Aperion Care Westchester
Inspection history, citations, penalties and survey trends for this long-term care facility in Westchester, Illinois.
- Location
- 2901 South Wolf Road, Westchester, Illinois 60154
- CMS Provider Number
- 145660
- Inspections on file
- 39
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Aperion Care Westchester during CMS and state inspections, most recent first.
A facility failed to keep call lights within reach, ensure a bed was functioning properly, and supervise a resident at risk for falls while outside smoking. One resident with dementia, severe cognitive impairment, and multiple prior falls was found in bed with the call light on the floor and out of reach, despite a care plan requiring accessible call lights. Another resident with hemiplegia and gait imbalance was observed with a call light dangling out of sight and a bed left at knee height that could not be lowered because it was not working. A third ambulatory resident with gait imbalance and intact cognition, who requires supervision, experienced an unwitnessed fall on the smoking patio during a smoke break, and was later observed with the call light tied to the bed rail and hanging near the floor, contrary to care plan interventions and the facility’s fall prevention program.
A resident with a care plan for IV hydration therapy received D5 IV fluids based on a physician order and MAR entry that lacked a prescribed infusion rate. Nursing staff documented that IV fluids were infusing and continuously running but did not record the rate, and during interviews an RN referenced a “normal” rate used at the facility while being unable to recall the actual amount given. The DON could not provide documentation that the order had been clarified, and an LPN who administered the IV fluids was unsure of the exact order, did not recall clarifying the missing rate with the physician, and reported no awareness of standing IV orders, despite facility policy requiring complete medication orders including route, dose, time, and frequency.
Several residents did not receive their scheduled morning medications within the facility's required two-hour window, as nurses were delayed due to workload and other resident care needs. Affected residents, with varying cognitive statuses, reported receiving medications late and expressed a desire for timely administration. Review of medication records confirmed the delays, and staff interviews acknowledged the failure to follow the facility's medication administration policy.
Surveyors found that dietary staff did not follow professional standards for food handling and personal hygiene. Several staff with facial hair were not wearing beard nets, and multiple staff wore hair nets that did not fully contain their hair, despite hair and beard nets being available. The dietary supervisor initially had long hair extending below the hair net and was unsure which staff should wear beard nets. A cook prepared gravy without gloves and later checked food temperatures while wearing a glove on one hand and using an ungloved hand that contacted the food. The ADON/IP nurse stated that gloves are used to prevent cross contamination, and the FDA Food Code requires effective hair and beard restraints to prevent hair from contacting exposed food.
The facility failed to maintain an effective pest control program in the kitchen, resulting in numerous fruit flies observed in a pantry where canned goods are stored and under dishwashing equipment. During a surveyor tour with the dietary supervisor, active fruit flies were seen in the pantry, and the supervisor acknowledged their presence. The maintenance director later confirmed additional fruit fly activity in the kitchen and reported that pest control services had recently treated the area. Pest control documentation showed earlier preventative treatment with no activity noted, followed by a later report indicating treatment for fruit flies and identifying the need for deep cleaning and repair of structural issues such as broken tiles and missing grout in dish room areas. This deficiency affects all residents who receive meals prepared in the kitchen.
A resident with documented oropharyngeal dysphagia and aspiration precautions was repeatedly given meals while positioned at about 30 degrees instead of the ordered 90-degree upright posture, despite physician and speech therapy orders for strict adherence to swallow precautions and 1:1 supportive feeding. Staff, including the DON, stated the resident could reposition independently and referenced behavior of sliding down in bed, although this behavior was not observed during the survey and the resident had consumed very little of a meal when checked. Multiple incontinent residents who were dependent or required substantial assistance for toileting were found with saturated briefs or inserts, reported being wet or having to hold urine while waiting for help, and experienced delays in response to call lights. CNAs reported providing incontinence care mainly at the beginning and end of shifts, which conflicted with facility policy and nursing leadership statements that incontinent residents should be checked and changed every 2–3 hours or every two hours and as needed.
Surveyors found that staff failed to follow the facility’s medication storage and labeling policy when opened and expired medications remained on medication carts. An insulin vial in use was open and not dated, and an ophthalmic solution was kept on the cart beyond its stated 28‑day usability period. In a separate cart inspection, two residents’ insulin pen injectors were dated in a way that showed they had been open longer than the 28–30 days staff reported insulin remains usable, yet they were still on the cart. The DON confirmed that only non‑expired medications should be on the cart, that insulin and eye drops must be dated when opened, and that expired medications must be removed from active supply, consistent with the written Storage of Medication policy.
Surveyors found that staff failed to follow infection control practices for both laundry handling and blood glucose monitoring. A laundry aide handled multiple soiled linen bins and bags without wearing gloves, despite having been trained on infection control and PPE and despite facility policy and CDC guidance requiring barrier precautions when handling soiled linen. During medication pass, a nurse obtained blood glucose readings for two residents with type 2 DM using the same glucometer, placing it directly on the medication cart without a barrier, not cleaning the device between residents, and not performing hand hygiene after glove removal, contrary to facility policies on glucometer use and hand hygiene and the DON’s stated expectations.
Staff failed to provide timely toileting and incontinence care, resulting in multiple residents remaining wet or soiled for extended periods. One resident reported being left in a wet brief since breakfast and was later found with a saturated brief and liner. Another resident’s call light remained unanswered for a prolonged time despite needing a brief change, and incontinence care was delayed even after staff acknowledged the need. A third resident reported holding urine while waiting for assistance and was found with a saturated brief after staff initially checked only the front and declared it dry. CNAs reported providing incontinence care only at the beginning and end of their shifts, which conflicted with the ADON’s statement and facility policy that incontinent residents should be checked and changed approximately every 2–3 hours or every two hours.
A resident’s signed POLST form documented DNR status, but the SSD reported the resident as full code based on an alleged family revocation that was not documented in the progress notes. The resident’s face sheet, care plan, and POS all continued to list the resident as full code, and there was no record of any oral revocation of the advance directive with time, date, and place as required by the facility’s advance directives policy.
A resident’s privacy was not maintained during a bed bath when a CNA and the ADON provided care without pulling the privacy curtain, despite the roommate being present in the room and facing the resident’s bed. The resident’s gown was removed in stages, exposing the resident’s breasts and abdomen while the curtain remained open and another staff member entered the room to speak with the ADON. The ADON later acknowledged that the door and privacy curtain should be used to ensure privacy before providing direct care.
A resident reported that the floor in his room was dirty and sticky, and a surveyor confirmed this by noting that their shoes stuck to the floor when walking in the room. This condition showed that the facility did not maintain a clean and sanitary environment in accordance with its housekeeping policy intended to ensure a safe and sanitary setting for residents, staff, and visitors.
