Atrium Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 1425 West Estes Avenue, Chicago, Illinois 60626
- CMS Provider Number
- 145479
- Inspections on file
- 37
- Latest survey
- October 23, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Atrium Health Care Center during CMS and state inspections, most recent first.
Two residents, both cognitively intact and with complex medical histories, were involved in a physical altercation after one verbally provoked the other, leading to physical abuse witnessed by staff and other residents. The incident was confirmed by multiple statements and facility documentation, revealing a failure to protect residents from abuse as required by policy.
A resident with multiple chronic conditions and intact cognition was physically assaulted by another resident, who grabbed her around the neck without provocation. Two other residents witnessed the incident. The assaulted resident did not sustain injuries and reported feeling safe, but the event occurred despite the facility's abuse prevention policy.
Surveyors found that the facility did not consistently label or date food items, failed to store opened products according to manufacturer instructions, and did not discard expired foods as required. Additionally, kitchen staff did not follow proper sanitization procedures for equipment, immersing items in sanitizer for only a few seconds instead of the required 60 seconds and using towels to dry them instead of air drying. These failures were acknowledged by dietary staff and had the potential to affect all residents receiving food from the kitchen.
Surveyors found that medications, including antibiotics and multiple types of insulin, were not stored according to pharmacy guidelines, with some requiring refrigeration found at room temperature and others kept refrigerated after opening despite instructions to store at room temperature. Additionally, opened inhalers lacked date labels, and expired multi-dose vials were not discarded as required. Staff interviews confirmed that these practices did not align with facility policy or professional standards.
Several residents with dysphagia and other conditions requiring pureed diets were served regular gelatin that was not pureed, contrary to physician orders, facility recipes, and dietary policies. Staff confirmed that the gelatin was not pureed for these residents, despite documentation specifying the need for pureed consistency, resulting in a failure to meet individualized dietary needs.
A nurse administered medication via G-tube to a resident on Enhanced Barrier Precautions without wearing a gown, as required by facility policy, using only gloves during the procedure. The resident had multiple indwelling devices and was severely cognitively impaired. Facility policy and posted signage specified that both gloves and gown must be worn during high-contact care activities for residents on EBP, but this protocol was not followed.
Two residents experienced delays in meal service when a CNA distributed trays to multiple tables and rooms before completing service at their table, resulting in one resident waiting seven minutes and another asking about their meal. The Dietary Supervisor and facility policy both state that all residents at a table should be served at the same time to maintain dignity, but this procedure was not followed.
A resident with diabetes and other significant health conditions was found with long, jagged toenails that had not been trimmed since admission. The resident reported no one had offered toenail care, and staff were unable to locate the binder used to track podiatry needs. Facility policy required staff to identify residents needing toenail care, but the resident was not seen by the podiatrist as required.
A controlled medication, Lorazepam oral concentrate, prescribed to a resident with multiple complex medical conditions, was found stored in an unlocked refrigerator rather than in a locked box as required by facility policy. The DON confirmed that this medication should have been secured to prevent unauthorized access.
Surveyors observed that nurses failed to administer medications as ordered for three residents, resulting in a medication error rate of 12.49%. Errors included missed doses, incorrect dosages, and improper administration techniques, such as giving only one tablet of Vitamin D3 instead of two and administering multiple sprays of Fluticasone nasal spray instead of the prescribed amount. These findings were based on direct observation, record review, and staff interviews.
The facility did not follow its policy to request fingerprint-based background checks within 72 hours for two residents who had 'HIT' results on their name-based criminal history checks, both of whom were cognitively intact and had qualifying offenses. Required documentation was incomplete, and staff failed to provide evidence of timely scheduling.
A facility failed to comply with involuntary psychiatric admission requirements for a resident involved in a physical altercation. The staff did not ensure the resident received a petition or was informed of his rights, and the process was not documented in the progress notes. The facility's policy lacked specific notice requirements for such admissions, leading to procedural gaps.
A resident admitted with acute osteomyelitis did not receive medications as ordered. Cefepime and Vancomycin were administered late and not according to the prescribed schedule. The facility's medication administration policy was not followed, leading to a deficiency.
A facility failed to provide proper pressure ulcer care for a resident admitted with severe wounds. The facility did not document wound assessments or include the resident in the wound report. Physician orders lacked details, and treatment records showed missed dressing changes. The DON and Wound Care Nurse acknowledged these documentation gaps, and the facility's wound assessment policy was not followed.
Two residents with intact cognitive function engaged in a physical and verbal altercation over a loud television, resulting in a failure to protect them from abuse. The incident was witnessed by a housekeeper and reported to the nursing staff, who intervened by separating the residents and notifying the appropriate personnel. The facility's failure to prevent the altercation and protect the residents from abuse was evident, breaching the Abuse Prevention Policy.
The facility failed to protect residents from abuse in two incidents. A resident reported verbal abuse by a visitor, which was confirmed by the Social Service Director. In another incident, two residents in wheelchairs had a physical altercation, leading to one resident slapping the other. The incidents were investigated, and abuse was substantiated.
A resident alleged sexual assault by an unidentified male staff member, but the facility failed to report the incident to the State Agency within the required two-hour timeframe. The administrator, acting as the Abuse Coordinator, acknowledged the delay, which was contrary to the facility's Abuse Prevention Program and state regulations.
