neglect, with the resident expressing concerns about being on restriction and disputing the medical justification for it. The Social Service Director confirmed that the care plan did not reflect the current need for supervised community access and that the target dates were not current. The facility's policy requires care plans to be reviewed and revised after each assessment and with any significant change, but this was not followed for these residents.
Failure to Maintain Safety Precautions Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure ongoing precautions were put into place and consistently maintained, resulting in a resident, R2, falling out of bed and sustaining a right femur fracture. R2, a 67-year-old resident with severe morbid obesity, bilateral primary osteoarthritis of the knee, and other medical conditions, was cognitively intact but required maximum assistance with bed mobility and was totally dependent on staff for ADL incontinence care and personal hygiene assistance. Despite these needs, the facility did not adequately follow R2's care plan, which included ensuring R2 was centered in bed while sleeping and checking and changing R2 three times per shift for incontinence. On the day of the incident, a Certified Nurse Assistant (CNA), V5, observed R2 sleeping in a twisted position near the edge of the bed but did not reposition R2 to the center of the bed or check for incontinence to avoid waking R2. Later, V5 found R2's leg hanging out of the bed and, before assistance could be provided, R2 fell to the floor. R2 reported that V5 pushed her over while trying to remove linen, despite R2's protest that she was at the edge of the bed. However, V5 denied pushing R2 and stated that R2 was already hanging off the bed when she arrived. The facility's failure to adhere to R2's care plan and provide adequate supervision and assistance contributed to the fall. The Assistant Director of Nursing and other staff acknowledged that if V5 had repositioned R2 and provided incontinence care as per the care plan, the fall might have been preventable. The incident was reported to the Illinois Department of Public Health, and an investigation was conducted, but the abuse allegation was not substantiated.
Failure to Provide Bedtime Snacks to Residents
Penalty
Summary
The facility failed to provide bedtime snacks to residents who wished to eat outside of scheduled meal service times, potentially affecting all 235 residents receiving oral diets. Observations and interviews revealed that residents were not receiving adequate snacks, with one resident keeping a slice of pizza in her bed to eat when hungry between meals. Another resident reported that snacks were scarce and had to be fought for, with only a small tray of snacks being sent up, requiring residents to be on a specific snack list to receive them. The meals provided were described as insufficient, particularly breakfast, and were often late, exacerbating hunger among residents, especially those on psychiatric medication. The Food Service Director confirmed that snacks were primarily prepared for residents on a snack list, which included diabetics and those who had requested snacks, with only a few extra snacks sent for others. The facility's documentation showed a 14.5-hour gap between dinner and breakfast, exceeding the policy limit of 14 hours unless a substantial evening snack is provided. The facility's policy also required that a bedtime snack be offered to all residents, which was not being adhered to, as evidenced by the limited number of residents on the snack list compared to the total number of residents with oral diets.
Medication Management and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper medication management and storage, affecting multiple residents across different floors. On the third floor, a medication cart was found with loose pills of various colors and shapes, which the LPN could not identify. Additionally, several medications, including insulin vials and inhalers, lacked open and expiration dates, and some were expired. The LPN acknowledged that expired medications should be discarded and that multi-dose vials and inhalers should be labeled with open and expiration dates. The third-floor medication refrigerator was found to be improperly maintained, with temperatures recorded at 53 and 48 degrees Fahrenheit, exceeding the recommended range of 36 to 46 degrees Fahrenheit. The LPN was unable to provide a temperature log for February 2025, and there was confusion about the origin of the log that was later presented. This lack of proper temperature control and documentation could compromise the efficacy of medications requiring refrigeration. On the first and second floors, similar issues were observed with loose pills in medication carts and medications lacking proper labeling. Expired medications were found, and a medication for a discharged resident was not removed from the cart. The facility's policy on medication storage, which requires proper labeling and temperature control, was not adhered to, leading to these deficiencies.
Deficiency in Personal Refrigerator Management
Penalty
Summary
The facility failed to ensure proper management of personal refrigerators for residents, leading to expired food items and inadequate temperature monitoring. Specifically, two residents, aged with various medical conditions including Type 2 diabetes and hypertension, were found to have expired milk in their personal refrigerators. These refrigerators lacked thermometers and temperature logs, and there were visible signs of uncleanliness, such as brown frozen or liquid substances at the bottom. The Housekeeping Director, who was responsible for maintaining these refrigerators, was absent for a week, and the housekeeping staff did not fulfill their duties of cleaning, temperature logging, and ensuring the presence of thermometers. Additionally, other residents' refrigerators were found without thermometers and temperature logs, and there was a lack of clarity among staff regarding who was responsible for monitoring these appliances. One resident's refrigerator had a temperature log that was not updated daily, with several missing entries. Despite the facility's policy requiring daily temperature checks and cleanliness maintenance by the housekeeping department, these procedures were not followed, potentially affecting all residents with personal refrigerators.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff wore appropriate Personal Protective Equipment (PPE) while providing high contact care to a resident with Enhanced Barrier Precautions (EBP). During an observation, a Certified Nursing Assistant (CNA) was seen providing perineal care to a resident with a chronic wound without wearing the required gown and gloves. The CNA justified the lack of PPE by stating that they were not near the wound area. This oversight has the potential to affect all 69 residents on the second floor. The Director of Nursing (DON) and the Infection Preventionist (IP) were not fully aware of the requirements for EBP, particularly for residents with chronic wounds. The IP admitted that the resident was not on the list for EBP, did not have orders in their chart for EBP, and was not care planned for EBP. The facility's document on EBP indicates that residents with chronic wounds should be on EBP to reduce the risk of transmitting multidrug-resistant organisms. The IP acknowledged the oversight and stated that a system was being worked out to ensure proper alerts for such cases.