Two residents with dementia-related diagnoses were found to be receiving psychotropic medications without adequate clinical justification and documentation. For one resident, the DON initially produced consents only for gabapentin and mirtazapine, while the ADON later confirmed the resident was also on olanzapine for a psychotic disorder but could not locate a consent in the EMR and did not address its appropriateness for dementia. A consent for olanzapine dated more than a year earlier was subsequently found in the medical records office rather than in the EMR. The care plan and orders documented olanzapine use for mood disorder and as an antipsychotic, with targeted behaviors of anxiety and agitation, despite prior NP notes describing dementia without behaviors and repeatedly stating GDR was contraindicated even before antipsychotic initiation. Another resident with multiple dementia and mood-related diagnoses and intact cognition was also identified in the context of this failure to prevent unnecessary psychotropic use.
A resident with dementia, impaired cognition, and a known history of UTIs, who was always incontinent and dependent on staff for toileting, had a UA with reflex to culture ordered after family reported behavioral changes consistent with prior UTI episodes. The LPN entered the order, but there was no evidence the UA was ever collected or resulted, and progress notes and a subsequent physician visit did not reference the pending test. Staff interviews showed poor recall of the family’s concerns and lack of awareness of the UA order, despite acknowledgment that incontinence and sitting in urine are UTI risk factors. Later, after the family again reported the resident was not at baseline, the resident was sent to the hospital, where a UA confirmed a UTI and treatment was initiated; the facility’s infection surveillance form for this episode was left largely incomplete and no grievance form from the family was found.
A resident receiving gastrostomy tube feedings was found with the feeding bag hanging on an IV pole, the tubing not connected to the enteral feeding pump, and the clamps on the tubing left open. The feeding container was not labeled with the resident’s name or the date and time it was hung. The DON acknowledged that the feeding should have been connected to the pump and reported that the day-shift nurse did not know how to connect the tubing. An RN confirmed that the container should be labeled and the tubing connected to the pump to ensure the correct hourly rate, as required by the facility’s gastrostomy tube feeding policy.
Two residents receiving oxygen therapy did not have their oxygen tubing managed in accordance with physician orders and facility practice. One resident was observed with undated oxygen tubing despite an order to change, date, and label tubing weekly on the night shift. Another resident’s oxygen tubing carried dates that did not align with the weekly change dates documented on the MAR. The ADON confirmed that oxygen tubing is expected to be changed weekly, dated when changed, and that the tubing date should match the MAR, but observations and record review showed this was not consistently done.
A dependent resident with osteoarthritis, lack of coordination, and need for assistance with personal care reported that the bathroom shower call light in her room was not working, despite having previously notified maintenance. Surveyors confirmed on two separate observations that pulling the shower call cord did not activate or illuminate the call system at the room, door, or nurse’s station. Maintenance staff acknowledged awareness that the call light was not working but could not recall who reported it or when, and the facility’s policy requiring prompt reporting and monitoring of call bell defects was not produced at survey exit.
The facility did not post required daily nurse staffing information in a prominent area accessible to residents and visitors. A surveyor observed that no staffing data were displayed at the desk or nearby, and a receptionist instead provided an internal staffing schedule directly to the surveyor. The interim DON reported that HR had prepared the current day’s nursing staff census but was unable to provide the daily nursing staff census for the preceding 30 days.
The facility did not ensure that state survey results were easily accessible for residents to view without requesting staff assistance. A resident council president believed the survey binder was at the front desk, while other residents reported they did not know what the survey binder was or that it contained state inspection results. During a tour, no survey binder was visible at the front desk, and the receptionist could not locate it among binders kept behind the desk. A regional nurse consultant stated the binder should be at the front desk, and staff searched multiple areas before the DON eventually produced it, acknowledging that the receptionist did not know what the survey binder was.
The facility failed to implement effective fall prevention measures for high-risk residents, resulting in multiple falls and injuries. A resident with severe cognitive impairment experienced several falls due to inadequate supervision and inconsistent documentation. Other residents also faced deficiencies in fall risk assessments, which were either not completed timely or inaccurately documented, despite their medical histories indicating a high risk for falls.
A facility failed to prevent a resident-to-resident physical assault when a resident with a history of aggression and dementia attacked his roommate with a cane. Despite having a care plan in place to manage potential aggression, staff were unable to redirect the resident during the incident. The facility's abuse prevention policy was not effectively followed, leading to the assault.
The facility experienced a 29.63% medication error rate due to improper administration and unavailability of medications. A resident with diabetes received insulin without priming the pen and not with meals as prescribed. Additionally, three residents did not receive their prescribed medications due to unavailability. The facility's policies on medication administration and availability were not effectively followed.
The facility failed to follow infection control policies, including improper handling of a urinary catheter bag, undated oxygen equipment, and inadequate PPE use. These deficiencies affected residents with serious health conditions, such as UTIs, COPD, and tracheostomy, highlighting lapses in infection prevention measures.
A resident with severe cognitive impairment reported being choked and pinched by a CNA, but the incident was not reported to the proper authorities. Several staff members, including a CNA and an LPN, were aware of the allegation but did not report it, assuming it was already known. The facility's policy requires immediate reporting of abuse allegations, which was not followed, leading to a deficiency in abuse prevention and reporting procedures.
A resident with a history of UTIs experienced repeated failures by staff to timely empty his catheter drainage bag, despite complaints from both the resident and a family member. The facility's policy requires catheter bags to be emptied as needed to prevent infection, but observations showed this was not consistently done.
The facility failed to provide adequate nursing coverage, resulting in residents not receiving timely incontinence care. Observations showed residents left in soiled briefs due to insufficient CNAs and nurses on duty. Staffing records confirmed the lack of staff on various shifts, and the acting administrator acknowledged challenges with short-notice call-offs and finding replacements.
The facility failed to provide timely incontinence care for residents dependent on staff for daily living activities. Four residents with various medical conditions were found with soaked incontinence briefs and pads, indicating a lack of timely care. CNAs cited staffing issues and workload as reasons for the delay, despite the facility's policy requiring checks every two hours.
The facility failed to perform and document physician-ordered dressing changes for two residents with pressure ulcers, leading to infections and deterioration of their wounds. The Treatment Administration Records showed multiple instances of undocumented dressing changes, which the Director of Nursing confirmed as not done. The facility's policy requires documentation of all treatments, but this was not followed, resulting in inadequate wound care.
A facility failed to provide timely incontinence care for a resident who requires extensive assistance with ADLs. A CNA did not change the resident's incontinence brief until 4.5 hours into their shift, resulting in a saturated brief and a room smelling of urine. The DON confirmed that residents should be changed every two hours or sooner if needed. The resident's care plan and facility policy both specify checks and changes every 2-3 hours.
The facility failed to perform and document wound dressing changes as ordered for two residents. A resident with venous stasis ulcers had missed dressing changes on several dates, and the Wound Care RN was unaware of the documentation lapses. Another resident with a full-thickness wound also had missed dressing changes, with the hospice nurse not visiting on most of the missed dates. The DON confirmed that undocumented treatments are considered not done, highlighting non-compliance with the facility's policy.