A facility failed to thoroughly investigate a sexual assault allegation involving a resident, as a key staff member, who was on duty during the alleged incident, was not interviewed. The investigation did not comply with the facility's Abuse Prevention Program, which requires interviewing all potential witnesses. The administrator acknowledged the oversight, resulting in a deficiency in handling the abuse allegation.
A resident with a history of falls and various medical conditions fell and sustained a head injury due to the facility's failure to update the care plan and provide necessary supervision. The resident was not listed on the fall risk list, and staff were unaware of the resident's fall risk status. The facility's policy on falls and fall prevention was not followed, contributing to the incident.
A cognitively intact female resident with schizophrenia and depressive disorder was involved in an altercation with a moderately cognitively impaired male resident with schizophrenia and agitation. The incident occurred when the female resident reported a conflict over seating space, leading to a verbal and physical altercation. The male resident's hand became entangled in the female resident's hair, causing her to fall. Despite care plans addressing their behaviors, the facility failed to prevent this resident-to-resident physical abuse.
A resident reported being physically abused by staff, but the social worker failed to inform the administrator, violating the facility's policy. The administrator, unaware of the allegations, did not initiate an investigation as required.
A resident reported being physically abused by staff, but the facility failed to follow its policy to investigate these allegations. The resident informed the social worker, who claimed to have notified the administrator, but the administrator was unaware of the allegations and had not initiated an investigation as required by the facility's policy.
Two residents in a LTC facility were injured due to the facility's failure to prevent abuse. One resident with schizophrenia was hit by another resident with a history of aggression, resulting in a swollen and bruised eye. Another resident was struck by their roommate after going through the roommate's belongings, leading to facial injuries. The facility's lack of effective monitoring and intervention for residents with known aggressive behaviors contributed to these incidents.
A resident with quadriplegia and a history of falls fell out of bed during repositioning by an LPN and a CNA, resulting in a scalp laceration. The resident was dependent on two-person assistance, but the staff failed to maintain control during the procedure. The facility did not update the resident's care plan with new fall prevention measures after previous falls, and no floor mats were in place at the time of the incident.
A resident with quadriplegia, requiring two-person assistance for care, fell from bed due to inadequate supervision, resulting in a head injury and post-concussion syndrome. The incident occurred when only one CNA was present, and the bed could not be lowered, contributing to the fall. Despite the care plan's requirements, the resident was often assisted by only one staff member, highlighting a failure to adhere to the facility's supervision policy.
The facility failed to protect residents from abuse, resulting in two incidents where residents with schizophrenia were physically harmed by other residents. One resident was hit in the mouth, causing facial trauma, and another was hit on the nose, resulting in bleeding and pain. Both incidents were substantiated through staff interviews, progress notes, and police reports.
The facility failed to properly secure and protect the money of six residents. Surveyors found unsealed envelopes with money in medication carts, contrary to the facility's protocol requiring money to be stored securely by social services or the administrator. The residents had varying levels of cognitive impairment, and there was no documentation of the money being inventoried.
A resident requested a fan from the social worker, who did not provide one or inform anyone else about the request. The resident's room felt warm, and the air conditioner was not effectively cooling the area near the resident's bed. The facility failed to uphold its commitment to providing a comfortable and homelike environment.
A resident's money was misappropriated after being sent to the hospital. The resident entrusted the money to a roommate, who handed it to a CNA. The money was placed in an unsealed envelope in a medication cart by an LPN without following proper protocol. Upon the resident's return, $200 was missing, and the facility failed to document or report the incident properly.
A resident reported missing money after returning from the hospital, but the facility failed to document, report, or investigate the incident as required by their policies. The resident had given the money to a roommate, who handed it to a CNA. The Assistant Psychiatric Rehabilitation Service Director returned only part of the money in an unsealed bag, and the abuse coordinator was unaware of the issue.
A resident with multiple diagnoses did not receive their prescribed Venlafaxine 150mg ER due to insurance issues and facility inaction. The medication was incorrectly documented as administered, and the resident refused the alternative medication. The LPN admitted to the documentation error, and the DON confirmed the medication was not stocked or promptly authorized.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from abuse by another resident, resulting in a physical altercation between two cognitively intact residents. One resident entered another's room to look for a peer, and after being told the peer was not present, used derogatory language towards the resident in the room. This verbal provocation led the resident in the room to follow and physically assault the first resident in the hallway, with multiple witnesses observing the incident. Staff members, including a Certified Nursing Assistant and a Licensed Practical Nurse, confirmed seeing one resident on the floor and the other resident hitting him, with the altercation requiring staff intervention to separate the individuals involved. Both residents involved had significant medical histories, including hemiplegia, osteomyelitis, hypertensive heart disease, tumor of the bronchus and lung, Parkinson's disease, and schizophrenia. Despite their cognitive intactness as documented by BIMS scores, the altercation escalated quickly from verbal to physical abuse. The incident was witnessed by other residents and staff, and both residents provided statements confirming the sequence of events, with the aggressor admitting to physical assault in response to being called derogatory names. Facility documentation, including progress notes and resident statements, corroborated the sequence of events and the physical nature of the altercation. The facility's abuse prevention policy and residents' rights documentation affirm the right of residents to be free from abuse, yet the incident demonstrated a failure to uphold these protections. The event resulted in one resident being sent for psychiatric evaluation and the initiation of involuntary transfer proceedings for the aggressor due to endangerment of others' safety.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with a history of diabetes mellitus with diabetic neuropathy, essential hypertension, hyperlipidemia, heart failure, and carcinoma of the oral cavity, and who was cognitively intact as indicated by a BIMS score of 15, reported being physically assaulted by another resident. The incident involved the other resident approaching and grabbing the resident around the neck without provocation. Two other residents witnessed the event and confirmed the physical contact. The assaulted resident did not report pain or injury at the time of assessment and expressed feeling safe and wishing to remain at the facility. The Director of Nursing confirmed being informed of the altercation, which resulted in the discharge of the aggressor from the facility. Facility documentation of the incident noted no visible injuries or complaints of pain. The facility's abuse prevention policy states a commitment to protecting residents from abuse by anyone, including other residents. Despite this policy, the incident demonstrates a failure to ensure that the resident was free from abuse.
