Aperion Care Wesley
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 1415 West Foster Avenue, Chicago, Illinois 60640
- CMS Provider Number
- 145591
- Inspections on file
- 25
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Aperion Care Wesley during CMS and state inspections, most recent first.
A resident with a history of cerebrovascular disease and dementia, who was on hospice with a POLST allowing selective treatment including hospitalization, developed new neurologic symptoms including facial deviation and inability to speak. A CNA reported these changes to an LPN, who contacted hospice but did not notify the attending physician, and the hospice MD was only told of nonspecific “weaknesses” without details of facial drooping. During the following shift, another LPN observed the resident’s mouth deviated to the right and continued care without calling the physician until a family member, a physician, recognized stroke signs and requested immediate contact, after which the resident was sent to the hospital and diagnosed with an embolic stroke. This sequence reflects a failure by nursing staff to follow policy requiring prompt physician notification of changes in condition.
The facility failed to maintain comprehensive, person-centered care plans for two residents with significant identified needs. One cognitively impaired resident with multiple neurologic diagnoses and a hospice consult order had no hospice-related care plan documented in the EMR or comprehensive care plan, despite facility policy requiring such planning. Another resident with vascular dementia, severely impaired cognition, and repeated documented wandering and exit-seeking episodes was assessed as at risk for elopement and recommended for an Elopement Risk Protocol, yet the active care plan lacked focuses for wandering or elopement risk after the elopement care plan was resolved in the EMR and not reactivated until the time of survey.
A resident with multiple wounds and recent amputation was admitted without timely entry of wound treatment orders, and required medications and treatments were not documented as administered. Gaps in communication and unclear staff responsibilities led to missed care, with unsigned entries on the TAR and MAR indicating treatments and medications were not provided as required by facility policy.
A resident with severe cognitive impairment and dysphagia was fed by an LPN who stood over them rather than sitting at eye level, contrary to facility policy and the resident's care plan. This action failed to uphold the resident's dignity and did not follow established procedures for safe and respectful mealtime assistance.
A resident with type 2 diabetes and other health conditions experienced severe foot pain and psychosocial harm due to inadequate foot care at the facility. Observations showed poor foot condition, and the resident reported not seeing a podiatrist for years. Despite an active podiatry consult order, the facility lacked evidence of recent visits, with the last documented in 2017. Staff interviews revealed a lack of awareness and adherence to facility policies on foot care.
The facility failed to implement a resident council that allows residents to meet regularly to discuss facility policies and quality of life. During a survey, only two residents could verbally participate in a meeting, while others were nonverbal. Residents reported not being informed about the meetings, and one was asked to be the Resident Council President without prior notice. The Activity Director acknowledged this was her first meeting, and there was confusion about the responsibility for organizing the meetings.
The facility failed to ensure agency staff received adequate competency checks and orientation before starting shifts, affecting all 87 residents. An agency LPN was unable to access the electronic health record, hindering medication administration, and was unsure of their scope of practice. The facility lacked documentation of orientation and training for agency staff, as confirmed by leadership, who admitted the need for process evaluation.
The facility's assessment failed to include input from residents' families, did not specify staffing needs per unit, and was not updated for new needs like a wound care nurse. The assessment lacked details on average daily census and input from the governing body, affecting care for 87 residents.
The facility failed to implement proper infection control measures, including the use of PPE and water management. Staff did not don PPE before entering rooms of residents on isolation precautions, and there were no disposal bins for PPE, leading to improper disposal. The facility also lacked documentation and testing for Legionella in its water management program, posing a risk to residents. Additionally, the infection control policies were outdated and not reviewed, indicating a lack of oversight.
The facility failed to follow its policies for COVID-19 immunization, as it did not offer the vaccine to eligible residents or document refusals and education in their medical records. The Infection Preventionist/DON could not provide a list of vaccinated residents, indicating a systemic issue. The facility's policy requires education and documentation of the vaccine's benefits and risks, but no clinics had been held since April 2024.
The facility failed to maintain a safe environment by not thoroughly cleaning the dryer lint screens, potentially affecting all 87 residents. During an inspection, the surveyor observed that the lint screens of two dryers were fully covered with lint, and loose lint was present on the floor of one dryer. The Laundry Aide admitted to not cleaning the lint traps that morning due to being late, despite facility policies requiring regular cleaning to prevent fire hazards.
The facility failed to ensure that two licensed personnel conducted a physical inventory of controlled substances at each change of shift, affecting residents prescribed controlled substances. Missing initials on the controlled substances count verification forms indicated that the required reconciliation was not performed for several shifts on the 3rd and 4th floor medication carts. Interviews with staff and review of policies confirmed the expectation for nurses to count and initial the forms at shift changes.
The facility failed to properly label and store medications, with loose tablets found in medication carts and insulin pens lacking open dates. Additionally, temperature logs for medication storage refrigerators were incomplete, violating the facility's policy for daily temperature checks. The DON confirmed nurses are responsible for these tasks, indicating a lapse in procedure adherence.
The facility failed to maintain proper temperature logs for personal refrigerators of six residents, potentially affecting food safety. Observations showed missing or incomplete logs, and expired food items were found. Staff interviews revealed confusion over responsibilities, with discrepancies between housekeeping and nursing staff duties, leading to non-compliance with the facility's policy.
The facility did not follow its policies for pneumococcal immunization, failing to vaccinate eligible residents and document vaccine offerings or education. Interviews revealed no pneumococcal vaccine clinics were held, and the DON could not provide records of vaccinations or refusals, contrary to facility policy.
The facility failed to ensure call light accessibility and functionality for two residents. One resident's call light was out of reach, while another's was broken, preventing them from requesting assistance. Both residents had moderate cognitive impairment and were at risk for falls. The facility's policy requires call lights to be accessible and defects promptly addressed, but these requirements were not met.
Two residents were found in unclean conditions, with one resident's room having dried tube feeding spills and soiled linens, and another resident's bed having feces on the linen. The facility's policies on cleanliness and linen changes were not followed, as confirmed by staff observations.