Failure to Cover Catheter Drainage Bags Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure that the indwelling catheter drainage bags for two residents were covered with privacy bags, compromising their dignity. Resident R101 was observed in bed with an uncovered catheter drainage bag hanging on the lower part of the bed, facing the entrance of the doorway. R101 has a diagnosis of obstructive and reflux uropathy and unspecified hydronephrosis, with a BIMS score indicating some cognitive impairments. The care plan for R101 specified that the catheter bag should be positioned below the bladder and away from the entrance room door, but this was not adhered to. Similarly, Resident R56 was observed sitting in a wheelchair with an uncovered catheter drainage bag. R56 has a diagnosis of displacement of an indwelling ureteral stent, sequela, and also has cognitive impairments as indicated by a BIMS score. A CNA acknowledged the absence of a privacy bag and mentioned that R56 had just returned from the hospital. Both the CNA and an LPN recognized the importance of using privacy bags for maintaining resident dignity. The Director of Nursing confirmed that the drainage bags should be covered to maintain dignity and prevent infection.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for two residents, leading to a deficiency in accommodating the needs and preferences of these residents. Resident 13, who has multiple diagnoses including Cerebral Palsy and Mild Intellectual Disabilities, was observed with a call light device wrapped around the side rail and not within reach. Despite having a hand splint on her left hand, the intervention in her care plan encouraged her to use a bell to call for assistance. A Licensed Practical Nurse confirmed that Resident 13 could not reach or use the call light, indicating a failure to provide an accessible call device. Similarly, Resident 41, who has diagnoses including Cerebral Infarction and Hemiplegia, was found with the call light on the floor behind the bed, out of reach. Although Resident 41's care plan also encouraged the use of a bell for assistance, the call light was not accessible. A Certified Nursing Assistant and the Director of Nursing both acknowledged that the call light should be within reach of the resident. The facility's call light policy mandates that the call light system be available and easily accessible to residents at all times, which was not adhered to in these cases.
Failure to Document Advanced Directives for Residents
Penalty
Summary
The facility failed to obtain a doctor's order for Advanced Directives for two residents, R133 and R56, which was identified during a survey. R133, who is cognitively intact with a BIMS score of 14, has a medical history of chronic obstructive pulmonary disease, diabetes, end-stage renal disease, and hypertensive heart disease. Despite these conditions, R133's Order Summary Report and Admission Record Form lacked a physician order for an Advanced Directive, leaving the section blank. Interviews with LPNs revealed that the Advanced Directive order should have been obtained and entered into the computer upon admission, but this was not done for R133. Similarly, R56, who has some cognitive impairments with a BIMS score of 9, was admitted with a diagnosis including displacement of an indwelling ureteral stent. R56's physician order sheet initially did not include a code status, which was only added upon request. The Director of Nursing explained that the code status should be reviewed and documented upon admission to prevent inappropriate actions during emergencies. The facility's policy requires a written physician's order for Advanced Directives, but this was not followed for R56, as the code status was not documented in the physician's orders upon the resident's return to the facility.
Resident's Bed Found with Old Food Due to Staffing Shortage
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for a resident, identified as R589, who was found with old food, condiments, and a meal tray in her bed. R589, who is cognitively intact with a BIMS score of 14, reported having a slice of pizza in her bed since the previous Friday, which she consumed intermittently due to a lack of snacks between meals. This situation was observed during a survey, and the resident expressed that she forgot to dispose of the pizza. The Certified Nurse Assistant (CNA) assigned to R589 admitted to placing the meal tray on the resident's bed due to the absence of a bedside table and a shortage of staff, as the unit was short one CNA at the time. The Licensed Practical Nurse (LPN) acknowledged that food should not be in the resident's bed due to unsanitary conditions. The Housekeeping Director confirmed that each resident should have a bedside table and that old food should be removed by either CNA or housekeeping staff. The facility's job description for CNAs and the housekeeping cleaning schedule emphasize the importance of maintaining a clean and sanitary environment.