Failure to Properly Label, Store, and Sanitize Food and Equipment
Penalty
Summary
The facility failed to ensure proper food labeling, storage, and disposal practices in the kitchen, as well as correct sanitization of kitchen equipment. During a kitchen tour, the Dietary Supervisor stated that all food items should be labeled with delivery, opened, and use by dates, and that items should be discarded after seven days. However, observations revealed several unlabeled and undated food items, such as a container of boiled eggs and a prepared tuna fish salad, both lacking prepared and use by dates. Additionally, a mechanical soft cold cut salad was found stored past its use by date and had not been discarded as required. Further observations showed improper storage of food items according to manufacturer recommendations. An opened bottle of lemon juice and a container of soy sauce were stored on a spice rack at room temperature, despite manufacturer instructions to refrigerate after opening. These items were also not labeled with opened or use by dates. The Dietary Supervisor acknowledged that these items should have been refrigerated and properly labeled, in accordance with both manufacturer guidelines and facility policy. The facility also failed to follow proper sanitization procedures for kitchen equipment. The cook was observed washing, rinsing, and quickly dipping blender parts into the sanitizing solution for only 2-3 seconds, rather than the required 60 seconds, and then hand drying the items with a towel instead of air drying. The Dietary Supervisor confirmed that the manufacturer's instructions, posted above the three-compartment sink, require full immersion for 60 seconds and air drying. The cook stated he was unaware of the required sanitization time and used a towel to dry the items due to time constraints and limited equipment availability.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's medication storage and labeling practices. During inspection of a medication cart, a Penicillin G injection labeled for refrigeration was found stored at room temperature, and an opened multi-dose Ventolin HFA inhaler was found without an open date label. The LPN confirmed that inhalers should be dated upon opening to track when they should be discarded. In the medication room refrigerator, several opened insulin vials and pens, including Lantus, Fiasp, Basaglar, and Humalog, were stored in the refrigerator despite pharmacy labels indicating they should be kept at room temperature after opening and discarded 28 days after opening. Additionally, an opened multi-dose Tuberlicin PPD Mantoux injection vial was found in the refrigerator past its expiration date, and the RN acknowledged that expired medications should be discarded. The Director of Nursing confirmed that unopened insulin should be refrigerated, but once opened, it should be labeled with the open and discard dates and stored according to pharmacy recommendations. The facility's policies require medications to be stored at appropriate temperatures and outdated medications to be removed and disposed of immediately. Physician orders for the affected residents included various insulin regimens and inhaler use, all of which require proper storage and labeling to maintain medication efficacy and safety. The failure to follow these procedures led to the deficiencies identified during the survey.
Failure to Provide Pureed Food Consistency for Residents on Pureed Diets
Penalty
Summary
The facility failed to provide pureed food in the appropriate consistency for residents on pureed diets, as required by their dietary orders and facility policy. During observation of the lunch tray line, regularly prepared gelatin without canned fruit was served to four residents on pureed diets, rather than the required pureed gelatin. The gelatin served was firm and held its shape, indicating it was not pureed. Interviews with the Dietary Manager and Cook confirmed that the gelatin for pureed diets was not pureed, but simply served without fruit, contrary to the recipe and spreadsheet instructions. The Registered Dietitian emphasized the importance of following recipes and spreadsheets to ensure correct food consistency for residents with swallowing difficulties or who are at higher nutritional risk. The residents affected had diagnoses including dysphagia, cerebrovascular disease, chronic obstructive pulmonary disease, seizures, dementia, and other conditions requiring pureed diets with specific liquid consistencies. Their physician orders and meal tickets documented the need for pureed diets, and facility documentation specified that pureed fruited gelatin should be served, prepared according to a standardized recipe. Facility policies required that food be provided in a form designed to meet individual needs and that standardized recipes be followed, but these procedures were not adhered to in this instance.
Failure to Use Required PPE During G-Tube Medication Administration Under Enhanced Barrier Precautions
Penalty
Summary
A deficiency occurred when a nurse administered medication via a G-tube to a resident on Enhanced Barrier Precautions (EBP) without wearing the required gown, using only gloves during the procedure. The resident was observed lying in bed with a G-tube feeding in progress, and EBP signage was posted in the room. Facility policy and posted signage both specified that staff must wear gloves and gowns during high-contact care activities, such as G-tube medication administration, for residents on EBP. Interviews with the Director of Nursing and the Infection Preventionist confirmed that proper PPE, including both gloves and gown, is required for such procedures to prevent cross contamination. The resident involved had multiple medical conditions, including a gastrostomy, end stage renal disease, and dependence on renal dialysis, and was severely cognitively impaired. Physician orders and the care plan indicated the resident was on EBP due to the presence of indwelling medical devices and wounds. Despite these precautions, the nurse failed to follow the facility's EBP policy during medication administration, resulting in noncompliance with infection prevention and control protocols.