The facility failed to maintain clean and sanitary resident rooms, with observations of urine-filled urinals without lids, overflowing garbage, sticky floors, and soiled beds. Multiple resident complaints and a short-staffed housekeeping department contributed to the deficiency.
The facility failed to provide adequate ADL assistance for three residents requiring support for toileting, incontinence care, nail care, and oral hygiene. One resident was found with stool leaking from his incontinence brief, another with a wet brief and a strong odor of urine, and a third reported not receiving help with oral care for months. The DON confirmed that staff should provide care every two hours, which was not followed.
Failure to Maintain Accessible Call Lights, Functional Equipment, and Supervision for Residents at Risk for Falls
Penalty
Summary
The deficiency involves the facility’s failure to maintain call lights within reach for multiple residents identified as at risk for falls, failure to ensure essential equipment was functioning, and failure to supervise a resident at risk for falls while outside smoking. One resident with dementia, bipolar disorder, end stage renal disease, difficulty walking, and a high fall risk score had a care plan requiring the call light to be within reach and prompt response to requests for assistance. This resident had seven documented falls over a 24‑month period, and the facility could not produce the fall occurrence note for one of those falls. During observation, the resident was lying in bed on a bordered mattress with the call light on the floor and out of reach, while alone in the room. The CNA assigned to this resident acknowledged the call light had been on the floor and confirmed the resident could not transfer independently. Another resident with hemiplegia/hemiparesis, gait imbalance, moderate cognitive impairment, and a documented fall risk had a care plan requiring the call light to be within reach and the bed to be in the low position. This resident had a recent fall and was described by the restorative nurse as intermittently confused and needing assistance with transfers but not always asking for help. On observation, the resident was in bed with the call light tied to the side rail and the button dangling below the bed, out of sight, and the bed was at about knee height rather than in the lowest position. When the assigned CNA attempted to lower the bed, it was discovered that the bed was unplugged and, even after plugging it in, the bed still did not work, and the CNA stated the bed was not working. A third resident with dementia, osteoarthritis of the hip, weakness, gait/balance problems, and poor safety awareness had a care plan requiring the call light to be within reach and use of a walker as a fall prevention intervention. This resident experienced an unwitnessed fall on the smoking patio, reporting that she lost her balance while turning and fell into the bushes during a smoke break, with no staff present to witness the event. The restorative nurse stated the resident is alert, ambulatory with a walker, has gait imbalance, and requires supervision. During observation, this resident was sitting on the bed with the call light tied to the side rail and hanging near the floor. The CNA assigned to this resident confirmed the call light was wrapped around the bed rail and hanging down, acknowledged that call lights should be across the bed within reach, and noted that not all facility call lights have clips. The facility’s fall prevention program requires safety interventions to be implemented and maintained for residents at risk, malfunctioning equipment to be reported or removed from service, and residents to be checked regularly to assure safe positioning.
Failure to Clarify and Document IV Fluid Infusion Rate
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe and appropriate administration of IV fluids for a resident who required IV hydration therapy. The resident’s care plan, revised on 1/29/26, identified a need for IV fluids/medications related to hydration therapy with an intervention to provide IV fluids as ordered. However, the physician order dated 1/1/26 for Dextrose 5% IV solution specified “Use 2 liter intravenously one time only for dehydration for 2 days” but did not include an infusion rate. This incomplete order was transcribed onto the January 2026 MAR with the same missing infusion rate, and the MAR documented that the IV fluid was administered at 6:32 p.m. without any documentation of the rate. Progress notes dated 1/2/26 stated that D5 normal saline IV fluids were infusing and continuously running, but again did not include the infusion rate. During surveyor interviews on 3/4/26, an RN stated that they followed the order and that staff “normally” run IV fluids at 75 mL per hour at the facility, but could not recall how much IV fluid the resident actually received. The DON initially stated that it was not possible that IV fluids were administered without a prescribed rate and later reported having spoken with a pharmacist who said IV fluid orders are based on patient weight, but no documentation of this was provided. The MAR showed that an LPN administered the D5 IV fluid on 1/1/26; when questioned, the LPN was unsure of the exact order, could not recall the infusion rate, and did not remember clarifying the incomplete order with the physician. The LPN stated that they would call a physician if there was a question about an order but did not recall doing so in this case and was not aware of any standing orders for IV fluids. The facility’s physician orders policy required that medication orders include route, dose, time, and frequency, and that verbal/telephone orders be documented in the electronic medical record, but there was no evidence that the IV fluid order was clarified or completed to include an infusion rate prior to administration.
Failure to Administer Medications in a Timely Manner
Penalty
Summary
The facility failed to follow its Medication Administration Policy by not administering medications in a timely manner to four residents. Observations revealed that multiple nurses were delayed in passing morning medications, with some residents receiving their scheduled 8:00 AM medications as late as 10:30 AM. Staff interviews confirmed these delays, with explanations including a high number of residents to medicate, residents requiring preparation for appointments, and attending to residents with acute symptoms. The facility's policy requires medications to be administered within a two-hour window around the scheduled time, which was not adhered to in these instances. Residents affected included individuals with varying levels of cognitive impairment and intact cognition, all of whom expressed a preference for receiving their medications on time. Medication Administration Records (MAR) and Physician Orders Sheets (POS) confirmed that prescribed medications, such as antihypertensives, anticoagulants, and other daily medications, were not administered within the required timeframe. The Director of Nursing acknowledged that staff are expected to follow the five rights of medication administration, including the right time, and that the observed practice did not meet this standard.
Improper Use of Hair Restraints and Gloves During Food Preparation and Temperature Checks
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service practices related to failure to follow professional standards for food handling and personal hygiene. On 7/22/25, with a facility census of 114 residents and four residents identified as strict nothing by mouth, multiple dietary staff members were observed in the kitchen with facial hair and without beard nets. Several staff, including the cook and dietary aides, had hair nets that did not fully contain their hair, with hair extending below the nets. A bag of hair nets and a bag of beard nets were observed available at the kitchen door, yet the dietary supervisor initially wore a hair net with long hair extending below it and only adjusted it after being questioned. When asked if staff should be wearing beard nets, the dietary supervisor stated he did not know, and when asked about hair coverage, he acknowledged that all hair should be in the hair net. On the same day, the cook was observed preparing gravy for the lunch meal service without wearing gloves. Later, while checking food temperatures prior to serving the meal, the cook wore a glove on the left hand but used an ungloved right hand to check temperatures, with the back of the right hand touching the food. The ADON/infection prevention nurse stated that gloves are worn to prevent cross contamination. The report cites the 2022 FDA Food Code, which states that food service employees shall wear hair restraints and beard restraints designed and worn to effectively keep their hair from contacting exposed foods.