The facility failed to conduct care plan conferences involving two residents, both cognitively intact, in the development and implementation of their care plans. One resident with multiple diagnoses was not invited to participate in care plan meetings after an initial meeting, while another resident with complex medical conditions expressed a desire to be involved in care planning but had no documented participation. Additionally, the facility's MDS assessments were incomplete and delayed due to staffing issues, lacking necessary signatures and failing to address a triggered care area assessment.
A facility failed to complete a comprehensive MDS for a resident within required timeframes due to the departure of the MDS nurse and lack of a registered nurse assessment coordinator. The incomplete MDS lacked necessary signatures, affecting the timely development of the resident's care plan.
Two residents in a facility did not receive necessary nail and hair care despite being dependent on staff for ADLs. One resident, with a history of diabetes and hemiplegia, had long, discolored nails and matted hair, while another resident, cognitively intact, had long nails and requested assistance with shaving. Both residents reported asking for help, but staff were too busy. Facility policies on ADLs and nail care were not followed, leading to unmet personal care needs.
The facility failed to provide proper pressure ulcer care for two residents. One resident's low air loss mattress was set incorrectly, potentially hindering healing, while another resident did not receive timely dressing changes as per physician orders. Both residents were at risk for further pressure ulcers, with inconsistencies noted in staff documentation and communication regarding their conditions.
The facility failed to secure oxygen cylinders and allowed the use of personal heaters, posing fire hazards. An unsecured oxygen cylinder was found in a resident's room, and a resident was using a space heater due to heating issues. Staff acknowledged the risks, and the facility lacked a policy on space heater safety.
A resident with a gastrostomy tube did not have their tube feeding syringe changed daily as required by the facility's policy, which mandates a change every 24 hours to prevent infection. The resident, who has a history of dysphagia and other medical conditions, reported not noticing recent changes to the syringe and also mentioned issues with personal care. A nurse indicated a misunderstanding of the policy, stating syringes should be changed every five days, while the DON confirmed the 24-hour requirement.
The facility staff failed to secure and date respiratory equipment for two residents, compromising infection control. One resident's oxygen tubing and nasal cannula were not bagged when not in use, while another resident's nebulizer equipment lacked proper dating. Both residents have significant health conditions, and the facility's policy requires regular changing and dating of such equipment.
A resident did not receive prescribed intravenous antibiotics due to insufficient staffing at the facility. The resident, who requires antibiotics for osteomyelitis and sepsis, reported irregular administration due to staff shortages. Observations confirmed the medication was not administered, and the facility's staffing records were incomplete. Additionally, the resident's comprehensive assessment and care plan were not completed on time, partly due to the absence of a registered nurse assessment coordinator.
Two residents experienced medication administration errors, leading to an 8% error rate. The DON administered an incorrect dosage of Enoxaparin Sodium, while an RN gave Acetaminophen without a current order. Both incidents violated the facility's medication administration policy.
A resident with osteomyelitis and sepsis experienced significant medication errors due to staffing issues, resulting in the failure to administer Ampicillin continuously as prescribed. Despite the Director of Nursing's awareness, the medication was not administered properly, potentially delaying the resident's healing process.
The facility failed to maintain air temperatures within the required range, affecting a resident with dementia and epilepsy, and potentially impacting all 82 residents. The Maintenance Director did not check temperatures daily and thermostats were not functioning. High temperatures were recorded without corrective actions, and concerns raised by a resident's family and an LPN were not effectively addressed.
The facility failed to lock medication and treatment carts when not in use or within the visual proximity of nurses, posing a potential hazard. On multiple floors, carts were found unlocked and unattended, contrary to facility policy. The DON acknowledged the need for further training for new nurses to ensure compliance with safety protocols.
A facility failed to follow infection control practices, as an RN was seen wearing gloves in the hallway, and a resident on MRSA contact precaution accessed a clean cart without hand hygiene. The DON confirmed the breach of protocol, which requires gloves to be discarded after use and residents in isolation to avoid general supplies.
The facility failed to ensure call lights were within reach for two residents, as observed during a survey. One resident was found in bed without the call light within reach, stating they did not know where it was, while another was shouting for help with the call light on the floor. Staff confirmed that call lights should be accessible, in line with the facility's policy.
The facility failed to notify two residents of their trust fund balances exceeding the SSI $2000.00 resource limit. One resident had a balance of $2144.75 and another $3522.31. The Regional Financial Coordinator mistakenly believed a new Medicaid rule allowed up to $17000.00. The facility could not provide evidence of notifications or a relevant policy, potentially affecting all 81 residents.
The facility failed to provide timely incontinent care for two residents dependent on staff for ADLs. One resident was found wet and with a bowel movement, while another was observed with a strong odor of urine and stool, both without timely assistance due to staff being busy. The facility's policy requires checks every two hours to prevent skin breakdown and maintain dignity.
A resident with Parkinson's and dementia developed avoidable stage 3 and unstageable pressure ulcers due to inadequate care in a facility. Despite being at risk, the resident did not receive consistent wound care, turning, or nutritional support, leading to the deterioration of their condition. The facility's policies on pressure ulcer prevention were not effectively implemented, contributing to the resident's worsening wounds.
Failure to Timely Notify Physician of Neurologic Change in Hospice Resident
Penalty
Summary
The deficiency involves the facility’s failure to notify the attending physician in a timely manner of a significant change in condition for one cognitively impaired resident with extensive cerebrovascular and dementia-related diagnoses, including prior TIA, cerebral infarction, Alzheimer’s disease, atrial fibrillation, hemiplegia/hemiparesis, and unspecified dementia. On the day in question, the resident was on hospice care and had a POLST specifying selective treatment, including hospitalization. During the morning shift, a CNA observed that the resident’s face was shifted to the right and that she was not talking, and she reported this to the LPN on duty. The LPN stated she noted the resident was not talking and had her eyes closed, checked vital signs, and called hospice, after which a hospice RN and a family member came to the bedside. The LPN did not notify the attending physician of these changes, despite facility policy requiring physician and family notification for any change in condition. During the same day, the hospice physician reported receiving a call from a female hospice nurse during the morning shift that the resident had “weaknesses,” but he was not informed of facial shifting or drooping to the right side. He stated he was not given detailed information about the change in condition and was unaware that the resident’s POLST allowed for selective treatment including hospitalization. The Director of Nursing later stated that the hospice doctor had been notified and made aware of the change in condition, but this was not documented, and the hospice physician’s account indicated he did not receive full details of the neurologic changes. On the evening shift, the incoming LPN was told by the outgoing LPN that the resident was “not doing good,” but she did not ask whether the attending physician had been notified, citing the resident’s hospice status. During her initial rounds, this LPN observed the resident’s mouth deviated to the right and later fed the resident around dinner time with a family member at the bedside, still without contacting the attending physician. Another family member, an eye surgeon, arrived later that evening, recognized signs of stroke, and requested that the LPN call the attending physician immediately. The physician reported that no staff had informed her of the facial drooping until this family member spoke with her, at which point she ordered the resident sent to the hospital, where the resident was admitted with a diagnosis of stroke due to embolism of the right middle cerebral artery. Progress notes documented that the LPN notified the physician only after the family member’s request.