Failure to Complete PASARR for New Admission
Penalty
Summary
The facility failed to complete a new pre-admission screening and resident review (PASARR) for a resident upon admission. This deficiency affected one resident who had multiple diagnoses, including Hemiplegia, Dementia with Behavioral Disturbance, Major Depressive Disorder, Bipolar Disorder, and Mood Disorder with Manic Features. The resident was receiving Quetiapine Fumarate for Bipolar Disorder, and their Brief Interview of Mental Status score was 10. Despite these conditions, there was no Level 1 or Level 2 PASARR found in the facility's Point Click Care software for the resident. The deficiency was identified when the surveyor requested the PASARR documentation, and the facility staff, including the Administrator and Assistant Administrator, confirmed the absence of the required screening. The Assistant Administrator mentioned that the resident was not in the Maximus system, which is used to monitor and update PASARR screenings. The Admission Director explained that new residents should come with a Level 1 PASARR screening from the hospital or have one completed immediately upon admission. However, the resident in question was admitted before the facility began using the Maximus system, leading to the oversight.
Failure to Provide Scheduled Showers to Dependent Resident
Penalty
Summary
The facility failed to ensure that a dependent resident, identified as R74, received her scheduled showers. R74, who is cognitively intact with a BIMS score of 13, has multiple diagnoses including contracture of muscle, cerebral infarction, and hemiplegia, which render her dependent on staff for showers, baths, and transfers. According to her care plan, she has a functional ability self-care and mobility deficit due to the effects of cerebral infarction. Despite having a bathing order for showers on Sundays and Wednesdays, R74 reported not having received a shower for over a month prior to January 26, 2025, and expressed dissatisfaction with the bed baths provided, stating they were inadequate. The facility's documentation survey report for the period of January 1 to January 29, 2025, corroborates R74's account, showing only one shower on January 26, 2025, and weekly bed baths on four occasions. There is no documentation of showers on the scheduled dates of January 5, 12, and 19, 2025. The Assistant Director of Nursing confirmed that each resident should be showered or bathed on their scheduled days and that any refusal should be documented. However, the lack of documentation for the missed showers indicates that the activity did not occur, highlighting a failure in adhering to the resident's care plan and facility policy regarding personal hygiene assistance.
Improper Use of Low Air Loss Mattress for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure proper use of a low air loss mattress for a resident identified as R13, who was at high risk for pressure ulcers. R13, who has multiple diagnoses including Cerebral Palsy, Type 2 Diabetes Mellitus, and mild intellectual disabilities, was observed lying on a low air loss mattress with an incontinence brief, mattress pad, and a flat sheet underneath. This setup was contrary to the manufacturer's guidelines and the facility's policy, which state that only a thin cotton sheet should be used over the mattress to prevent skin breakdown and promote healing. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the resident should have had only a flat sheet and a mattress pad or incontinence brief under them. The improper layering of linens on the low air loss mattress compromised its effectiveness in preventing and treating pressure ulcers, as outlined in the manufacturer's guide and the facility's pressure ulcer prevention policy. This deficiency was identified during a survey and affected one resident in a sample size of 84.
Failure to Supervise Fall-Risk Residents in Dining Room
Penalty
Summary
The facility failed to ensure adequate supervision for residents at risk for falls in the dining room, affecting two residents, R82 and R88. R82 has a history of hypertension, schizophrenia, schizoaffective disorder, and type 2 diabetes mellitus, with a severely impaired mental status and a high fall risk score of 15. R88 has dementia with behavioral disturbances and epilepsy, with moderately impaired cognitive skills and a fall risk score of 10. On a specific date, both residents were left unsupervised in the dining room, despite being identified as at risk for falls. Staff members, including the Wound Care Coordinator and the Administrator in Training, were present but did not provide continuous supervision. The Director of Nursing and the Restorative Nurse confirmed that residents at risk for falls should be supervised to prevent accidents. However, there was no formal policy on supervision, only an expectation of frequent monitoring and keeping fall-risk residents within sight. The facility's Fall Prevention Program emphasizes the need for safety interventions for residents identified at risk, but these measures were not adequately implemented in this instance. The lack of supervision in the dining room contravened the residents' rights to safety as guaranteed by state and federal laws.
Failure to Change Nebulizer Mask as per Policy
Penalty
Summary
The facility failed to adhere to its policy regarding the timely changing of oxygen equipment, specifically a nebulizer mask, for a resident with asthma and hypertensive heart disease with heart failure. The resident, who has cognitive impairments as indicated by a BIMS score of 6, was observed with a nebulizer mask that had not been changed since June 17, despite the facility's policy requiring weekly changes. This oversight was confirmed through interviews with a CNA and an LPN, both of whom indicated that the responsibility for changing the nebulizer mask lies with the night shift nurse. The Director of Nursing (DON) reiterated that the nebulizer mask should be changed weekly and as needed to maintain hygiene and prevent infections. The facility's documented guidelines emphasize the importance of changing disposable respiratory supplies to minimize infection risk. However, the failure to change the nebulizer mask as per the facility's policy was observed, indicating a lapse in infection control practices and adherence to established procedures.