Failure to Maintain Effective Pest Control in Kitchen Areas
Penalty
Summary
The facility failed to maintain an effective pest control program and to ensure the kitchen area was free from flying insects, specifically fruit flies, affecting all residents who receive meals there. During a kitchen tour with the dietary supervisor, a surveyor observed numerous fruit flies in the pantry where canned goods are stored. The dietary supervisor acknowledged the presence of fruit flies, stated that no food was stored in the pantry, and noted that the outside pest control company had treated the kitchen the previous day. The maintenance director later reported that additional traps for fruit flies were being placed throughout the facility, mostly in the kitchen, and that fruit flies had been seen under the dishwasher after being informed by the dietary supervisor of fruit flies in the kitchen. A pest control service inspection report from earlier in the month documented only preventative treatment with no pest activity seen, while a subsequent report documented treatment for fruit flies and identified the need for deep cleaning in dish room areas, especially under the dishwasher, the food extractor, and in corners, as well as repair of broken tiles and missing grout to address conditions contributing to fruit fly breeding. No specific residents or their medical histories are mentioned in the report, but the deficiency applies to all residents receiving meals prepared in the affected kitchen areas.
Failure to Follow Aspiration Precautions and Provide Timely Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and speech therapy recommendations for safe feeding positioning, and failure to follow its own incontinence care policy requiring checks at least every two hours or as needed. One resident with documented oropharyngeal dysphagia and aspiration precautions was repeatedly observed receiving meals while not positioned upright at 90 degrees as ordered. This resident was seen in a reclining chair at approximately 30 degrees while being fed lunch and coughing after each bite, and later in bed with the head elevated only about 30 degrees while breakfast was placed in front of them. When the resident requested that the head of the bed be raised, a CNA stated the resident could do it independently and left the room. The DON later stated the resident was alert and oriented and “keeps scooting self-down in bed,” but when the room was entered, the resident had eaten only two bites of breakfast and was not positioned as ordered. During the survey, the resident was not observed sliding down in bed or chair. Clinical records for this resident included a modified barium swallow study documenting at least moderate oropharyngeal dysphagia with reduced bolus control, delayed swallow initiation, and suspected reduced swallow safety with possible aspiration, along with recommendations for a puree diet, teaspoon sips of thin liquids, slow 1:1 supportive feeding assistance, and strict adherence to swallow precautions in an upright/midline 90-degree position. The physician order sheet documented puree solids and nectar thick liquids, upright positioning for all oral intake, slow rate, small bites/sips, alternating solids and liquids, no straws, and aspiration precautions. A speech therapy discharge summary reiterated the need for upright posture during meals and for more than 30 minutes after meals, with prognosis dependent on staff follow-through. Despite these orders and recommendations, staff and nursing leadership relied on the assertion that the resident could reposition independently and did not ensure the ordered upright positioning during meals. The facility also failed to provide incontinence care at least every two hours or as needed, as required by its incontinence care policy. One resident was observed with a large bulging brief; upon assessment by a nurse, the resident was found wearing a brief with a urine-soaked and saturated insert, and the nurse stated it took over two hours to become that saturated and was unsure when the last incontinence care was provided. Another resident reported being wet and that staff would not change the brief; when a CNA provided care, the resident was found with a saturated panty liner inside a saturated brief, and the CNA stated they provided incontinence care only twice per shift (at the beginning and end). A third resident activated the call light and indicated the need for a brief change; staff turned off the call light, informed another CNA, and incontinence care was not provided until approximately 25 minutes after the initial observation. A fourth resident stated they needed to use the bathroom and had been holding urine while waiting for staff; when checked, the front of the brief appeared dry, but the back was saturated with urine. CNAs reported providing incontinence care at the beginning and end of shifts, while the DON and ADON stated incontinent residents should be checked and changed every 2–3 hours or every two hours and as needed. MDS assessments documented that these residents were always or frequently incontinent and required staff assistance for toileting, and one resident’s care plan called for peri-care after each incontinent episode.
Failure to Remove Expired Medications and Date Opened Insulin and Eye Drops
Penalty
Summary
Surveyors identified a failure to follow the facility’s medication storage and labeling policy, specifically related to opened and expired medications on medication carts. During a medication cart inspection with a nurse, one resident’s lispro insulin vial was observed to be open, in use, and not dated, despite the facility policy requiring that the date opened be written on the container when the manufacturer’s seal is broken. Another resident’s Brimonidine ophthalmic solution was found on the cart with a date indicating it had exceeded the 28‑day usability period identified by the nurse, who acknowledged that the eye drops were expired and that expired medications should not remain on the cart. In a separate medication cart inspection with another nurse, two residents’ insulin pen injectors (Fiasp FlexTouch and Lyumjev KwikPen) were observed with dates indicating they had been open beyond the 30‑day period the nurse stated insulin remains usable, and the nurse confirmed both insulins were expired and should not be on the cart. The DON stated that only non‑expired medications should be on the medication cart, that insulin is good for 28–30 days after opening, and that eye drops are good for 30 days, and also confirmed that opened insulin and eye drops should be dated on the package when first opened. The facility’s Storage of Medication policy states that outdated medications must be immediately removed from inventory and that containers must be dated when first opened, with undated vials defaulting to the dispensed date for expiration calculation, and that all expired medications must be removed from active supply and destroyed.
Infection Control Failures in Laundry Handling and Glucose Monitoring
Penalty
Summary
Surveyors identified deficiencies in the facility’s infection prevention and control practices related to handling soiled laundry and performing blood glucose testing. On the 200 hall, a laundry aide was observed removing laundry from multiple soiled bins and adjusting soiled laundry bags on her cart without wearing gloves. The aide stated that staff were told not to wear gloves when collecting laundry in the hallway. The facility’s Infection Preventionist later stated that gloves should be worn when handling soiled items, including laundry, and specifically when removing laundry from bins because the items are soiled and in case the bag tears. The aide’s orientation checklist indicated she had been trained on linen handling, infection control procedures, and use of personal protective equipment. The facility’s Infection Prevention and Control Program policy required all personnel to routinely wash hands and use appropriate barrier precautions to prevent transmission of infections, and CDC guidance cited by the surveyors stated that reusable rubber gloves should always be worn before handling soiled linen. Surveyors also found that nursing staff failed to follow the facility’s glucose testing policy and hand hygiene requirements during blood glucose monitoring for two residents with type 2 diabetes mellitus. During a medication pass, a nurse donned gloves, obtained a blood glucose level for one resident, then placed the used glucometer directly on the medication cart without a barrier, without cleaning the device, and without performing hand hygiene after removing gloves. Shortly afterward, the same nurse donned new gloves and used the same uncleaned glucometer to obtain a blood glucose level of 147 mg/dL for another resident, again without cleaning the glucometer or performing hand hygiene after glove removal. The nurse later acknowledged he was supposed to wash or sanitize his hands before and after donning and doffing gloves and between each resident, and to clean the glucometer between residents with bleach wipes. The DON stated she expected nursing staff to follow the glucometer policy, including placing a barrier on the surface, performing hand hygiene before and after glove use, and cleaning the glucometer. Facility policies on glucose testing and hand hygiene required use of a clean barrier on surfaces, removal of gloves and hand hygiene, and hand hygiene at room entry, before aseptic tasks, after contact with blood or body fluids, and after glove removal.