Failure to Maintain Comprehensive Care Plans for Hospice and Elopement Risk
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain individualized, comprehensive, person-centered care plans addressing all identified needs for two residents. One resident with Alzheimer’s disease, dementia, prior cerebral infarction with hemiplegia, atrial fibrillation, and a history of transient ischemic attack was cognitively impaired and had a physician order for a hospice consult. The DON stated that this resident should have a comprehensive person-centered care plan tailored to hospice care to ensure collaboration with the hospice team and that her end-of-life wishes were respected and met. However, review of the resident’s comprehensive care plan and EMR showed no documentation of hospice and no hospice care plan in place, despite the facility’s Comprehensive Care Plan policy requiring development and implementation of a comprehensive person-centered care plan for each resident. The second resident had vascular dementia with severely impaired cognition, documented wandering behavior occurring 4 to 6 days during the MDS assessment period, and multiple progress notes describing incidents of being found in stairwells, near exits, or on different units, with documented wandering and exit-seeking behavior. Elopement Risk & Community Survival Skills Assessments identified this resident as at risk to elope, indicated placement on the Elopement Risk Protocol, and stated that a care plan for elopement was indicated. Staff interviews confirmed the resident’s history of wandering, exit-seeking, and ongoing elopement risk. Despite this, the current care plan did not contain focuses for wandering or elopement risk. The MDS Coordinator confirmed the absence of these focuses, and the Social Service Director stated that the EMR had resolved or cancelled the wander/elopement risk care plan earlier in the year and it was not reinstated until the date of the survey, leaving the resident without an active care plan addressing elopement risk for a period of time.
Failure to Obtain and Administer Wound Treatments and Medications Upon Admission
Penalty
Summary
The facility failed to follow its policies and procedures to ensure that wound treatment orders were obtained and implemented upon a resident's admission, and failed to ensure that medications and wound treatments were administered as ordered. Upon admission, the resident had significant medical conditions including Type 2 Diabetes Mellitus with skin complications, Peripheral Vascular Disease, and a recent left foot amputation. The admission assessment documented multiple wounds, including a surgical wound on the left foot, a vascular wound on the left ankle, and a vascular wound on the left abdomen. However, wound treatment orders were not entered into the system until several days after admission, and there were gaps in the documentation of wound treatments and medication administration on the Treatment Administration Record (TAR) and Medication Administration Record (MAR). Interviews with nursing staff revealed confusion and lack of clarity regarding responsibility for entering and carrying out wound treatment orders. The admitting nurse did not complete a full body assessment or enter wound treatment orders, citing late admission and shift cut-off times. The nurse who completed the admission assessment entered medication orders but not wound treatment orders, and notified the DON and wound care nurse about the wounds. The wound care nurse was on vacation at the time, and the DON was not present in the facility, leaving floor nurses responsible for treatments. However, the night shift nurse did not perform wound treatments, believing they were not assigned, and the necessary orders were not in place for treatments to be carried out. Facility policies require that a full skin assessment and verification of treatment orders be completed upon admission, with prompt entry of orders and documentation of all treatments and medication administration. The failure to obtain and implement wound treatment orders and to document administration of medications and treatments resulted in missed care for the resident, as evidenced by unsigned entries on the TAR and MAR and staff statements confirming that if documentation is missing, the care was not provided.
Failure to Maintain Resident Dignity During Assisted Feeding
Penalty
Summary
A staff member failed to maintain a resident's dignity during mealtime assistance. Specifically, an LPN was observed feeding a resident with severe cognitive impairment and multiple medical diagnoses, including dementia and dysphagia, while standing over the resident in the dining room. The LPN remained standing and fed the resident more than ten spoonfuls of food while the resident was seated in a wheelchair at the dining table. Facility policy and the Director of Nursing both state that staff are required to sit at eye level with residents when feeding them to promote dignity and allow for proper monitoring of swallowing or choking concerns. The resident's care plan and physician orders documented the need for a mechanically altered diet, supervision during meals, and monitoring for signs of dysphagia due to a history of aspiration pneumonia and other health conditions. Facility policies on dignity and resident rights specifically prohibit staff from standing over residents while assisting with eating, emphasizing the importance of maintaining dignity and respect. The observed actions were inconsistent with these policies and the resident's care plan requirements.
Failure to Provide Adequate Foot Care for Resident
Penalty
Summary
The facility failed to provide adequate foot care for a resident, identified as R1, who suffered from unbearable foot pain and associated psychosocial harm, including depression, irritability, and difficulty sleeping. Observations revealed that R1's feet were in poor condition, with long, discolored toenails and substances between the toes. R1 reported that the staff refused to provide nail care, citing the need for a podiatrist, and stated that it had been years since seeing a podiatrist. R1's medical history includes type 2 diabetes mellitus, which increases the risk of foot health issues, and other conditions such as cerebral infarction and hemiplegia. The resident's care plan indicated a need for assistance with personal care and noted a dependency on staff for activities of daily living. Despite an active order for a podiatry consult dated 9/16/25, the facility could not provide evidence of recent podiatry visits, with the last documented visit occurring in March 2017. Interviews with facility staff, including a registered nurse and the social services director, confirmed a lack of awareness regarding R1's podiatry care and the scheduling of appointments. The facility's policies on activities of daily living and nail care were not followed, as evidenced by the lack of regular foot care and documentation. The medical director acknowledged the potential impact of diabetes on foot health but was unaware of any specific issues with R1's foot care.