Failure to Maintain Accurate Narcotic Count and Documentation
Penalty
Summary
The facility failed to ensure proper narcotic count procedures were followed, affecting one resident who was receiving controlled drug administration. During a medication cart review, it was observed that the shift change controlled substance inventory count sheet was missing from the narcotic binder. Additionally, there was a discrepancy in the narcotic count for the resident's Tramadol 50 mg tablets, with the Controlled Drug Administration record showing 21 tablets while only 20 tablets were present in the medication bingo card. The Licensed Practical Nurse (LPN) admitted to administering a Tramadol tablet to the resident without signing the Controlled Drug Administration Record. The Director of Nursing (DON) confirmed that the facility's policy requires nurses to document the narcotic count and sign off on the controlled drug administration sheet at the time of administration. The policy also mandates that any discrepancies in the narcotic count be reported to the Nursing Director for reconciliation. The facility's policy, revised in 2017, emphasizes the importance of counting controlled substances with a partner and verifying the accuracy of log sheets at the beginning and end of each shift. The LPN's failure to adhere to these procedures resulted in an inaccurate narcotic count and lack of proper documentation.
Failure to Implement Fall Interventions Leads to Resident Injury
Penalty
Summary
The facility failed to implement adequate fall interventions for a resident, resulting in serious injury. The resident, a male with multiple diagnoses including Parkinson's disease, dementia, and a history of falls, was at high risk for falls. Despite being alert and able to verbalize needs, the resident was forgetful and impulsive, requiring persistent redirection for safety. On the day of the incident, the resident attempted to pick up an item from the floor while seated in his wheelchair, lost balance, and fell forward, sustaining cervical fractures. The resident's care plan included interventions such as using a sticky pad to prevent sliding from the wheelchair and re-educating the resident to lock the wheelchair when stationary. However, the report indicates that it was unclear whether the wheelchair was locked at the time of the fall, which could have contributed to the injuries. The resident was found on the floor with a laceration on the forehead and complained of significant pain, leading to hospitalization for cervical spine fractures. Interviews with staff revealed that the resident was known to be non-compliant with safety instructions and often attempted to perform tasks independently despite being unable to walk unaided. The facility's fall prevention program required assessing individual needs and implementing appropriate interventions, but the documentation did not confirm if all necessary measures, such as ensuring the wheelchair was locked, were in place at the time of the fall.
Pest Infestation in Resident Rooms
Penalty
Summary
The facility failed to maintain a pest-free environment, as evidenced by the presence of roaches in residents' rooms, affecting three residents directly and potentially impacting all 242 residents in the facility. Resident R3, who is cognitively intact, reported a significant roach problem in their room, exacerbated by a roommate who hoards food and dishes. Despite multiple complaints to housekeeping, the issue persisted. Similarly, R4, with moderate cognitive impairment, and R5, who is cognitively intact, also reported ongoing issues with roaches in their rooms. Observations confirmed the presence of live and dead roaches in these areas. The facility's Service Inspection Reports documented recurring roach infestations in various parts of the facility, including resident rooms, the kitchen, and common areas, over several months. The reports highlighted the need for thorough cleaning after pest control treatments to prevent re-infestation. The facility's pest control policy mandates maintaining conditions that prevent pest harborage, yet the repeated sightings and resident complaints indicate a failure to adhere to this policy effectively.
Inadequate Smoking Supervision in Facility
Penalty
Summary
The facility failed to implement adequate safety precautions to address the risk of residents smoking inside their rooms and other areas, which poses a significant fire hazard. Two residents, identified as R3 and R5, were observed engaging in smoking activities within the facility, despite the established smoking policy that restricts smoking to designated outdoor areas. R3, who has a history of smoking in prohibited areas, was observed smoking in the fourth-floor lounge and her bathroom. The facility's records, including R3's care plan and social services notes, document her inappropriate smoking behavior, yet effective measures to prevent such actions were not evident. R5, another resident with a history of mental health issues and nicotine dependence, was also found to be involved in smoking inside the facility. R5 was observed with a cigarette in the elevator and admitted to planning to smoke it later in his room. Despite the facility's policy and smoking assessment indicating that R5 requires supervision while smoking, there was no evidence of adequate supervision or intervention to prevent R5 from smoking indoors. The facility's social services director acknowledged the ongoing issue of residents smoking inside and the challenges in completely eliminating this behavior. The facility's administrator confirmed reports of residents smoking in their rooms and acknowledged the associated health and fire hazards, especially considering the presence of residents on oxygen. Although the facility has implemented some measures, such as searching visitor bags and testing residents suspected of drug use, these actions have not been sufficient to prevent residents from smoking inside the building. The facility's smoking safety policy outlines designated smoking areas and the need for smoking assessments, but the lack of enforcement and supervision has contributed to the continued occurrence of indoor smoking by residents.
Failure to Conduct Resident Care Plan Meetings
Penalty
Summary
The facility failed to ensure that residents participated in care planning conferences, as required, for three residents who were cognitively intact. The clinical records for these residents lacked documentation of any care plan meetings since their admission. Interviews with the residents confirmed that they had not been informed of or participated in any care plan meetings. One resident expressed frustration about not having a care plan meeting scheduled despite being close to discharge. Interviews with facility staff, including the Social Service Director, Director of Nursing, and MDS Coordinators, revealed a lack of clarity and coordination in scheduling and documenting care plan meetings. The staff members were unsure of the scheduling process and had not attended any care plan meetings for the residents in question. The facility's policy requires that a comprehensive care plan be developed and reviewed with the resident or their representative at least quarterly, but this was not adhered to in these cases.