Failure to Provide Timely Toileting and Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide timely toileting and incontinence care, resulting in residents remaining wet or soiled for extended periods. One resident reported being wet and stated that staff would not change her brief, adding that she had not been changed since being placed in a reclining chair for breakfast. When a CNA later provided incontinence care, the resident was found with a saturated panty liner and a saturated brief. The CNA stated that incontinence care was provided to assigned residents only twice per shift, once at the beginning and once at the end of the shift, which did not align with the facility’s policy or the ADON’s expectations for checks every 2–3 hours. Another resident’s call light was observed to be on for an extended period before staff responded. When asked, the resident indicated a need for a brief change. A CNA entered the room, turned off the call light, exited, and only later informed another CNA that the resident needed incontinence care, which was not provided until several minutes afterward. A third resident stated she needed to use the bathroom and had been holding her urine while waiting for staff. After being taken to her room, the CNA initially checked only the front of the brief and stated it was dry; when asked to check the back, the brief was found to be saturated with urine. This CNA also reported providing incontinence care only at the beginning and end of the shift. The ADON and the written incontinence care policy both indicated that incontinent residents should be checked and changed every 2–3 hours or every two hours, more often for heavy wetters, which contrasted with the observed practices.
Failure to Accurately Reflect DNR Status in Medical Record
Penalty
Summary
The facility failed to accurately incorporate a resident’s directive for life-sustaining treatment into the medical record when a completed and signed POLST form documented a DNR (do not resuscitate) order, but multiple parts of the record continued to identify the resident as full code. During an interview, the SSD stated that the resident was full code and that the family had revoked the DNR status, but when the SSD and surveyor reviewed the SSD’s progress notes together, there was no documentation that the DNR had been revoked. The SSD also acknowledged that neither the resident’s care plan nor the face sheet had been updated to reflect any change in code status. At the time of review, the face sheet, care plan, and physician order sheet all listed the resident as full code despite the signed DNR on the POLST form. The facility’s advance directives policy required that advance directives, including CPR and POLST forms, be included in the plan of care, reviewed during care plan meetings, and that any oral revocation be documented in the health record with time, date, and place, which had not been done in this case. This deficiency affected one resident whose advance directive for life-sustaining treatment was not consistently or accurately reflected across the medical record, including the care plan, face sheet, and physician orders, and for whom there was no documented evidence of revocation of the existing DNR order as required by facility policy.
Failure to Provide Privacy During Bed Bath
Penalty
Summary
The facility failed to maintain privacy and confidentiality of a resident’s personal and medical care during a bed bath. During an observation on 7/23/25 at 9:35 AM, a CNA and the ADON entered the resident’s room and closed the door, while the resident’s roommate remained in the room sitting in a wheelchair facing the resident’s bed. The CNA gathered supplies to provide a bath but did not pull the privacy curtain around the resident’s bed. The CNA then removed the resident’s right arm from the gown, exposing the right breast, and subsequently removed the left arm from the gown, exposing both breasts and the abdomen, all while the privacy curtain remained open and the roommate was present and facing the bed. Another staff member entered the room and spoke with the ADON while the resident remained exposed, and only afterward did the CNA pull the privacy curtain to finish bathing the resident. On 7/25/25 at 9:50 AM, the ADON stated that the resident’s door should be closed and the privacy curtain pulled around the resident’s bed to provide privacy prior to providing resident care.
Failure to Maintain Clean and Sanitary Resident Room Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary resident room environment for one resident when the floor in the resident’s room was observed to be dirty and sticky. During an observation, the resident reported that the floor in his room was dirty and sticky, and the surveyor’s shoes stuck to the floor when walking in the room. The facility had a housekeeping policy, with no date noted, that stated it was to provide guidelines to maintain a safe and sanitary environment for residents, staff, and visitors, but the condition of this resident’s room floor did not meet that standard.
Failure to Ensure Appropriate Indication and Consent for Antipsychotic Medication Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate use and documentation of antipsychotic medications, including having an appropriate diagnosis, identifying specific target behaviors, and maintaining required consents. For one resident (R9) with diagnoses including unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, the DON initially provided only psychotropic consents for gabapentin and mirtazapine and confirmed these were all of the resident’s psychotropic consents. The ADON later identified that R9 was also receiving olanzapine for a psychotic disorder but could not locate a corresponding consent in the electronic medical record and did not respond when asked if olanzapine was appropriate for a resident with dementia. A signed consent for olanzapine dated 4/10/24 was later produced from the medical records office, and the ADON acknowledged it should have been in the electronic record but could not explain why it had not been uploaded or how it was located so quickly after more than a year. R9’s care plan noted use of olanzapine related to a mood disorder, and the physician order sheet documented olanzapine 2.5 mg at bedtime as an antipsychotic, with a psychotropic medication intervention review listing anxiety and agitation as targeted behaviors. However, prior to initiation of olanzapine, the psychiatry NP’s documentation described R9 as having dementia without behaviors, with fair judgment, fair short-term memory, adequate long-term memory, and ability to obey commands, and the NP repeatedly documented that gradual dose reduction was contraindicated even before any antipsychotic was started and continued this after olanzapine was initiated. The report notes that, per the FDA, olanzapine is approved for schizophrenia and is not approved for treatment of dementia-related psychosis, and that elderly residents with dementia-related psychosis treated with antipsychotic drugs are at increased risk of death. Another resident (R8) was also identified as having dementia-related diagnoses, including unspecified dementia without behavioral disturbance, psychotic disturbances, mood disturbance, depression, and anxiety disorder, with an intact cognitive score, in the context of the facility’s failure to prevent unnecessary psychotropic medication use.