Failure to Serve Meals Simultaneously at Dining Tables Compromises Resident Dignity
Penalty
Summary
The facility failed to maintain or enhance residents' dignity during meal service in the dining room. During an observation, a Certified Nurse Assistant (CNA) was seen distributing meal trays to residents at multiple tables and in resident rooms without completing service to all residents at one table before moving to another. As a result, one resident waited seven minutes to be served after the first resident at their table received a meal, and another resident at the same table inquired about their meal tray after experiencing a delay. The CNA explained that residents do not always arrive at the same time, making it difficult to align meal tray distribution, and acknowledged that the previous practice was to serve one table at a time. The Dietary Supervisor confirmed that the expectation is for all residents at a table to be served before moving to another table, and that residents typically sit at the same table. Facility policy and residents' rights documents both state that meals should be served at approximately the same time to all residents at a table to respect their dignity. The observed practice of serving residents at different times at the same table was inconsistent with these policies and procedures.
Failure to Provide Timely Podiatry Services for Toenail Care
Penalty
Summary
A deficiency was identified when a resident was observed with excessively long and jagged toenails, which had not been trimmed since their admission to the facility approximately 2.5 months prior. The resident reported that their toenails had not been cut since October 2024, and no one had offered or asked about toenail care since their arrival. The resident expressed difficulty putting on socks due to the length of their toenails. Staff interviews revealed that CNAs only cut fingernails and that toenail care is provided by an outside podiatrist who visits twice a month. However, the process for identifying residents in need of podiatry services was not effectively implemented, as the binder used to track residents requiring toenail care could not be located, and the resident's name was not on the list of those seen by the podiatrist. The Director of Nursing confirmed that toenail care is part of daily grooming and should be monitored by nursing staff during ADL care, with staff responsible for alerting nurses if toenails need attention. The resident in question had a medical history including diabetes, cerebrovascular disease, heart failure, and hemiplegia, and required supervision or assistance with personal hygiene. Despite these needs and the facility's policy requiring staff to identify residents needing toenail care, the resident had not received podiatry services, resulting in the deficiency.
Improper Storage of Controlled Medication in Unlocked Refrigerator
Penalty
Summary
Surveyors observed that a controlled medication, Lorazepam oral concentrate, prescribed to a resident with multiple diagnoses including cerebral infarction, hypothyroidism, seizure disorder, heart failure, vascular dementia, and dysphagia, was stored improperly in an unlocked refrigerator in the medication room. The facility's policy requires that controlled substances needing refrigeration be kept in a locked box attached inside the refrigerator. During the inspection, the Lorazepam was found accessible without the required additional security. The DON confirmed that Lorazepam is a controlled medication and acknowledged that it should have been stored in a locked box or locked refrigerator, as per facility policy and regulations.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, resulting in a 12.49% error rate during observed medication administration. Surveyors observed medication passes for three residents, during which four errors occurred out of 28 opportunities. For one resident, a nurse failed to administer Risperidone and Oyster shell calcium as ordered, and did not provide the correct dose of Vitamin C, Acetaminophen, and Polyethylene glycol according to the frequency specified in the physician's orders. Another resident received only one tablet of Vitamin D3 instead of the ordered two tablets. A third resident was administered Fluticasone nasal spray with two sprays in each nostril, contrary to the physician's order for one spray in each nostril. These errors were identified through direct observation of medication administration, review of the Medication Administration Record (MAR) and Physician Order Sheet (POS), and interviews with nursing staff. The Director of Nursing confirmed that nurses are expected to follow the five rights of medication administration and acknowledged that missed or incorrectly administered medications could have effects on residents. The facility's medication administration policy requires checking all medications against the MAR and following specific instructions, which was not consistently done during the observed medication passes.
Failure to Timely Request Fingerprint-Based Background Checks After Criminal History 'HIT'
Penalty
Summary
The facility failed to follow its policy requiring a fingerprint-based background check to be requested within 72 hours after receiving a name-based criminal history background check with a 'HIT' result for two residents. Specifically, for both residents, the required fingerprinting consent forms were found to be unsigned and undated, and there was no documentation that the fingerprinting had been scheduled within the required timeframe. The staff responsible for scheduling the fingerprinting was unable to provide evidence of timely communication with the fingerprint service provider, and in one case, admitted to not sending the scheduling email at all. The administrator confirmed that the fingerprinting should have been scheduled within 72 hours according to facility policy, but this was not done. Both residents involved had 'HIT' results on their criminal history reports, with one resident having a conviction for prostitution (Class 4) and the other for burglary (Class 2). Both residents were documented as cognitively intact based on their BIMS scores. The facility's Identified Offender Policy and Procedure clearly states the requirement to request a fingerprint-based background check within 72 hours after a name-based check with qualifying offenses, but this process was not followed for the two residents reviewed.