Failure to Implement Resident Council
Penalty
Summary
The facility failed to develop and implement a resident council that allows residents to meet regularly to discuss facility policies, procedures, care, treatment, and quality of life. This deficiency was observed during a survey where only two residents were able to verbally participate in a resident council meeting, while eight others were nonverbal and inattentive. Several residents reported not being informed about the existence of resident council meetings, and one resident was asked to be the Resident Council President on the same day of the meeting without prior notice or election by peers. The Activity Director, who was responsible for organizing the meeting, acknowledged that this was the first meeting she hosted and that the responsibility had shifted from the Social Services department after a change in facility ownership. The facility's policy requires the Activity Director to coordinate the establishment of the Resident Council and ensure that all residents are informed and able to participate voluntarily. However, the survey revealed that residents were not adequately informed or involved in the council's activities, and the leadership structure was not determined by the residents as per the policy. The Director of Nursing and the Social Service Director provided conflicting statements about the responsibility for organizing the meetings, indicating a lack of clarity and communication within the facility's administration. This failure to adhere to the established policies potentially affects all residents in the facility.
Inadequate Competency Checks for Agency Staff
Penalty
Summary
The facility failed to ensure that agency staff received adequate competency checks and orientation before starting their shifts, which could potentially affect all 87 residents. An agency LPN was observed unable to access the electronic health record, which hindered their ability to administer medications, including IV medication through a PICC line. The LPN was unsure if administering IV medications was within their scope of practice and confirmed they had not received any training, orientation, or competency checks from the facility. Additionally, the LPN was unable to provide the code to disengage the alarm to the stairwell or elevators. The facility lacked documentation of orientation and training for agency staff, as confirmed by the Regional President of Operations and the Director of Nursing. The facility's policy states that sufficient numbers of staff with the necessary skills and competencies are required to provide care and services for all residents. However, the facility did not have a formal orientation or competency process for agency staff, nor did they document any such processes. This deficiency was acknowledged by the facility's leadership, who admitted that the current process needed evaluation.
Facility Assessment Lacks Comprehensive Input and Updates
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources for resident care during both regular operations and emergencies. The assessment lacked input from residents' family members, did not specify staffing needs per unit, and was not updated to reflect new needs, such as the requirement for a wound care nurse and an assistant director of nursing. Additionally, the assessment did not include the average daily census or input from a specific member of the facility's governing body. These omissions were confirmed through interviews with the facility's administrator and regional director of operations, who acknowledged the deficiencies in the assessment process. The facility's assessment, last reviewed on October 23, 2024, indicated staffing requirements but failed to break down these needs by unit or shift. The facility has two specialty units, a memory care unit and a short stay unit, but the assessment did not specify the staffing needs for these units. The regional director of operations confirmed that family members were not involved in the assessment process and that the staffing needs were not detailed by unit. The facility is in the process of hiring for the identified positions of assistant director of nursing and wound care nurse, which were not previously included in the assessment.
Infection Control Deficiencies in PPE Use and Water Management
Penalty
Summary
The facility failed to properly implement its infection prevention and control program, as evidenced by several deficiencies observed during the survey. Staff did not don personal protective equipment (PPE) before entering the room of a resident on enhanced barrier precautions, which is necessary to prevent the transfer of pathogens. Additionally, there were no PPE disposal bins available in the rooms of residents on isolation precautions, leading to improper disposal of PPE and increasing the risk of infection spread. The facility's water management program for preventing Legionella growth was also found to be lacking. There was no documentation of weekly thermostat readings or sanitizing of medical devices, and the facility had not tested its water supply for Legionella, a potentially deadly pathogen. This oversight could affect all residents, especially those at increased risk for Legionnaires' disease. The facility's infection prevention and control policies were outdated and had not been reviewed or approved by the appropriate personnel. The Director of Nursing was unable to provide a date for the last review of the infection control program, indicating a lack of oversight and adherence to established protocols. These deficiencies highlight significant gaps in the facility's infection control measures, potentially impacting the health and safety of all residents.
Failure to Document and Administer COVID-19 Vaccinations
Penalty
Summary
The facility failed to adhere to its policies and procedures for the immunization of residents against COVID-19, as evidenced by the lack of vaccination for eligible residents. Specifically, the facility did not offer the COVID-19 vaccine to three residents, nor did it document the refusal or the benefits and side effects of the vaccine in the residents' electronic medical records. This deficiency was identified during a review of records for three residents, where there was no documentation of COVID-19 vaccine offering or education, and no physician orders for the vaccine were found. The facility's Infection Preventionist/Director of Nursing was unable to provide a list of residents who had received or declined the COVID-19 vaccine, indicating a systemic issue in the facility's vaccination process. The facility's policy, revised in December 2024, mandates that residents be provided with education regarding the benefits and risks of the COVID-19 vaccine before it is offered. Additionally, the policy requires documentation of the education provided, the administration of the vaccine, or the resident's refusal. The Infection Preventionist/Director of Nursing acknowledged the importance of offering the vaccine upon admission and documenting any refusals in the electronic medical record. However, the facility had not conducted COVID-19 or pneumococcal vaccine clinics since the Infection Preventionist/Director of Nursing's tenure began in April 2024, further contributing to the deficiency.
Failure to Clean Dryer Lint Screens
Penalty
Summary
The facility failed to maintain a safe environment by not thoroughly cleaning the dryer lint screens in the laundry room, which has the potential to affect all 87 residents. During an inspection, the surveyor, accompanied by the Administrator, observed that the lint screens of two dryers were fully covered with lint, and loose lint was present on the floor of the lint compartment of one dryer. The Administrator acknowledged that the lint traps should be cleaned daily to ensure proper drying of linen and to prevent fire hazards. However, the Laundry Aide admitted to not cleaning the lint traps that morning due to being late and rushing. The facility's policy on laundry services and maintenance requires that lint screens be cleaned at least every three loads or every two hours, whichever comes first, and that motor vents be kept free from lint by the maintenance department weekly. The job description for the Laundry Aide includes the responsibility of removing lint from equipment. The Administrator's job description emphasizes ensuring that the facility is maintained in a clean and safe manner, including fire protection and prevention. Despite these policies and job descriptions, the failure to clean the lint screens as required was observed, indicating a lapse in adherence to established safety procedures.