Failure to Complete Ordered Urine Analysis for Resident With History of UTIs
Penalty
Summary
The deficiency involves the facility’s failure to follow through on a physician order for a urine analysis (UA) for a resident with a known history of urinary tract infections (UTIs). The resident had impaired cognition with diagnoses including Alzheimer’s disease, major depressive disorder, and dementia, and was documented as always incontinent of urine and dependent on staff for toileting hygiene. On 4/6/25, after the resident’s daughter reported that the resident was “rambling,” which she recognized as a sign of developing UTI, an LPN entered an order for a UA with reflex to culture. However, there were no UA results in the record corresponding to this order, and no documentation that the ordered test was obtained. Interviews showed that staff were aware of the resident’s incontinence and risk factors for UTI, but key personnel either did not recall the family’s concerns or were not present. The CNA caring for the resident reported that the resident did not communicate needs and was always incontinent, and the Infection Preventionist later confirmed that incontinence and sitting in urine are risk factors for UTI and that the resident had a past history of UTIs. The LPN who wrote the UA order stated that if a change in condition is reported, they assess, notify the physician, and document, and that urine collection orders are passed to the next shift if not completed; however, the LPN did not recall specific family reports about the need for a UA and there was no evidence the UA was ever collected. The NP, who saw the resident routinely on 4/7/25, stated she was not aware of the UA order and indicated she would expect staff to carry out any orders given. Progress notes between 4/6/25 and 4/25/25 did not reference the 4/6/25 UA order. The physician saw the resident on 4/17/25 and reviewed labs from March, again with no mention of the pending UA. On 4/24/25, progress notes documented the family reporting to the DON that the resident was not at baseline; the physician then offered labs and UA with culture and sensitivity, and the family requested transfer to the hospital. The resident was transported to the hospital, where records showed a diagnosis of acute cystitis/UTI, a UA collected on 4/24/25 meeting criteria for urinary infection, and treatment with Rocephin followed by an oral antibiotic prescription. The facility’s McGeer Criteria form for this infection episode was incomplete, and no concern/grievance form from the family was found for that month.
Improper Management and Labeling of Enteral Feeding Setup
Penalty
Summary
The facility failed to ensure proper administration and management of enteral feeding for a resident receiving gastrostomy tube feedings. During observation, the resident summoned the surveyor and pointed to his gastrostomy feeding setup, which was hanging on an IV pole with the feeding tubing not connected to the feeding pump and the clamps on the tubing left open. The feeding container was not labeled with the resident’s name or the date and time it was hung. When interviewed in the room, the DON acknowledged that the feeding should not be running in that manner, stated that the tubing should be connected to the pump, and reported that the day-shift nurse did not know how to connect the tubing to the feeding pump, adding that nurses are expected to ask the DON for assistance if they do not know how to use the equipment. A RN also confirmed that the feeding container should be labeled with the resident’s name and the date and time the feeding was started, and that the tubing should be connected to the feeding pump to ensure the correct hourly amount is administered. The facility’s gastrostomy tube feeding and care policy, revised 8/3/20, states that cyclic feedings are a prescribed amount of formula volume given over a specific period of time by an enteral feeding pump, and that the feeding container should be labeled with the resident’s name, flow rate, and the date and time it was hung. The observed failure to connect the tubing to the pump, to close the clamps, and to label the feeding container as required by policy led to the identified deficiency for this resident receiving enteral nutrition.
Failure to Consistently Change and Date Oxygen Tubing per Orders
Penalty
Summary
Surveyors identified a deficiency in the facility’s provision of respiratory care related to changing and dating oxygen tubing as ordered. One resident was observed in their room with oxygen tubing placed behind them that was not dated, despite a physician order dated 9/18/22 directing that oxygen tubing be changed out, dated, and labeled every Sunday on the night shift. Another resident was observed in the dining room with oxygen tubing dated 7/14/25, and on a later observation the same resident’s oxygen tubing was dated 7/23/25, while the July 2025 MAR documented that this resident’s oxygen tubing had been changed on 7/13 and 7/20. The ADON stated that oxygen tubing is to be changed weekly and as needed, that it should be dated when changed, and that the date on the tubing should match the date documented on the MAR, but observations and record review showed that this practice was not consistently followed for these two residents receiving oxygen therapy. These findings demonstrate that the facility did not ensure oxygen tubing was changed and dated weekly in accordance with physician orders and facility practice for two residents reviewed for respiratory care, as evidenced by undated tubing for one resident and discrepancies between tubing dates and MAR documentation for another resident.
Failure to Maintain Functioning Bathroom/Shower Call Light System
Penalty
Summary
The deficiency involves the facility’s failure to ensure a functioning call light system in a resident bathroom/shower area. One dependent resident with diagnoses including unspecified osteoarthritis, lack of coordination, and a need for assistance with personal care reported that the shower call light in her bathroom was not working. She stated that the call light should be operational so she can pull the string to obtain staff assistance and reported that she had informed maintenance about the problem the prior week. During the surveyor’s observation, when the shower call cord in this resident’s bathroom was pulled, the string did not pull properly and the call light did not illuminate at the call light box or above the entry door to the room. On a subsequent observation with maintenance staff, the same shower call light still did not function; it did not illuminate at the call box, above the door, or activate at the nurse’s station. The maintenance staff member stated that call lights should function by activating and lighting above the door and registering at the nurse’s station and acknowledged being made aware that this bathroom shower call light was not working, but could not recall who informed him or when he was informed. The facility’s call light policy states that call bell system defects will be reported promptly to maintenance for servicing and that rooms should be checked frequently until the system is repaired. The facility did not provide a policy for a functioning call light system at the time of survey exit.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information in a prominent area accessible to residents and visitors. On 07/22/2025 at 11:49 AM, the surveyor observed that staffing information was not posted at the desk; instead, the receptionist (V5) handed the surveyor the staffing schedule for review. The surveyor checked the surrounding area and did not see any staffing posting. Later that day, at 1:56 PM, the interim DON (V3) stated that Human Resources staff (V2) had created the daily nursing staff census for that day but reported being unable to provide the daily nursing staff census for the past 30 days. No resident-specific information or medical histories were documented in relation to this deficiency.
Failure to Make State Survey Results Readily Accessible to Residents
Penalty
Summary
The facility failed to ensure that state inspection/survey results were readily accessible for residents to view without having to request them from staff. During interviews, the resident council president stated that the survey binder with state inspections was kept at the front desk, while two other residents reported they did not know what the survey binder was or that it contained state survey results. On a subsequent tour, no survey binder was observed in public view at the front desk. When surveyors requested to review the survey binder, the receptionist searched binders located behind the desk and stated the survey binder was not there. The Regional Nurse Consultant reported that the survey binder should be at the front desk, and the Regional Nurse Consultant and another staff member searched the administrator’s office and areas around the front desk and foyer. The DON later produced the survey binder and stated that the receptionist did not know what the survey binder was, and when asked whether the receptionist should know what it was or whether it should be available for residents to review without asking, the DON declined to answer. This deficiency affected four residents in the sample reviewed for residents’ rights related to access to state inspection results, including the resident council president and other residents who were unaware of the survey binder or its contents.