Failure to Provide Comprehensive Bladder Function Assessment and Care Planning
Penalty
Summary
The facility failed to provide appropriate and sufficient services to ensure comprehensive bladder function assessment and care planning for residents with indwelling urinary catheters. Specifically, the facility did not complete a comprehensive bladder function assessment or develop a comprehensive care plan for two residents with indwelling urinary catheters. Additionally, the facility failed to address a resident's urinalysis results, leading to untreated dysuria and burning upon urination for several weeks. One resident, who had recently completed a course of antibiotics, reported burning upon urination. A urinalysis was ordered and collected, revealing significant abnormalities, but the results were not communicated to the provider in a timely manner. The resident continued to experience symptoms without appropriate follow-up care. The facility's process for notifying providers of laboratory results was not followed, and there was no documentation of provider notification in the electronic health record. Another resident, who was admitted with multiple diagnoses including urinary retention, was found to have an indwelling urinary catheter without a completed bladder function assessment or a care plan addressing the catheter use. The resident expressed distress and agitation about the catheter, indicating a lack of appropriate assessment and care planning. The facility's policies for bowel and bladder assessment and comprehensive care planning were not adhered to, resulting in inadequate care for residents with indwelling urinary catheters.
Failure to Provide Mail Services on Saturdays
Penalty
Summary
The facility failed to provide mail services to residents on Saturdays, affecting all 213 residents. During a resident council group meeting, multiple residents reported that mail is not delivered to them on Saturdays. The mail delivery process involves the business office first checking the mail, then passing it to the receptionist, who then gives it to the Activity department for final delivery to residents. However, since the business office does not work on weekends, mail delivered on Saturdays is not sorted and distributed until Monday. Additionally, residents reported that their mail is sometimes opened when they receive it. The Activity Director confirmed that Activity Aide staff members are expected to deliver mail every day, including Saturdays. The receptionist corroborated that mail is delivered on weekends but is not dispersed until the business office sorts it. The Business Office Manager stated that she is the only one who checks the mail first and opens mail from specific agencies like the Department of Human Services and the Social Security office, which is then uploaded into the resident's electronic medical record. This protocol results in delays and potential privacy violations, as residents' mail is sometimes opened without their permission.
Inadequate Staffing and Delayed Maintenance
Penalty
Summary
The facility failed to ensure adequate staffing to provide care for the residents, affecting all 213 residents. Interviews with staff revealed that there were frequent call-offs, especially on weekends, making it challenging to complete their jobs and take care of the residents. The Human Resource Director/Nursing Staff Scheduler confirmed that the facility was short-staffed on multiple occasions between October 1, 2023, and December 31, 2023. The facility does not use agency staff and has been relying on contracted nurses since January 2024 to improve staffing levels. The Director of Nursing and the Administrator acknowledged the staffing issues, noting that there has been an improvement since January 2024. However, during the period from October to December 2023, the facility was short-staffed on several dates, affecting both CNAs and nurses across different shifts and floors. Additionally, maintenance issues were reported, with repairs being delayed until weekdays due to the absence of maintenance staff on weekends. This led to resident complaints about delayed repairs for issues like a leaking toilet and a broken television antenna.
Improper Food Handling and Sanitization Practices
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items, proper storage of scoops, adherence to manufacturer's guidelines for food storage, and correct sanitization of cooking equipment. During an initial kitchen tour, several food items in the walk-in cooler and kitchen prep cooler were found unlabeled and undated, including gelatin mixed with fruit, liquid eggs, meat sandwiches, shredded mozzarella cheese, vanilla pudding, sliced American cheese, fruit cocktail, fresh tomato, grape jelly, and pancake/waffle syrup. Additionally, an ice machine scoop was found laying directly on top of the ice, and a clear plastic scoop was left uncovered on top of a thickener container. The soy sauce was stored at room temperature despite the manufacturer's guideline to refrigerate after opening. These observations were confirmed by the cook and the food service director, who acknowledged the lapses in proper food handling and storage practices. The facility also failed to properly sanitize cooking equipment according to the manufacturer's directions. An industrial blender used to prepare pureed ham was not fully sanitized; the lid was dipped in sanitizing solution for less than 5 seconds, and the blender container was not placed in the sanitizing solution at all. The equipment was returned to the preparation area while still wet, and the cook proceeded to use it to prepare food. The food service director and a former food service manager confirmed that the sanitizing solution requires a contact time of 60 seconds to be effective, and the facility's policy mandates that items be air-dried completely before being put away. The facility's policies on labeling and dating foods, using a three-compartment sink, and storing utensils were not followed, leading to potential risks of cross-contamination and foodborne illness. The facility's provided policies and the manufacturer's guidelines for the sanitizing solution were not adhered to, as confirmed by the food service director and the former food service manager. These deficiencies have the potential to affect all 209 residents receiving food prepared in the facility's kitchen.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that the dumpster lids were covered to prevent the harborage and feeding of pests, insects, and rodents. During an observation of the outside garbage dumpsters with the Former Food Service Manager, it was noted that two out of the four dumpster lids were fully opened. The Former Food Service Manager acknowledged that the lids should be fully shut to prevent rodents from getting inside and to prevent garbage from flying outside the dumpster. The Housekeeping Director also confirmed that the dumpster lids should always be kept shut to keep away animals and pests. Despite these instructions, a surveyor observed two of the four dumpster lids wide open later in the day. The facility's kitchen policy on garbage and rubbish disposal, dated 2020, mandates that outdoor trash receptacles be kept covered and the surrounding area kept free of litter.