Failure to Conduct Controlled Substances Inventory at Shift Changes
Penalty
Summary
The facility failed to ensure that two licensed personnel conducted a physical inventory of controlled substances at each change of shift. This deficiency was observed on the 3rd and 4th floor medication carts, affecting residents prescribed controlled substances. Specifically, the controlled substances count verification forms for January 2025 had missing initials for several shifts, indicating that the controlled substances were not reconciled at the end and beginning of those shifts. The absence of initials was noted for the night shift on January 10, 2025, and for the day and evening shifts on January 13, 2025, on the 3rd floor. Similarly, the day shift on January 4, 2025, on the 4th floor also had missing initials. Interviews with the RN and LPN revealed that the expected procedure was for the nurse coming onto the shift to count the narcotics with the nurse leaving the shift, and both should initial the controlled substances count verification form. The Director of Nursing confirmed this expectation and stated that the nurses are required to initial the forms to indicate the count is correct. The facility's policy and job descriptions for RNs and LPNs also support this requirement, emphasizing the importance of participating in the counting of controlled substances at the beginning and ending of shifts and performing routine charting duties as required.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of drugs and biologicals, as observed during an inspection of medication carts and storage refrigerators. On the 3rd, 4th, and 2nd floors, medication carts contained loose tablets of various colors and types, indicating a lack of proper organization and potential risk of medication errors. Additionally, insulin pens on the 3rd floor were found without documented open dates, contrary to the facility's policy requiring such documentation to ensure proper storage and usage within the recommended timeframe. Furthermore, the temperature logs for medication storage refrigerators on the 3rd and 4th floors were incomplete, with several dates missing temperature documentation. This oversight contradicts the facility's policy, which mandates daily temperature checks to maintain appropriate storage conditions for medications requiring refrigeration. The Director of Nursing confirmed that nurses are responsible for these tasks, highlighting a lapse in adherence to established procedures for medication management.
Failure to Maintain Refrigerator Temperature Logs
Penalty
Summary
The facility failed to properly log refrigerator temperatures for personal refrigerators of six residents, which could potentially affect the safety of personal food items for these residents. Observations revealed that several residents' refrigerators either lacked temperature logs or had incomplete logs. For instance, one resident's refrigerator had no temperature log or thermometer, while another had a log with missing check dates. Additionally, some refrigerators contained expired food items, such as an unopened carton of milk past its expiration date. Interviews with staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), confirmed that refrigerator temperature logs were not consistently maintained as required by the facility's policy. The facility's policy mandates that all refrigerators in resident rooms should have a thermometer and that temperatures should be logged daily. Housekeeping is responsible for cleaning the refrigerators daily, while nursing staff is tasked with maintaining the temperature logs. However, there was confusion among staff regarding responsibilities, with some stating that housekeeping was responsible for maintaining the logs, while others indicated it was the nursing staff's duty. This lack of clarity and adherence to policy resulted in the failure to ensure the safety and proper storage of food items in residents' personal refrigerators.
Failure to Administer and Document Pneumococcal Vaccinations
Penalty
Summary
The facility failed to adhere to its policies and procedures for the immunization of residents against pneumococcal disease, as evidenced by the lack of vaccination for eligible residents. Specifically, three residents were not offered the pneumococcal vaccine, and there was no documentation of the vaccine being offered or any education provided regarding its benefits and side effects. Additionally, there were no physician orders for the pneumococcal vaccination for these residents, and their immunization records did not list any current pneumococcal vaccinations. Interviews with facility staff revealed that the facility had not conducted a pneumococcal vaccine clinic, and the Director of Nursing was unable to provide documentation of residents receiving or declining the pneumococcal vaccine. The facility's policy requires that residents be provided with information about the risks and benefits of vaccines and that any refusal be documented in the electronic medical record. However, this was not done for the residents in question, indicating a failure to follow established procedures.
Call Light Accessibility and Functionality Deficiencies
Penalty
Summary
The facility failed to ensure that the call light was within reach for one resident and that the call light was functioning properly for another resident. For the first resident, identified as R63, the call light cord was observed hanging off the side of the bed, out of reach. This was confirmed by a CNA who acknowledged that the call light should be attached to the resident and within close reach. The resident, who has a BIMS score indicating moderate cognitive impairment and is at risk for falls due to paraplegia, was unable to access the call light to request assistance, as documented in their care plan. For the second resident, identified as R229, the call light was observed to be on but not functioning properly. A registered nurse confirmed that the call light was broken and stated that they would check on the resident whenever passing by the room. The resident, who also has a BIMS score indicating moderate cognitive impairment and a history of falls, expressed the need for assistance with mobility and bathroom use, which was hindered by the malfunctioning call light. The maintenance director explained that the call light cord was improperly wrapped around the bedrail, causing it to disconnect when the bedrail was lowered. The facility's policy requires that call lights be available and accessible to residents at all times, and that defects be promptly reported and addressed. However, the failure to adhere to this policy resulted in the residents being unable to effectively communicate their needs for assistance, as evidenced by the observations and interviews conducted during the survey.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment for two residents, R1 and R54, as observed by the surveyor. R1 was found lying in bed with two areas of a brown substance on the bottom sheet and multiple areas of a tan/beige substance on the floor and bedside dresser, which R1 identified as tube feeding spills. R1 expressed dissatisfaction with the cleanliness of the room, suggesting neglect by the staff. R1's medical history includes cerebral infarction, hemiplegia, and dysphagia, requiring tube feeding and assistance with personal care. R54 was observed sitting on the side of his bed with three areas of a brown substance on his bottom linen, which he identified as feces. R54, who is cognitively intact, reported that the nurse was aware of the issue but had not returned to address it. The facility's Director of Nursing acknowledged that all residents should have clean rooms and linen, emphasizing the importance of cleanliness in preventing infection and promoting recovery. The facility's policies on housekeeping and pressure ulcer prevention require that rooms be kept clean and linens changed when soiled. However, these policies were not adhered to in the cases of R1 and R54, as evidenced by the observations of soiled linens and unclean rooms. The Registered Nurse, V3, confirmed the presence of dried tube feeding spills in R1's room and acknowledged the need for clean linen, but did not take immediate action to rectify the situation.