Failure to Comply with Involuntary Psychiatric Admission Requirements
Penalty
Summary
The facility failed to ensure compliance with the requirements for involuntary psychiatric admission for a resident involved in a physical altercation. The resident, identified as the aggressor, was involved in an incident with a co-peer, leading to a decision to transfer him to a hospital for psychiatric evaluation. The Social Service Director, V7, acknowledged that a petition for involuntary admission was written, and the physician was contacted for an evaluation order. However, the petition was not signed by a nurse to confirm that the resident received a copy or was informed of his rights. Additionally, the petition was not documented in the resident's progress notes, and the facility's policy provided did not include specific notice requirements for involuntary/judicial admission. The surveyor's inquiry revealed that the staff was unclear about the process and documentation required for involuntary psychiatric admissions. V7 mentioned that the petition was typically given to the ambulance driver, with copies made for the hospital and the ambulance, but was unsure about the third copy. The facility's policy on involuntary discharge did not address the specific requirements for involuntary psychiatric admissions, indicating a gap in the facility's procedures. This lack of clarity and documentation resulted in the resident not being properly informed of his rights during the involuntary admission process.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals, as evidenced by their handling of a resident's medication administration. The resident was admitted with a diagnosis of acute osteomyelitis, which was not included in the facility's records. The facility was instructed to continue the resident's hospital medications, which included Cefepime and Vancomycin, both to be administered intravenously every 8 hours. However, the facility did not adhere to these instructions. Cefepime was administered 6 hours after the prescribed start time, and Vancomycin was not administered until 12 hours after the prescribed start time, with subsequent doses not following the 8-hour schedule. The Director of Nursing confirmed that the medications were not administered as directed, with Cefepime starting 15 hours after admission and Vancomycin 21 hours after admission. The facility's medication administration policy requires medications to be administered within a 2-hour window, but this was not followed. The failure to administer medications as ordered and to include the correct diagnosis in the resident's records contributed to the deficiency identified by the surveyors.
Failure in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident (R3) who was admitted with a diagnosis of acute osteomyelitis and a stage 4 pressure injury on the right hip, complicated by a deep penetrating ulcer on the left buttock. The facility did not follow its own policy procedures, as there was no documented assessment of R3's wounds upon admission, and the facility wound report did not include R3. Additionally, the Physician Order Sheets (POS) lacked specific details about wound locations and required medications or dressings, and the Treatment Administration Record (TAR) indicated that wound dressing changes were not administered on several occasions. The Director of Nursing (V2) and the Wound Care Nurse (V9) acknowledged the lack of documentation and assessment for R3's wounds. V2 confirmed that the wound vac ordered for R3 was received 23 hours after admission, but there was no documentation of its implementation. The facility's wound assessment policy requires a comprehensive assessment and documentation of wounds, including classification, location, staging, and other details, which was not adhered to in R3's case. This lack of adherence to policy and documentation resulted in a failure to ensure accurate and effective wound care for R3.
Failure to Prevent Resident Altercation
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in a physical and verbal altercation between them. Resident 1, diagnosed with schizoaffective disorder and bipolar disorder, and Resident 2, with chronic pain syndrome and a history of heroin poisoning, both have intact cognitive function as indicated by their BIMS scores. The incident occurred when Resident 2 asked Resident 1 to lower the volume of the television, leading to Resident 1 hitting Resident 2, who then retaliated. The altercation was witnessed by a housekeeper who reported the incident to the nursing staff. The staff intervened by separating the residents and notifying the appropriate personnel, including the Administrator, Director of Nursing, and social services. The police were also called, and a case of simple battery was documented. Despite the intervention, the facility's failure to prevent the altercation and protect the residents from abuse was evident. The facility's Abuse Prevention Policy defines abuse as any physical or mental injury inflicted upon a resident other than by accidental means. The policy outlines that physical abuse includes hitting and controlling behavior through corporal punishment, while verbal abuse involves the use of disparaging language. The incident between the two residents highlights a breach of this policy, as both physical and verbal abuse occurred, and the facility did not implement preventive measures to avoid such altercations.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by two separate incidents involving verbal and physical abuse. In the first incident, a resident with a history of burns, panic disorder, schizophrenia, and chronic pain reported verbal abuse by her roommate's sister during a visit. The resident, who has a BIMS score of 15/15 and uses a wheelchair, reported the incident to the Social Service Director, who confirmed the verbal abuse after an investigation. The visitor was subsequently restricted from accessing the resident's floor. In the second incident, a physical altercation occurred between two residents, one with schizoaffective disorder and anxiety, and the other with spinal stenosis, dementia, and diabetes. Both residents were in wheelchairs when they bumped into each other, leading to an argument. One resident grabbed the other's sleeve, prompting the other to slap the first resident's arm. A Licensed Practical Nurse witnessed the incident, separated the residents, and reported it to the Administrator. The facility's investigation substantiated the physical abuse, and the resident who slapped the other was placed under 1:1 monitoring pending further evaluation.
Failure to Timely Report Alleged Sexual Assault
Penalty
Summary
The facility failed to report an allegation of sexual assault within the mandated timeframe, as required by their policy and state regulations. The incident involved a resident who alleged that she was sexually assaulted by an unidentified male staff member. The allegation was made on December 6, 2024, at approximately 3:30 PM, but the initial report to the State Agency was not sent until 6:15 PM, exceeding the required two-hour reporting window. The facility's policy mandates that such allegations be reported within two hours, which was not adhered to in this case. The administrator, who serves as the Abuse Coordinator, acknowledged the delay in reporting during an interview with the surveyor. The facility's Abuse Prevention Program outlines the necessity for immediate reporting of abuse allegations to the State Agency, emphasizing the importance of filing accurate and timely investigative reports. Despite these guidelines, the facility did not comply with the two-hour reporting requirement, resulting in a deficiency being noted by the surveyors.