Failure to Properly Label and Remove Discontinued Medications
Penalty
Summary
The facility failed to ensure medications were properly labeled when opened and did not remove discontinued medications from the medication cart. During a review of four out of five medication carts, it was observed that several medications, including inhalers and insulin, were opened and undated. Specific examples include an Advair Diskus for a resident that was opened and undated, despite the label indicating it should be discarded one month after opening. Similarly, Symbicort and Trelegy Ellipta inhalers were found opened and undated. Additionally, an insulin aspart injection solution that was discontinued was still present in the medication cart, undated and not removed as required. The Director of Nursing confirmed that medications, including over-the-counter drugs and insulin, should be labeled with the date when opened and that discontinued medications should be removed from the medication cart. The facility's policy on the storage of medications states that medications and biologicals should be stored safely, securely, and properly, following the manufacturer's recommendations. The policy also specifies that certain medications require an expiration date shorter than the manufacturer's expiration date once opened to ensure medication purity and potency. However, the facility failed to adhere to these guidelines, affecting nine residents reviewed for medication storage.
Infection Control Deficiencies in Cleaning Devices and PPE Usage
Penalty
Summary
The facility failed to ensure the proper cleaning and disinfection of multi-use blood pressure devices and glucometers between resident use. Specifically, an LPN checked the blood pressure of two residents using the same device without cleaning or disinfecting it in between uses. Additionally, another LPN failed to properly disinfect a glucometer between uses for multiple residents, only wrapping it with a sanitizing wipe instead of using a separate wipe to clean it first. These actions were observed during specific instances and confirmed through interviews with the staff, including the Director of Nursing (DON) and the Infection Preventionist, who acknowledged the correct procedures were not followed. The facility also failed to ensure that Enhanced Barrier Precaution (EBP) signage was posted as required for residents with indwelling medical devices. One resident with an indwelling urinary catheter did not have the necessary EBP signage above their bed or on the door to their room. This was confirmed by the Infection Preventionist, who stated that such signage should be in place to inform staff and visitors of the necessary precautions. Additionally, the DON confirmed that residents with indwelling medical devices should have EBP signage to prevent the spread of infection. Furthermore, the facility did not ensure that Personal Protective Equipment (PPE) was readily accessible and worn when providing care to residents on Enhanced Barrier Precautions. Multiple residents on EBP did not have PPE bins near their rooms, and staff were observed providing care without the necessary PPE. This was confirmed by the DON, who acknowledged that PPE should be accessible for high-contact activities and that the absence of PPE bins could lead to staff not following proper infection control protocols. The lack of PPE and proper signage increases the risk of cross-contamination among residents.
Failure to Document Immunizations and Education
Penalty
Summary
The facility failed to follow its policy and procedure to ensure residents' medical records included documentation of whether influenza and pneumococcal immunizations were received or not for three residents. Additionally, the facility did not document that education was provided to eligible residents and/or their representatives regarding the benefits and potential side effects of these immunizations for five residents. One resident was not assessed for eligibility and offered the influenza immunization, and another resident was not assessed for eligibility and offered the pneumococcal immunization. These deficiencies were identified during a review of the residents' electronic health records and the facility's immunization tracker. The review revealed that several residents' records lacked documentation of immunization status and education provided. For instance, one resident's electronic health record had no documentation of immunization records or education provided, and the facility's immunization tracker had no information about the resident's immunizations. Similar issues were found for other residents, with some records showing consent refusals but no documentation of education provided. The Assistant Director of Nursing/Infection Preventionist admitted that the immunization tracker was not updated and that there was no paper documentation of the education provided. The Director of Nursing confirmed that if services are not documented, it means they were not done. The facility's policy on influenza and pneumococcal immunizations requires that pertinent information about the risks and benefits of vaccines be provided to residents or their representatives and that this education be documented in the residents' medical records. The policy also mandates that the medical records include documentation of whether the residents received or did not receive the immunizations due to medical contraindications or refusal. The facility failed to adhere to these requirements, leading to the identified deficiencies.