Failure to Conduct Resident Care Plan Conferences
Penalty
Summary
The facility failed to conduct care plan conferences that allowed residents to participate in the development and implementation of their care plans, affecting two residents in a sample of 49. One resident, identified as R19, was diagnosed with spinal stenosis, chronic obstructive pulmonary disease, unspecified dementia without behavioral disturbance, major depressive disorder, and epilepsy. Despite being cognitively intact, as indicated by a Brief Interview of Mental Status Summary Score of 13, R19 was not invited to participate in care plan meetings after an initial meeting documented on 3/13/2024. No further documentation of care plan meetings or invitations for R19 was provided during the survey. Another resident, R328, with diagnoses including osteomyelitis, sepsis, paraplegia, neuromuscular dysfunction of the bladder, and colitis, also did not participate in care plan meetings. R328, who had a Brief Interview of Mental Status summary score of 15, indicating cognitive intactness, expressed a desire to be involved in care planning, especially concerning discharge plans. However, there was no documentation of care plan conferences or invitations for R328. Additionally, R328's comprehensive Minimum Data Set (MDS) was incomplete, lacking necessary signatures and failing to address a triggered care area assessment for nutritional status. The facility's Director of Nursing confirmed the absence of a registered nurse assessment coordinator, which contributed to the delay and incompleteness of the MDS assessments. The Regional Director of Clinical Reimbursement acknowledged that the assessment for R328 was late due to staffing changes, and the facility was in the process of hiring for the position. The facility's policy requires comprehensive care plans to be developed within seven days after the completion of the comprehensive assessment, with resident participation to the extent practicable, but this was not adhered to in the cases of R19 and R328.
Incomplete MDS and Lack of RN Coordinator Lead to Deficiency
Penalty
Summary
The facility failed to complete and submit a comprehensive assessment for a resident within the required timeframes, as mandated by the Resident Assessment Instrument (RAI) guidelines. The assessment reference date for the resident was noted as 12/17/2024, and the comprehensive Minimum Data Set (MDS) was incomplete, lacking signatures in several sections, including the RN Assessment Coordinator's verification of completion. The assessment was confirmed to be late by the Regional Director of Clinical Reimbursement, who attributed the delay to the departure of the previous MDS nurse and the subsequent reliance on a remote company to complete the MDS. The Director of Nursing confirmed that the facility did not have a registered nurse assessment coordinator at the time and was in the process of hiring for the position. The absence of a completed MDS and the lack of a registered nurse assessment coordinator compromised the timely development of the resident's care plan, which is essential for identifying resident conditions and needs. This deficiency had the potential to affect one resident in a sample of 49.
Failure to Provide Adequate Nail and Hair Care
Penalty
Summary
The facility failed to provide adequate nail and hair care for two residents who depend on staff assistance for activities of daily living (ADL). One resident, who has a medical history including type 2 diabetes mellitus, cerebral infarction, and hemiplegia, was observed with long, discolored fingernails and matted hair. Despite requesting assistance from the nursing staff, the resident's grooming needs were not met, as evidenced by their unkempt appearance and the resident's own statements of dissatisfaction. The resident's care plan indicates a dependency on staff for personal care, yet these needs were not addressed during routine bathing. Another resident, who is cognitively intact and has a history of falling and difficulty walking, was also observed with long fingernails and expressed a desire for assistance with nail trimming and shaving. This resident reported having asked staff for help multiple times but was told they were too busy. The facility's policies on ADLs and nail care outline the expectation for staff to assess and address grooming needs during bathing, yet these policies were not followed, resulting in unmet personal care needs for the residents.
Failure in Pressure Ulcer Care and Mattress Settings
Penalty
Summary
The facility failed to ensure proper pressure ulcer care and prevention for two residents, R24 and R54, who are at risk for developing further pressure ulcers. For R54, the low air loss (LAL) mattress was not set at the correct weight setting, which was observed to be set at greater than 350 pounds, while R54's actual weight was documented as 139.2 pounds. This incorrect setting could potentially prevent the mattress from functioning effectively, as noted by the Director of Nursing, who stated that the mattress should be set at the resident's weight to prevent further pressure ulcers and aid in healing. Additionally, R54's care plan and medical records indicated the presence of a Stage IV pressure ulcer on the coccyx and a Stage III pressure ulcer on the midline back, both requiring specific wound care treatments. However, there was no indication that these treatments were being administered as per the physician's orders. The resident expressed discomfort with the mattress, indicating it was too firm, which could further exacerbate the risk of pressure ulcers. For R24, the facility failed to change the foam dressings on the resident's bilateral hips as per the physician's order, which required changes every night shift. Observations revealed that the dressings were dated 1/8/2025, despite the requirement for daily changes. The resident was noted to have red and purple blanchable erythema on the hips, indicating potential pressure injuries. The facility's documentation and staff interviews revealed inconsistencies regarding the presence and treatment of pressure injuries, with the Regional Nursing Consultant initially stating that R24 did not have pressure wounds, only to later acknowledge the presence of scar tissue from previous injuries.
Safety Hazards: Unsecured Oxygen Cylinders and Space Heaters
Penalty
Summary
The facility failed to ensure the safety of its residents by not securing oxygen cylinders and allowing the use of personal heaters, which are potential fire hazards. An unsecured oxygen cylinder was observed next to a resident's bed, who relies on supplemental oxygen due to chronic obstructive pulmonary disease and other respiratory conditions. The resident confirmed that the holder for the oxygen cylinder had been removed by the facility months prior. A Licensed Practical Nurse acknowledged the risk of the unsecured cylinder and removed it from the room. The facility's policy mandates that oxygen cylinders be secured to prevent them from becoming dangerous projectiles. Additionally, a resident was observed using an electric space heater at their bedside, which they stated was known to the facility due to ongoing heating issues. The Director of Nursing admitted that space heaters are fire hazards and should not be in resident rooms, despite allowing them due to climate conditions. The Maintenance Director also confirmed that space heaters pose a safety risk. The facility administrator was unable to locate a policy regarding the safety and hazards of space heaters, indicating a lack of proper documentation and adherence to safety protocols.