Failure to Implement Effective Fall Prevention Measures
Penalty
Summary
The facility failed to develop an effective plan to prevent and reduce the risk of falls for residents identified as high risk, and did not follow their fall prevention protocol to complete fall risk assessments quarterly and accurately assess and document fall risk factors. This deficiency affected six residents, all of whom were reviewed for falls and fall risk assessments. One resident, identified as R1, experienced multiple falls, including an unwitnessed fall in his room and two falls in the dining room, resulting in injuries that required medical attention. R1, a resident with severe cognitive impairment and a history of falls, was not adequately supervised despite being identified as high risk for falls. The facility's staff failed to document a fall incident accurately and did not complete a fall risk assessment following the incident. R1's care plan included several risk factors such as impulsive behavior, poor balance, and unsteady gait, yet the interventions in place were insufficient to prevent further falls. The facility's staff, including the Restorative Nurse/Fall Coordinator and the Director of Nursing, provided conflicting accounts of the incidents and the measures taken, indicating a lack of consistent and effective fall prevention strategies. Other residents, such as R2, R4, R5, R6, and R7, also experienced deficiencies in their fall risk assessments. These assessments were either not completed timely, inaccurately documented, or failed to identify the residents as at risk for falls despite their medical histories and conditions. The facility's fall prevention program, which was supposed to include regular assessments and appropriate interventions, was not effectively implemented, leading to a failure in identifying and mitigating fall risks for these residents.
Failure to Prevent Resident-to-Resident Physical Assault
Penalty
Summary
The facility failed to adhere to its abuse prevention policy, resulting in an incident of resident-to-resident physical assault. On 9/3/24, a resident (R2) with a history of aggressive behavior and a diagnosis of dementia and psychotic disturbance, attacked his roommate (R3) with a cane. This incident occurred despite R2's care plan, which identified the potential for physical aggression and included interventions to prevent escalation of agitation. Staff members, including an LPN and a CNA, reported that R2 was non-redirectable and aggressive at the time of the incident, although R2 had previously been redirectable when exhibiting similar behaviors. The facility's abuse investigation report and R2's hospital records indicate that R2 had been physically and verbally aggressive towards staff and his roommate. R2's aggressive behavior assessment noted moderate problems with general awareness and a history of non-compliance with medications and treatment. Despite these documented issues, the facility did not effectively intervene to prevent the assault on R3. The facility's abuse prevention and reporting policy defines abuse as the willful infliction of injury, which includes actions by cognitively impaired residents who strike out at others.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 29.63%. This involved four residents out of a sample of 47. The errors included failure to prime an insulin pen before administration and administering insulin at incorrect times relative to meals. Specifically, a resident with Type 2 Diabetes Mellitus was given insulin without priming the pen and not in conjunction with meals as prescribed. Additionally, the facility did not ensure the availability of medications during administration. Two residents did not receive their prescribed medications because the medications were not available. One resident with Acute on Chronic Systolic Heart Failure and Paroxysmal Atrial Fibrillation did not receive Midodrine due to unavailability, and another resident with Hypertensive Urgency did not receive Hydralazine for the same reason. A third resident with Atrial Fibrillation and Hypertension also did not receive Metoprolol as it was not available during medication pass. The facility's policies require medications to be administered as prescribed and to be readily available. However, the staff failed to follow these guidelines, as evidenced by the lack of medication availability and improper administration techniques. The Director of Nursing acknowledged the procedures for checking medication availability and the use of emergency kits, but these were not effectively implemented, leading to the deficiencies observed.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies, resulting in several deficiencies. Observations revealed that a resident's catheter urinary drainage bag was left uncovered and lying on the floor, contrary to the facility's policy that requires such bags to be protected from contaminated surfaces. This resident, who has a history of UTIs and other serious health conditions, reported experiencing discomfort and burning sensations, which he attributed to the improper handling of his catheter bag. Additionally, the facility did not follow its procedures for oxygen equipment management. Multiple residents were observed with oxygen tubing and humidifier bottles that were not dated, as required by the facility's policy. This oversight was noted in residents with significant respiratory and cardiovascular conditions, including COPD and heart failure, who rely on supplemental oxygen for their care. The facility also failed to implement proper hand hygiene and personal protective equipment (PPE) protocols. A staff member was observed providing care to a resident on Enhanced Barrier Precautions without donning a gown or performing hand hygiene before and after the procedure. This resident had a tracheostomy and was under contact precautions for ESBL, highlighting the critical need for strict adherence to infection control measures to prevent the spread of multidrug-resistant organisms.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, identified as R73, who has severe cognitive impairment and requires substantial assistance with daily activities. R73 reported being choked and pinched by a Certified Nursing Assistant (CNA) named V8, which allegedly occurred three weeks prior to the surveyor's interview. Despite the resident's communication challenges, he was able to convey the incident using gestures and verbal responses. The resident expressed dissatisfaction with the facility and mentioned wanting to leave. During the investigation, it was revealed that several staff members were aware of the allegation but did not report it to the appropriate authorities. A CNA, V19, heard about the incident from a coworker but did not report it, assuming it was already known. Similarly, an LPN, V18, was informed by the resident about the choking incident but did not report it, believing the administrator, V1, was already aware. The administrator, V1, claimed to have no prior knowledge of the incident until informed by the surveyor. The facility's policy requires immediate reporting of any abuse allegations to the administrator or a designated individual in their absence. However, this protocol was not followed, as evidenced by the lack of communication and reporting among staff members. The administrator acknowledged that the staff should have reported the incident and followed up on the information they received. The failure to report the abuse allegation promptly is a significant deficiency in the facility's abuse prevention and reporting procedures.
Failure to Timely Empty Catheter Bags
Penalty
Summary
The facility failed to adhere to its policy and procedures for urinary catheter care by not ensuring timely emptying of a catheter urinary drainage bag for a resident with a history of urinary tract infections (UTIs). The resident, a male with multiple diagnoses including neuromuscular bladder dysfunction and pressure ulcers, was observed on multiple occasions with an extremely full catheter bag. The resident expressed concerns about the potential for complications if the bag was not emptied, stating that staff frequently forgot to do so. Despite complaints from both the resident and a family member, the issue persisted. The Director of Nursing acknowledged that catheter bags should be emptied before becoming completely full to prevent infection, and that all nursing staff are responsible for this task. The facility's urinary catheter care policy, reviewed during the survey, states that catheter drainage bags should be emptied as needed to reduce the risk of infection. However, observations and interviews indicated that this policy was not consistently followed, leading to the deficiency noted in the report.