Failure to Document COVID-19 Immunization and Education
Penalty
Summary
The facility failed to follow its policy and procedure to ensure that residents' medical records included documentation of whether COVID-19 immunizations were received or not received for three residents. Additionally, the facility did not document that education regarding the benefits and potential side effects of COVID-19 immunization was provided to five residents. Specific residents involved include those with diagnoses such as Dementia, Type 2 Diabetes Mellitus, Heart Failure, Hypertension, Chronic Obstructive Pulmonary Disease, and Atherosclerotic Heart Disease. The facility's immunization tracker and electronic health records (EHR) lacked the necessary documentation for these residents. The Assistant Director of Nursing/Infection Preventionist (V4) admitted that the immunization tracker was not updated and that there was no access to the database system to obtain information regarding residents' immunization records. V4 also stated that education about the COVID-19 immunization was provided to residents but was not documented in the EHR. The Director of Nursing (V3) confirmed that if services are not documented, it means they were not done. The facility's policy required documentation of education provided to residents and their representatives, as well as records of each dose of the COVID-19 vaccine administered or reasons for not receiving the vaccine, which was not adhered to in these cases.
Failure to Provide Privacy and Dignity for Resident with Urinary Catheter
Penalty
Summary
The facility failed to provide privacy and promote dignity for a resident reviewed for urinary catheters. The resident, who had medical diagnoses including neuromuscular dysfunction of the bladder, acute kidney failure, hematuria, essential hypertension, chronic obstructive pulmonary disease with acute exacerbation, and schizoaffective disorder, was observed lying in bed with a urinary bag half-filled and visible from the hallway. The resident expressed discomfort with the visibility of the urinary bag. A Licensed Practical Nurse acknowledged the issue and stated that Certified Nurse Assistants should keep urinary bags emptied and covered for privacy. The Director of Nursing confirmed that urinary bags should always be kept in privacy bags to avoid embarrassment and dignity issues. Facility policy mandates that drainage bags and excess tubing be placed in a secondary vinyl bag to ensure privacy.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure the call light was within reach for three residents, leading to a deficiency in accommodating their needs. Resident 82, with multiple diagnoses including Cognitive Communication Deficit and Chronic Diastolic Heart Failure, was observed lying in bed with the call button hanging out of reach. Additionally, the call button did not light up when pressed by the surveyor. Resident 114, who has conditions such as Major Depressive Disorder and Orthostatic Hypotension, was found lying in bed with the call light located behind her, out of reach. When asked, she did not know the location of the call light. Resident 39, diagnosed with Schizoaffective Disorder and Chronic Diastolic Heart Failure, was observed with the call light lying on the floor, out of reach. A Certified Nurse Assistant admitted to leaving the call light on the floor after changing the resident's bed linens. The Director of Nursing confirmed that the call light should be within easy reach of the residents and that any defects in the call light system should be reported to Maintenance. The facility's policy, revised in 2018, mandates that the call light system be accessible to residents at all times and that any defects be promptly reported for servicing. Despite these policies, the observations and interviews revealed that the call lights were not within reach for the three residents, compromising their ability to call for assistance when needed.
Failure to Update PASARR Screening After Change in Mental Health Status
Penalty
Summary
The facility failed to make a referral for re-evaluation after a change in mental health status for one resident (R2) who was admitted with diagnoses including Cocaine Abuse, Abnormal Posture, Seizures, Bipolar Disorder, and Essential Hypertension. The resident's care plan noted a mood problem related to Bipolar Disorder, with interventions to administer medications and monitor for side effects and effectiveness. However, the facility did not update the PASARR Level II screening after a significant change in the resident's mental health status, relying instead on an outdated OBRA screen from 1998, which indicated no severe mental illness or developmental disability at that time. The Assistant Administrator acknowledged that residents admitted before the new PASARR system implementation were not referred for Level II screenings, believing the OBRA screen was sufficient unless the resident moved or had a significant change in condition. The facility's policy, revised in 2018, required annual PASARR Level I screenings and updates upon any significant change in status for individuals identified as needing specialized services. Despite this policy, the Assistant Administrator admitted to not updating Level II PASARR screenings for long-term residents with only OBRA I screens. This oversight led to the failure to provide necessary re-evaluations and referrals for residents like R2, who experienced changes in their mental health status, thus not ensuring they received the appropriate care and services in the most suitable setting.
Failure to Initiate New PASARR Screen for Resident with Mental Illness
Penalty
Summary
The facility failed to initiate a new Level I PASARR screen for a resident with known mental illness. The resident, identified as R59, was admitted with diagnoses including major depressive disorder, generalized anxiety disorder, bipolar disorder, and unspecified dementia with behavioral disturbances. Despite these diagnoses, the resident's Interagency Certification of Screening Results OBRA-I Initial Screen from 2008 indicated no reasonable basis for suspecting mental illness. However, the resident's Minimum Data Set (MDS) from March 2024 documented active diagnoses of anxiety, depression, and bipolar disease. The Assistant Administrator (V2) acknowledged that Level II PASARR screenings were not performed for residents admitted before the new PASARR system was implemented, and there was uncertainty about who was responsible for referring residents for Level II screenings if they developed psychiatric conditions after admission. V2 did not follow up with the surveyor to clarify this responsibility, leading to a deficiency in the facility's PASARR process for residents with mental health diagnoses. The facility's policy, dated November 2018, mandates annual PASARR Level I screenings and screenings upon significant changes in status, but this was not adhered to in the case of R59.