Failure to Change Tube Feeding Syringe Daily
Penalty
Summary
The facility failed to ensure that a tube feeding syringe was changed daily for a resident with a gastrostomy tube, as per the facility's policy. The surveyor observed that the tube feeding syringe for the resident had an open date of 1/9/25, and it was not changed by 1/13/25. The resident, who has a medical history of dysphagia, gastro-esophageal reflux disease, and gastrostomy status following a cerebral infarction, expressed doubt about the staff changing the syringe recently. The resident also mentioned issues with personal care, such as not having their hair washed or brushed. The facility's policy requires that feeding tube syringes and irrigation containers be changed every 24 hours to prevent infection. However, a registered nurse stated that syringes should be changed every five days, although they personally change them every other day. The Director of Nursing confirmed that syringes are to be changed every 24 hours to prevent infection. This discrepancy between the facility's policy and the staff's actions led to the deficiency, as the resident's tube feeding syringe was not changed according to the established guidelines.
Deficiencies in Respiratory Equipment Management
Penalty
Summary
The facility staff failed to properly manage respiratory care equipment for two residents, leading to deficiencies in infection control practices. For one resident, the oxygen tubing and nasal cannula were observed hanging on the oxygen concentrator machine without being secured in a bag when not in use. This was confirmed by a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), who both stated that the tubing should be placed in a plastic bag to prevent contamination and infection. The resident in question has a history of chronic obstructive pulmonary disease, chronic respiratory failure, and other significant health issues, and has a severely impaired cognitive status. For another resident, the facility staff failed to date the oxygen tubing, humidifier bottle, and nebulizer tubing, which are required to be changed weekly for infection control purposes. This resident was observed receiving a nebulizer treatment without any dates on the equipment, and the LPN confirmed the absence of dates. The DON stated that the equipment should be dated and changed every seven days. This resident has a history of chronic diastolic congestive heart failure, hypertensive heart disease, and other health conditions, with intact cognitive function. The facility's policy mandates the regular changing and dating of respiratory equipment to minimize infection risks.
Staffing Deficiency Leads to Missed Antibiotic Administration
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of its residents, specifically affecting a resident identified as R328. This deficiency resulted in the resident not receiving intravenous antibiotics as prescribed, which were critical for treating conditions such as osteomyelitis and sepsis. The resident, who is cognitively intact, reported that the lack of staff led to irregular administration of antibiotics, contributing to delayed healing of pressure ulcers. Observations confirmed that the resident's intravenous medication was not connected, and the Director of Nursing acknowledged staffing issues due to a nurse calling off. Further investigation revealed that the facility's staffing records were incomplete, lacking details about agency nursing staff. The facility's contingency plan for staffing crises was inadequate, as it only addressed situations where 75% of the workforce was unavailable, not individual call-ins. Additionally, the facility's assessment did not specify staffing needs by unit or include recruitment strategies, despite acknowledging the need for additional nursing staff, including a wound care nurse and an MDS nurse. The facility also failed to complete a comprehensive assessment and care plan for R328 in a timely manner. The MDS assessment was incomplete and late, with missing signatures and unaddressed care areas. The delay was attributed to the departure of the previous MDS nurse, and the facility's inability to appoint a registered nurse assessment coordinator. The Director of Nursing confirmed that the MDS is crucial for driving the resident's plan of care, and the lack of sufficient staff could result in residents not receiving necessary care.
Medication Administration Errors Result in 8% Error Rate
Penalty
Summary
The facility failed to administer medications according to physician orders for two residents, resulting in an 8% medication error rate. For one resident, the Director of Nursing (DON) administered a prefilled syringe of Enoxaparin Sodium at a dosage of 30 mg/0.3 ml to the resident's left thigh, instead of the prescribed 20 mg/0.2 ml. The DON did not discard the excess 0.1 ml before administration, as required by the physician's order. The DON later acknowledged the error and the potential risk of excessive bleeding due to the incorrect dosage. In another incident, a Registered Nurse (RN) prepared and administered Acetaminophen 325 mg to a resident, despite the absence of a current physician order for this medication. The RN initially prepared a 500 mg tablet but corrected the dosage to 325 mg after realizing the error. However, the RN admitted to following an outdated order from the previous day, as all orders for Acetaminophen had been discontinued. The facility's policy on medication administration, which includes verifying the 'Five Rights' of medication administration, was not adhered to in these instances.
Significant Medication Error Due to Staffing Issues
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically involving the administration of antibiotics. The resident, who is cognitively intact and has diagnoses including osteomyelitis and sepsis, was prescribed Ampicillin and Vancomycin to be administered intravenously. However, observations revealed that the Ampicillin was not being continuously infused as ordered. The Director of Nursing acknowledged the issue, citing staffing shortages as a reason for the lapse in medication administration. Despite being aware of the problem, the Ampicillin was not administered as required, leading to potential delays in the resident's healing process. Further observations showed that the Ampicillin was repeatedly not connected to the resident's PICC line, and the Vancomycin was administered late. A pharmacist confirmed that both medications could be administered simultaneously through the same PICC line, as they are compatible. The facility's policy on medication administration emphasizes the importance of administering medications as prescribed, yet this was not adhered to, resulting in a significant medication error for the resident.
Failure to Maintain Safe Air Temperatures
Penalty
Summary
The facility failed to maintain air temperatures within the required range of 68 to 79 degrees Fahrenheit in resident rooms and common areas during the winter months, affecting a resident with dementia and epilepsy, and potentially impacting all 82 residents. The Maintenance Director, responsible for monitoring and adjusting the facility's heating system, admitted to not checking air temperatures daily due to time constraints and only responding to complaints. During an environmental tour, temperatures were recorded as high as 84 degrees Fahrenheit in some areas, exceeding the facility's policy limits. The Maintenance Director revealed that the facility's thermostats were not functioning properly and were not connected to the heating sources. Despite having a policy in place, the Maintenance Director did not document actions taken for high temperatures on the air temperature logs, and there was no communication with the Administrator about the excessive temperatures. The logs showed multiple instances of temperatures exceeding the policy limits, with no corrective actions noted. The resident's family member and a Licensed Practical Nurse (LPN) had previously raised concerns about the excessive heat in the resident's room, but the issue was not addressed effectively. The LPN opened a window to alleviate the heat but did not use the special key to adjust the room's central air heat. The Maintenance Director was unaware of how to properly adjust the boiler temperatures and only learned about it after consulting with the previous maintenance director. The Administrator was not informed of the high temperature readings, and the facility lacked functioning thermometers in key areas, further complicating the monitoring of air temperatures.