Incomplete Investigation of Sexual Assault Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual assault involving a resident, identified as R2, who reported being assaulted by an unidentified male staff member. The incident was alleged to have occurred during the early morning hours of the third shift on September 25, 2024. The investigation process was initiated by interviewing the resident and reviewing the staffing schedules to identify potential witnesses. However, the investigation was incomplete as one staff member, V17, who was assigned to R2 during the alleged time, was not interviewed. V17 was reportedly on vacation during the investigation period and was not contacted for a witness statement upon returning to work. The facility's Abuse Prevention Program mandates that all allegations of abuse be promptly and aggressively investigated, including interviewing anyone likely to have direct knowledge of the incident. Despite this policy, the investigation was not thoroughly conducted as V17, a key staff member who worked during the alleged incident, was not interviewed. The facility's administrator acknowledged the oversight, stating that the investigation was not complete without V17's input. This failure to interview all relevant staff members resulted in a deficiency in the facility's handling of the abuse allegation.
Failure to Update Care Plan and Provide Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to update the care plan and provide necessary assistance to a resident who required supervision when ambulating, resulting in a fall. The resident, who had a history of falling and various medical conditions including type 2 diabetes and schizoaffective disorder, was found on the bathroom floor with a laceration to the head. The resident's Minimum Data Set (MDS) indicated intact cognition and a need for setup or cleanup assistance for mobility, but the care plan did not reflect the necessary supervision for ambulation. The incident occurred because the resident was not listed on the facility's fall risk list, and staff were unaware of the resident's fall risk status. The Director of Nursing (DON) admitted that the fall risk list is updated quarterly or after a fall, but was unaware of who was responsible for updating it. Additionally, the Physical Therapy Director noted that the resident had a gait/balance impairment and required staff assistance during toileting, but this information was not communicated effectively to the nursing staff. The facility's policy on falls and fall prevention was not followed, as the resident was not assisted to the toilet or supervised as required. The Restorative Coordinator was not informed of the resident's change in functional level from independent to supervision, which occurred while she was on vacation. This lack of communication and failure to update the care plan contributed to the resident's fall and subsequent injury.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to prevent and protect residents from resident-to-resident physical abuse, specifically involving an altercation between two residents, R1 and R2. R1, a cognitively intact female with a history of schizophrenia and depressive disorder, reported that R2, a moderately cognitively impaired male with schizophrenia and a history of restlessness and agitation, pushed her to the floor. The incident occurred in the early morning when R1 approached the nurse's station for her medication and later returned, reporting a conflict with R2 over seating space. Despite being advised by the LPN on duty to find another seat or return to her room, R1 engaged in a verbal altercation with R2, which escalated to physical contact. The LPN on duty witnessed the altercation, noting that R1 approached R2, leading to a situation where R2's hand became entangled in R1's hair, resulting in R1 falling to the ground. The LPN intervened by separating the residents and detangling R2's hand from R1's hair. The incident was reported to the facility administrator and the police department. Interviews with staff, including a CNA and the Social Services Director, revealed that R1 has a tendency to provoke others, and both residents have care plans addressing their behaviors. The facility's abuse prevention program affirms residents' rights to be free from abuse, yet the incident highlights a failure to protect R1 from physical abuse by R2. The facility's documentation and staff interviews indicate that both residents have histories of behavioral issues, with R2 exhibiting physically aggressive behavior towards others. Despite having care plans in place, the incident suggests a lapse in effectively managing and preventing resident-to-resident altercations, resulting in R1's fall and subsequent report of abuse.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to adhere to its policy for reporting allegations of abuse, neglect, or mistreatment. A resident, identified as R5, reported to a social worker that he had been physically abused by nurses and CNAs, including an incident where his walker was used to hit him. R5 also provided written statements detailing multiple instances of abuse by staff members across different shifts. Despite these allegations, the social worker did not report the incidents to the administrator, who is also the abuse coordinator, as required by the facility's policy. The administrator, V1, stated that she was unaware of the allegations made by R5 and would have initiated an investigation had she been informed. The facility's policy mandates that any suspicion or allegation of abuse must be reported immediately to the administrator, who is then responsible for conducting a full investigation and reporting the findings to the Department of Public Health within five working days. The failure to report these allegations resulted in a deficiency as the facility did not follow its own procedures for handling reports of abuse.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to follow its policy to investigate allegations of abuse for a resident, identified as R5, who reported being physically abused by nurses and CNAs. On the day of the survey, R5 informed the surveyor that he had been hit by staff members and had previously reported these incidents to the social worker. The social worker, V5, confirmed that R5 had provided written statements about the abuse and that she had notified the administrator and the Social Worker Director. However, the administrator, V1, who is also the abuse coordinator, stated that she was not informed of these allegations and had not initiated an investigation as required by the facility's policy. The facility's abuse policy mandates that any incident, allegation, or suspicion of abuse must be reported immediately to the administrator, who is then responsible for initiating an investigation and completing a full report within five days. Despite this policy, the administrator was unaware of R5's allegations until the surveyor's inquiry, indicating a breakdown in communication and failure to adhere to the established procedures for handling abuse allegations. This oversight resulted in a lack of timely investigation into the serious claims made by R5, compromising the facility's responsibility to ensure resident safety and compliance with regulatory standards.