Failure to Include Advance Directives in Care Plans
Penalty
Summary
The facility failed to follow their policy to include Advance Directives in the residents' care plans, affecting three residents. Resident 12, with multiple diagnoses including Parkinson's Disease, Type 2 Diabetes Mellitus, and Major Depressive Disorder, had a full code status ordered but did not have a care plan for Advanced Directives in their electronic health record (EHR). Similarly, Resident 91, with diagnoses such as Seizures, Schizoaffective Disorder, and Hypertension, also had a full code status ordered but lacked a care plan for Advanced Directives. Resident 186, diagnosed with Major Depressive Disorder, HIV Disease, and Chronic Obstructive Pulmonary Disease, had a full code status ordered but did not have a care plan for Advanced Directives in their EHR. The Assistant Director of Social Services, who had been working at the facility since January 2023, confirmed that all residents should have care plans for Advanced Directives to ensure staff are aware of the residents' code status choices. The facility's policies on Advance Directives and Comprehensive Care Plans both mandate the inclusion of Advanced Directives in the residents' care plans. However, the review of the EHRs for Residents 12, 91, and 186 revealed that these care plans were missing, indicating a failure to adhere to the facility's policies.
Failure to Update Care Plan with Accurate Advanced Directive Status
Penalty
Summary
The facility failed to ensure that a resident's comprehensive care plan was current and aligned with the medical regimen. Specifically, for one resident who was not cognitively intact and had multiple diagnoses including Paranoid Personality Disorder, Dementia, Parkinson's disease, and Chronic Obstructive Pulmonary Disease, the care plan did not reflect the resident's Do Not Resuscitate (DNR) status as ordered by the physician. Instead, the care plan incorrectly documented the resident's status as Full Code, which was inconsistent with the physician's orders and the resident's Practitioner Orders for Life Sustaining Treatment (POLST). Interviews with facility staff revealed that the care plan should be revised quarterly, annually, and as needed to reflect any significant changes. Both the MDS/Care Plan Coordinator and the Assistant Director of Social Services acknowledged the discrepancy and attributed it to an oversight. The facility's policies for Advance Directives and comprehensive care plans mandate that the care plan should be updated to reflect the resident's current medical orders, which was not adhered to in this case. This inconsistency could potentially lead to inappropriate treatment against the resident's wishes.
Failure to Provide Adequate Fingernail Care for Dependent Resident
Penalty
Summary
The facility failed to provide adequate fingernail care for a dependent resident, identified as R169, who requires assistance with activities of daily living (ADL). R169's Minimum Data Set (MDS) and care plan indicate that the resident is totally dependent on staff for bathing and showering and requires maximal assistance with other ADL tasks. Despite this, R169 reported that he had requested a male CNA to cut his fingernails 2-3 days prior, but the request was not fulfilled. Upon observation, R169's fingernails were found to be overgrown, yellow in color, and had a collection of dirt underneath. The resident's left hand, which cannot be opened, had a towel rolled inside to prevent the nails from digging into the skin, but the nails were still overgrown and dirty. The CNA responsible for R169's care admitted that it had been approximately four weeks since she last cut the resident's nails and expressed that if she did not perform grooming tasks, no one else would do it in her absence. The Director of Nursing (DON) confirmed that staff are expected to perform ADL care as needed or requested by residents and that it is unacceptable for residents' nails to be unkempt and dirty. The facility's document on Activities of Daily Living (ADLs) outlines the responsibilities for maintaining personal hygiene, including nail care. However, the observations and interviews revealed that these standards were not met for R169. The DON stated that once a resident requests nail care, it should be completed, and if the assigned staff member is unable to perform the task, it should be endorsed to another staff member. The failure to provide timely and adequate fingernail care for R169 highlights a deficiency in the facility's adherence to its own ADL care policies and procedures.
Failure to Ensure Adequate Oxygenation and Proper Equipment Maintenance
Penalty
Summary
The facility failed to ensure adequate oxygenation, proper head elevation, and appropriate storage and replacement of oxygen tubing for a resident with chronic obstructive pulmonary disease (COPD). The resident's care plan indicated the need for the head of the bed to be elevated and oxygen to be administered at 3 liters per nasal cannula. However, the resident was observed lying flat in bed with labored breathing and without oxygen infusing. The nasal cannula tubing was found hanging off the bed and was dirty, having not been replaced as required. The oxygen concentrator was also set incorrectly at 1 liter instead of the prescribed 3 liters, and the equipment was noted to be broken. The Certified Nurse Assistant (CNA) admitted to removing the oxygen tubing for shaving and not replacing it properly. The Licensed Practical Nurse (LPN) confirmed that the head of the bed should have been elevated and the oxygen tubing should have been changed days earlier. The Director of Nursing (DON) stated that oxygen tubing is supposed to be changed every seven days and that the oxygen concentrator should have a sticker indicating the correct oxygen setting. The failure to follow these protocols resulted in the resident experiencing respiratory distress and low blood oxygen levels, as evidenced by an oxygen saturation reading of 87% to 88%.
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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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