Medication and Treatment Carts Left Unlocked
Penalty
Summary
The facility failed to ensure that medication and treatment carts were locked when not in use or when not within the visual proximity of the nurse, creating a potential accident hazard. On the 3rd floor, a medication cart was observed unlocked and unattended by the RN, who acknowledged that the facility's protocol requires carts to be locked when not in use. Similarly, on the 1st floor, a treatment cart was found unlocked and unattended, with the RN admitting that it should have been locked to prevent unauthorized access to treatment medications. Additionally, the nurse's station door was left open with an unlocked medication cart inside, and no nurse was present. An LPN explained that they had left to respond to a call light, leaving the cart unsecured. The Director of Nurses confirmed that all medication and treatment carts should be locked when not in the nurse's line of sight, and acknowledged that some nurses were new graduates who might require further training. The facility's policy mandates that medication supplies be locked when not attended by authorized personnel.
Infection Control Deficiency: Improper Glove Use and Isolation Protocol Breach
Penalty
Summary
The facility failed to adhere to infection control practices regarding glove use, which could potentially affect all 24 residents on the 3rd floor. An RN was observed walking in the hallway with gloved hands, contrary to the facility's policy that gloves should not be worn in hallways and should be removed after use. Additionally, a resident on contact precaution isolation for MRSA was seen leaving an isolation room without performing hand hygiene and touching supplies on a clean cart in the hallway. This resident should not have been in contact with general supplies, as stated by an LPN who acknowledged the need for supervision of the resident. The Director of Nursing confirmed that gloves should be discarded at the door of the room after use and that residents in isolation should not access the clean linen or supplies cart. The facility's policy on proper hand washing and glove use, which lacks a documented revision date, mandates that all employees follow state and federal sanitation guidelines.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, R2 and R3, as observed during a survey. On the morning of 08/14/24, R2 was found in bed without the call light within reach, and when asked to use it, R2 stated they did not know where it was. The call light was observed on the floor, out of reach. This was confirmed by V4, an LPN, who acknowledged that the facility's policy requires call lights to be within residents' reach. Similarly, R3 was found shouting for help for incontinent care, with the call light also on the floor. V5 and V6, CNAs, confirmed that rounds are made every two hours and that call lights should be accessible to residents. The Director of Nursing, V2, reiterated that call lights should be placed within reach, in accordance with the facility's policy revised on 02/02/18, which mandates that residents capable of using call lights should have them accessible at all times.
Failure to Notify Residents of Trust Fund Balances Exceeding SSI Limits
Penalty
Summary
The facility failed to notify two residents of their trust fund balances before these balances exceeded the Social Security Administration (SSA) Supplemental Security Income (SSI) $2000.00 resource limit for individuals. This deficiency was identified during an interview and record review, which revealed that one resident had a trust fund balance of $2144.75 and another had a balance of $3522.31. The Regional Financial Coordinator incorrectly stated that a new Medicaid rule allowed residents to have up to $17000.00, which contradicted the SSA's 2024 guidelines that set the resource limit at $2000.00 for individuals. The facility was unable to provide evidence of quarterly notifications or any notifications to the residents about their trust fund balances, nor could they present a policy regarding this matter. This oversight potentially affects all 81 residents at the facility.
Failure to Provide Timely Incontinent Care for Residents
Penalty
Summary
The facility failed to provide timely personal hygiene and incontinent care for two residents, R2 and R3, who rely on staff assistance with activities of daily living (ADLs). On the morning of 08/14/24, R2 was found in bed, covered and requesting help for cleaning due to being wet and having a bowel movement. R2 also complained of a migraine headache. The Licensed Practical Nurse (LPN), V4, acknowledged the delay, attributing it to the Certified Nurse's Aides (CNAs) being busy. R2 had not been checked for incontinence since 7:30 am, despite the facility's policy of conducting rounds every two hours. R2's medical history includes a recent admission with conditions such as a non-displaced fracture, Alzheimer's disease, and dementia. Similarly, R3 was observed in an adjacent room, shouting for help with a dry brownish substance on their fingers, hair, linens, and a strong odor of urine and stool present. R3's friend, visiting from their church, expressed concern about the lack of assistance. V4 admitted that the CNAs were busy and acknowledged the risk of skin impairment from prolonged exposure to urine and stool. R3's medical records indicate a dependency on staff for personal hygiene and other ADLs, with a care plan highlighting the need for assistance with toileting and hygiene. The facility's policy on incontinence care emphasizes the importance of preventing skin breakdown and maintaining dignity, requiring checks every two hours or as needed.
Failure to Prevent Pressure Ulcers in Resident
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident, resulting in the development of avoidable bilateral buttock pressure injuries. The resident, an elderly male with Parkinson's disease, dementia, and other conditions requiring extensive assistance, was initially documented as having no pressure ulcers upon admission. However, subsequent assessments revealed the development of a stage 2 pressure ulcer and an unstageable pressure ulcer, which later progressed to a stage 3 pressure ulcer and an unstageable ulcer. Interviews and record reviews indicated several lapses in care that contributed to the resident's condition. The treatment nurse acknowledged that the resident might not have received proper wound care, turning, or nutritional support, which are critical for pressure ulcer prevention. The resident's care plan included turning and repositioning, but there were indications that these measures were not consistently implemented. Additionally, the resident's nutritional intake was inconsistent, with documented weight loss, which could have further exacerbated the risk of pressure ulcers. The facility's policies on skin condition assessment and pressure ulcer prevention were not effectively followed, as evidenced by the deterioration of the resident's wounds. The registered nurse and wound clinician noted that the resident's wounds could have been prevented with better management of pressure, nutrition, and repositioning. Despite being followed by a wound care team, the resident's condition worsened, highlighting deficiencies in the facility's care practices.
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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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