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents, R8 and R10, from abuse, resulting in both sustaining injuries. R10, a 50-year-old with schizophrenia and other medical conditions, was assaulted by another resident, R11, who has a documented history of aggressive behavior. On the day of the incident, R10 was seen by a family member and staff with a swollen and bruised eye after being hit by R11. Interviews with staff and residents confirmed that R11, who is deaf and non-speaking, became agitated with R10's behavior and struck him in the eye. Despite R11's known aggressive tendencies, he was not adequately monitored or separated from other residents, leading to the incident. R8, another resident, was also a victim of abuse by their roommate, R9. R8, who is cognitively intact, was hit in the face by R9, resulting in swelling and discoloration of the eye. R9, who has a history of socially inappropriate behavior and aggression, admitted to hitting R8 because R8 was going through R9's belongings. Staff interviews and records confirmed that R8 had a tendency to wander and go through other people's belongings, which triggered R9's aggressive response. The facility's investigation substantiated the incident, highlighting a failure to prevent abuse between residents. Both incidents demonstrate a lack of effective monitoring and intervention strategies for residents with known aggressive behaviors. The facility's policies on abuse prevention were not adequately enforced, as evidenced by the repeated aggressive incidents involving R11 and R9. The failure to protect residents from abuse and ensure their safety resulted in physical harm to R8 and R10, indicating a significant deficiency in the facility's care and supervision practices.
Failure to Prevent Resident Fall During Repositioning
Penalty
Summary
The facility failed to ensure safe practices during the repositioning of a resident, identified as R7, who was dependent on two-person assistance for bed mobility. R7, who had a history of falls and was considered a high fall risk, fell out of bed during a repositioning procedure conducted by a Licensed Practical Nurse (LPN) and a Certified Nurse Assistant (CNA). The incident occurred when the LPN and CNA attempted to trade places while repositioning R7, resulting in the resident slipping out of the LPN's grip and falling to the floor, sustaining a laceration to the scalp. R7 had multiple diagnoses, including quadriplegia, chronic pain, and pressure ulcers, and was entirely dependent on staff for mobility. Despite these conditions, the facility did not update R7's care plan with new fall prevention interventions after previous falls. The care plan noted R7 as a two-person assist for bed mobility, but the staff failed to maintain control during the repositioning, leading to the fall. The incident was further complicated by the lack of fall prevention measures, such as floor mats, which were not in place at the time of the fall. Interviews with staff revealed that the LPN and CNA were aware of R7's spontaneous movements and the need for careful handling. However, during the repositioning, the LPN moved away from the bed, and the CNA was unable to prevent the fall. The Director of Nursing acknowledged that the incident could have been avoided if the staff had adhered to proper repositioning protocols. The facility's policy emphasized the importance of proactive fall prevention strategies, but these were not effectively implemented in R7's case.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide safe and adequate care for a resident who required a two-person assist for incontinence care and bed mobility. This deficiency resulted in the resident falling out of bed, hitting his head on a bedside dresser, and subsequently being diagnosed with post-concussion syndrome. The resident, who has quadriplegia and other medical conditions, was dependent on staff for daily activities and required supervision and assistance from two staff members for safety. On the day of the incident, only one certified nursing assistant (CNA) was providing care to the resident, despite the care plan indicating the need for two-person assistance. During the incontinence care, the CNA attempted to turn the resident, which led to the resident falling from the bed, as the bed was in a high position and could not be lowered due to a malfunction. The resident reported hitting his head during the fall and experienced severe headaches, leading to two hospital visits where he was diagnosed with post-concussion syndrome. Interviews with staff revealed that the resident was typically cared for by one CNA, contrary to the documented requirement for two-person assistance. The facility's supervision policy was not adhered to, as the resident's needs for adequate supervision and assistance were not met, contributing to the accident. The administrator and director of nursing were unaware of the concussion diagnosis, indicating a lack of communication and awareness of the resident's condition following the incident.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure the right of residents to be free from abuse, resulting in two incidents involving physical harm. In the first incident, a male resident with schizophrenia and restlessness was hit in the mouth by another male resident with schizophrenia and aggressive behavior. The incident occurred near the nursing station during medication administration, leading to facial trauma and bleeding for the victim. The aggressor was subsequently transferred for psychological evaluation and did not return to the facility. The incident was substantiated through staff interviews, progress notes, and a police report documenting the simple battery incident. In the second incident, a female resident with schizoaffective disorder and paranoid schizophrenia was hit on the nose by a male resident with paranoid schizophrenia and aggressive behavior. The incident occurred in the early morning hours when the female resident entered the male resident's room without permission. The male resident admitted to hitting her, resulting in nosebleed and pain. Despite being offered medical evaluation, the female resident refused to be transferred to the hospital. The incident was confirmed through staff interviews, progress notes, and a police report. Both incidents highlight the facility's failure to protect residents from abuse, as evidenced by the physical altercations and resulting injuries. The facility's abuse prevention policy affirms the right of residents to be free from abuse, neglect, and mistreatment, yet these incidents demonstrate a lapse in ensuring this right. The facility's response included updating care plans and conducting risk assessments, but the initial failure to prevent the abuse remains a significant concern.