Inadequate Staffing Leads to Resident Neglect
Penalty
Summary
The facility failed to provide sufficient nursing coverage on specific days and shifts, which affected the care and assistance provided to residents. On one occasion, a resident receiving oxygen treatment reported that her incontinence brief was not changed in a timely manner, leading to her being left in a soiled state from the previous night until the morning. Another resident also experienced similar neglect, with her brief not being changed since the previous night, resulting in her being left in a soiled condition. Observations confirmed that other residents' briefs were saturated with urine, indicating a lack of adequate care. The facility's staffing records revealed that there were insufficient numbers of CNAs and nurses on various shifts, which contributed to the inadequate care provided to residents. For instance, during a night shift, only one CNA was available for a unit with 43 residents, and there were only two nurses on duty during certain night shifts. The staffing coordinator and acting administrator acknowledged the staffing issues, citing challenges with staff calling off at short notice and the difficulty in finding replacements. Despite efforts to offer bonuses and petition for additional staff, the facility did not present a policy regarding staffing as requested.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for residents who are dependent on staff for activities of daily living. This deficiency was observed in four residents, each with specific medical conditions requiring assistance. For instance, one resident with Chronic Obstructive Pulmonary Disease and Parkinson's Disease was found with a fully soaked incontinence brief and pad, indicating a lack of timely care. The CNA responsible admitted to being busy and unable to change the resident since the night shift. Another resident with Acute and Chronic Respiratory Failure and Heart Failure was also found in a similar state, having not been changed since the previous night, despite calling for assistance since early morning. The report further details similar deficiencies for two other residents, one with Primary Generalized Osteoarthritis and Major Depressive Disorder, and another with Heart Failure and Hemiplegia. Both were found with fully soaked briefs and pads, with one resident also having a bowel movement in the brief. The CNAs involved cited staffing issues and workload as reasons for the delay in care. The facility's policy mandates checking and changing residents every two hours, which was not adhered to, as evidenced by the observations and interviews conducted during the survey.
Failure to Perform and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to perform pressure ulcer dressing changes as ordered by the physician for two residents, leading to significant health issues. Resident 1 was admitted with an unstageable pressure ulcer on the right heel, which progressed to a stage 4 ulcer with heavy purulent drainage, indicating an infection. The Treatment Administration Record (TAR) showed multiple instances where the ordered dressing changes were not documented, suggesting they were not performed. The wound culture confirmed an infection, and the resident was on antibiotic therapy. The Director of Nursing confirmed that if treatments are not documented, they are considered not done, and the wound physician emphasized the importance of regular dressing changes to prevent infection. Resident 2 was admitted with an unstageable left trochanter pressure ulcer. The TAR indicated that numerous dressing changes were not documented, similar to Resident 1. The facility's policy requires that all physician-ordered treatments be documented in the TAR, but this was not adhered to, leading to a lack of proper wound care. The Director of Nursing reiterated that treatments must be documented, and the failure to do so suggests they were not completed, contributing to the residents' deteriorating wound conditions.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident who requires extensive assistance with activities of daily living. On the morning of June 28, 2024, a Certified Nursing Assistant (CNA) began their shift at 6:00 AM and did not change the resident's incontinence brief until 10:30 AM. During this time, the resident's room smelled of urine, and the brief was saturated. The CNA admitted that the resident had not been changed since before the start of their shift, approximately 4.5 hours prior. The Director of Nursing confirmed that incontinent residents should be changed every two hours or sooner if needed, and that four hours is too long. The resident's Minimum Data Set assessment indicates that she is dependent on staff for toileting and is always incontinent of urine and stool. Her Bowel and Bladder Incontinence Care Plan specifies that she should be checked and changed every 2-3 hours and as needed. The facility's Incontinence Care Policy, revised in April 2021, also states that incontinent residents should be checked approximately every two hours and provided with perineal and genital care after each episode.
Failure to Perform and Document Wound Dressing Changes
Penalty
Summary
The facility failed to ensure that wound dressing changes were performed as ordered by the physician for two residents, R1 and R6. For R6, the Wound Care Registered Nurse (V11) was observed performing a dressing change on the resident's left lower leg, which had multiple open areas with bright red blood. The dressing was supposed to be changed every Monday, Wednesday, and Friday, but the Treatment Administration Record (TAR) showed missed dressing changes on several dates in May and June. V11 admitted to not knowing why these changes were not documented, and the Director of Nursing (V2) confirmed that if a treatment is not documented, it is considered not done. R6's care plan indicated the presence of venous stasis ulcers, and the facility's policy required documentation of treatments on the TAR. Similarly, R1 had a full-thickness wound on her right lateral calf, with physician orders for daily dressing changes. However, the TAR indicated that these changes were not performed on multiple occasions in April and May. V11 stated that the hospice nurse would perform dressing changes, but the Hospice Communication Log showed that the nurse did not visit R1 on most of the missed dates. The Director of Nursing reiterated the importance of documenting treatments, as per the facility's policy. R1's care plan included interventions for wound treatment as ordered, but the lack of documentation suggested non-compliance with the prescribed care.
Failure to Maintain Clean and Sanitary Resident Rooms
Penalty
Summary
The facility failed to maintain resident rooms in a clean and sanitary manner for four residents. Observations included a urinal filled with urine without a lid placed next to a sandwich, an overflowing garbage container, and sticky floors in the hallway. Additionally, another resident's urinal was found half-filled with urine next to a glass of drinking water. In one room, a foul odor was present, and the floor was littered with food debris and garbage. One resident's bed was soiled with food debris, and another resident was found lying on a bare mattress with stool leaking from an incontinence brief. The facility's records showed multiple complaints from residents about the cleanliness of their rooms and common areas. The Housekeeping Supervisor acknowledged that each resident room should be cleaned daily, including emptying garbage, sweeping and mopping floors, wiping down furniture, and cleaning bathrooms. However, the facility was short-staffed in the housekeeping department. The facility's policy stated that it aims to maintain a clean, odor-free, comfortable, and orderly environment, but the current staffing levels were insufficient to meet these standards.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for three residents who required staff support for toileting, incontinence care, nail care, and oral hygiene. Resident R4, who has a diagnosis of cerebrovascular accident (CVA) and dementia, was found with stool leaking from his incontinence brief onto his bare mattress, and his fingernails were noted to have thick, black debris. The Certified Nursing Assistant (CNA) attending to R4 was unsure when the last incontinence care was provided, and records showed no documentation of care between midnight and 8:33 AM. Additionally, R4's buttocks and perineal area appeared red, indicating prolonged exposure to urine and stool. Resident R3, who has altered mental status, weakness, and vision loss, was found with a wet incontinence brief that was so heavy it was pulling down towards his knees. The CNA attending to R3 was also unsure when the last incontinence care was provided, and R3 expressed a need to be taken to the shower and assisted to the bathroom. The room had a noticeable odor of urine, indicating a lack of timely incontinence care. Resident R2, who has a diagnosis of CVA, was found in bed with dirty lips and food debris, and he reported that he had not received assistance with brushing his teeth for months. R2 stated that he only used mouthwash daily and was unsure if he even had a toothbrush in his bathroom, which he could not access without assistance. The Director of Nursing (DON) confirmed that staff should provide toileting and incontinence care every two hours and as needed, and that oral care should be provided daily unless the resident does not require assistance. The facility's Incontinence Care policy also mandates that incontinent residents be checked every two hours and provided with perineal and genital care after each episode, which was not adhered to in these cases.
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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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