Failure to Secure Residents' Money
Penalty
Summary
The facility failed to properly secure and protect the residents' money for six out of eight residents reviewed. On multiple occasions, surveyors observed unsealed envelopes containing money inside the narcotic lock boxes in medication carts. Licensed Practical Nurses (LPNs) and Certified Nursing Assistants (CNAs) were aware of the money stored in these envelopes but did not follow the facility's protocol for safeguarding residents' money. The protocol requires that residents' money be given to social services or the administrator for secure storage in a facility safe. Instead, the money was improperly stored in medication carts, accessible only to nursing staff. The residents involved had varying levels of cognitive impairment, with some being moderately impaired and others being cognitively intact. There was no documentation to show that the money was inventoried by the facility. The facility's policy and the Ombudsman Program Residents' Rights for People in Long Term Care Facilities both emphasize the importance of safeguarding residents' property. The failure to follow these protocols resulted in a deficiency in protecting the residents' financial affairs.
Failure to Accommodate Resident's Preference for a Fan
Penalty
Summary
The facility failed to accommodate a resident's preference for a fan, which would have contributed to a comfortable and homelike setting. On 03/19/24 at 10:00 AM, the surveyor observed the resident sitting up on her bed without a fan in her room. The resident had requested a fan from the social worker the previous week, but the social worker did not provide one and failed to inform anyone else about the request. The resident's room felt warm, and although there was an air conditioner, it was located on the window side, while the resident's bed was closer to the room door. The social worker confirmed that the resident had requested a fan but admitted that she did not have one to give and did not communicate this to anyone else or update the resident. The facility's document on residents' rights emphasizes the importance of providing a comfortable and homelike environment, which was not upheld in this instance. The resident's diagnoses included depressive episodes, multiple sclerosis, paranoid schizophrenia, personality disorder, muscle spasm, and diabetes, highlighting the need for a supportive and accommodating environment.
Misappropriation of Resident's Money
Penalty
Summary
The facility failed to protect a resident's belongings, leading to the misappropriation of $200. The incident involved a resident (R2) who was sent to the hospital and entrusted her money to her roommate (R3) due to the absence of the social worker. R3 handed the money to a CNA (V6), who then informed an LPN (V4) about the money. V4 placed the money in an unsealed envelope inside the narcotic lock box in the medication cart. Upon R2's return from the hospital, only $185 was returned to her, leading to the discovery that $200 was missing. The investigation revealed that V6 did not touch or count the money but informed V4, who then placed the money in the medication cart without informing social services or following proper protocol. V4 admitted to not being familiar with the protocol for handling resident money and did not inform anyone about the money's location. V7, the Assistant Psychiatric Rehabilitation Service Director, was made aware of the missing money but could not verify the amount as it was never counted or documented. The facility's administrator (V1) was not informed about the missing money until the surveyor's interview. The facility's policies on personal property and abuse were not followed, as there was no documentation of the money being inventoried, and the incident was not reported to the state agency. The facility's failure to follow proper procedures and protocols led to the misappropriation of R2's money, violating the resident's right to be free from misappropriation of property.
Failure to Report and Investigate Misappropriation of Resident Property
Penalty
Summary
The facility failed to report and investigate the misappropriation of property for one resident (R2). R2 was transferred to the hospital and gave $385 in cash to her roommate (R3) for safekeeping. Upon returning from the hospital, R2 received only $185 back from the Assistant Psychiatric Rehabilitation Service Director (V7) in an unsealed brown paper bag. R2 reported the missing money to V7, who acknowledged the issue but did not document or report it to the state agency or the facility's abuse coordinator (V1). Interviews with R3 and V6 (CNA) confirmed that R3 handed the money to V6, who then informed V4 (LPN) and V7 about the missing amount. However, V4 stated that this was the first time hearing about the missing money during the surveyor's interview. The facility's records, including the Facility Reported Incident logs and grievance logs, showed no documentation of R2's missing money. The facility's policies on personal property and abuse and neglect require immediate reporting and investigation of such incidents, but these procedures were not followed. V1, the abuse coordinator, confirmed that she was unaware of the incident and that it should have been reported to her and the state agency. The lack of documentation and failure to follow the facility's policies led to the deficiency in handling the misappropriation of R2's property.
Failure to Administer and Document Medication Correctly
Penalty
Summary
The facility failed to acquire a physician-ordered medication and accurately document the administration of medication for one resident. The resident, who has a history of depressive episodes, multiple sclerosis, paranoid schizophrenia, personality disorder, muscle spasm, and diabetes, was admitted with a prescription for Venlafaxine 150mg ER. Despite the physician's order to continue this medication, the facility did not obtain it due to insurance coverage issues and failed to notify the provider immediately. The resident did not receive the medication from 03/12/2024 to 03/16/2024, although it was incorrectly documented as administered in the MAR. The resident reported not receiving Venlafaxine since admission and refused the alternative medication, Sertraline, ordered by the doctor. The LPN admitted to incorrectly documenting the administration of Venlafaxine. The Director of Nursing confirmed that the medication was not stocked in the facility's emergency medication box and that the prior authorization form was sent to the doctor, but could not recall the date. The facility's Medication Administration Policy requires checking all medications against the MAR prior to administration and signing out medications immediately after administration, which was not followed in this case.
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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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