Avantara Evergreen Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Evergreen Park, Illinois.
- Location
- 10124 South Kedzie, Evergreen Park, Illinois 60805
- CMS Provider Number
- 145734
- Inspections on file
- 47
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Avantara Evergreen Park during CMS and state inspections, most recent first.
The facility failed to timely submit required initial and final reports to the State Agency for an injury of unknown origin involving a resident who sustained a displaced right hip fracture requiring emergency surgical fixation. The resident, admitted for therapy and medical management with multiple comorbidities and mobility issues, complained of hip pain, and the DON reported that the resident’s daughter expressed concern about the appearance of the hip. An agency nurse notified the unit manager, who obtained orders for an X-ray and PRN Tylenol, but the daughter requested hospital transfer rather than waiting for on-site imaging. Progress notes documented the family’s request for transfer and subsequent ER confirmation of a right hip fracture, with no documented fall or injury in the facility. An incident report categorized the event as an injury of unknown origin and indicated an investigation was initiated, but the final report was not sent to the State Agency until it was requested by a surveyor, and the Administrator acknowledged she had forgotten to send it, contrary to facility policy requiring immediate reporting and submission of a final investigation within five working days.
A resident with multiple chronic conditions and intact cognition reported that dentures documented on an earlier inventory were missing after readmission, but staff did not complete a grievance form or provide timely follow-up as required by facility policy. The resident repeatedly requested to speak with administration and Social Services without receiving a response, and although the resident was placed on a monthly dental sign-up list, the resident was never actually seen by the dental provider before discharge. Facility policies required grievances to be filed and addressed within 72 hours and mandated prompt dental referral within three days for lost dentures or documentation of measures taken to ensure the resident could still eat and drink, but these procedures were not followed for this resident.
A resident with multiple comorbidities, including ESRD, heart transplant status, depression, and type 2 DM, had a care plan requiring a safe environment with a working, reachable call light for fall prevention. While seated in his room and needing assistance back to bed, he repeatedly called out for help after pressing his call light without response. A surveyor and staff confirmed that pressing the call light produced no corridor light or audible signal for either bed in the room. The maintenance assistant later found the call light unit disconnected with a wire needing soldering, noting he had previously repaired the same unit. Staff interviews showed reliance on the call light system for residents to request help and uncertainty about how residents would obtain assistance when call lights were nonfunctional, while the maintenance log documented a prior call light request for the room without details of the repair, despite facility policy requiring daily checks of call lights and alternative means for residents to call for assistance when call lights are not functional.
A resident with a complex medical history exhibited clear signs of sepsis, including hypoxia, tachycardia, low blood pressure, and altered mental status, but staff did not follow facility sepsis protocols or promptly transfer the resident to the hospital. Despite abnormal vital signs and family requests for transfer, the resident remained in the facility for several hours before being sent to the hospital, where they were diagnosed with septic shock and pneumonia.
The facility did not maintain room temperatures within the required comfort range, resulting in multiple rooms exceeding 81 degrees Fahrenheit. Several residents, including those with respiratory and cardiac conditions, experienced discomfort due to excessive heat, and staff were aware of the issue but did not take timely or effective action. Maintenance staff confirmed that air conditioning units were not functioning properly, and portable fans were only considered after residents complained.
A deficiency occurred when the facility did not maintain acceptable ambient temperatures in two wings due to a malfunctioning cooling system. Broken fan belts on roof fans and non-functioning individual AC units led to hallway temperatures exceeding the facility's policy range, resulting in uncomfortable conditions for residents, staff, and visitors.
A resident with multiple chronic conditions and moderate cognitive impairment, who was prescribed tramadol and a fentanyl patch for pain, did not receive effective bowel management. Despite facility policy requiring monitoring and documentation of bowel movements, the resident experienced several days without a bowel movement, leading to severe fecal impaction and hospitalization. Staff interviews confirmed that the issue was not identified or communicated in a timely manner.
Two residents at high risk for pressure ulcers did not receive consistent assessment or proper use of pressure-relieving equipment. One developed a facility-acquired unstageable sacral wound without clear documentation of preventive interventions, while another experienced pain and inadequate pressure redistribution due to a deflated alternating air mattress that was not promptly addressed by staff.
The facility did not consistently assess residents for the need of bed side rails or obtain proper consent prior to their use, as required by policy. Several residents had side rails in use without current assessments or documented consent, and some were unable to use the rails independently. Staff confirmed that required assessments and consents were missing or outdated for these individuals.
Surveyors found that staff did not consistently label opened insulin with open or expiration dates and failed to remove or discard medications for discharged residents. Insulin vials and pens for several residents with diabetes were observed on medication carts without required labeling, and staff confirmed that these actions were not in line with facility policy.
Staff and contracted personnel failed to follow infection prevention and control policies by not performing required hand hygiene and not donning gowns when providing direct care to residents under enhanced barrier precautions. Multiple staff, including nurses, nurse practitioners, a wound care director, and a laboratory employee, entered rooms and performed care activities with inadequate PPE, contrary to facility policy.
The facility did not follow its electronic monitoring policy by failing to post required signage and obtain informed consent from two residents before initiating video and audio monitoring in their shared room. Both residents and a resident's POA were unaware of the monitoring, and documentation was incomplete, lacking necessary signatures and details.
A resident who was alert and able to communicate was observed in bed with the call light out of reach, unable to locate or use it to request assistance. The call light remained inaccessible during multiple observations, despite facility policy requiring call lights to be within reach for prompt staff response.
Staff failed to accurately code MDS assessments for three residents, including incorrect documentation of dialysis treatment, hospice status, and terminal prognosis. These errors were identified through record review and staff interviews, revealing discrepancies between residents' actual care needs and what was recorded in the MDS.
A resident recovering from a hip fracture was transferred by CNAs without the use of a gait belt or mechanical lift, contrary to the care plan that required two staff and a full-body mechanical lift for transfers. Staff actions did not align with the documented care plan or the resident's current needs, resulting in a deficiency related to care plan implementation.
A resident who was totally dependent on staff for ADLs did not receive incontinence care or repositioning for at least two hours. During this time, staff failed to check or change the resident's saturated brief, resulting in soiled bedding and a saturated pressure ulcer dressing, despite facility expectations for care every two hours.
A resident recovering from a hip fracture was transferred without the use of a gait belt or mechanical lift, as required by facility policy and care plan, resulting in a fall and acute femoral fracture. Staff did not follow established transfer protocols or provide adequate supervision, and documentation failed to specify necessary safety interventions.
A resident with a need for supplemental oxygen was observed with a nasal cannula in place, but the oxygen concentrator was off and not functioning properly. Staff replaced the faulty concentrator, but it was discovered that there was no current physician order for oxygen therapy, as required by facility policy. The last order had been discontinued after a hospital stay and was not renewed upon readmission.
A resident with a history of C. diff was on antibiotics, but staff failed to consistently monitor and document antibiotic use and potential side effects as required by the care plan. The facility lacked protocols and a system for antibiotic monitoring, and nurses did not complete daily assessments or documentation, despite expectations from the IP Nurse.
A resident was found in a room with persistent dry substances on the floor, walls, tube feeding machine, and bed framing, as well as soiled bed linens that were not changed after a bed bath. The resident reported discomfort due to urine-stained linens, and staff confirmed that cleaning and linen changes should have occurred according to facility policy.
A hospice resident with multiple diagnoses experienced a fall that was not documented in the electronic health record, and the family was not notified promptly. The nurse on duty, who was new to the facility, did not complete the required risk management forms or notify the family, as per the facility's protocols. The Director of Nursing confirmed the lapse in protocol adherence, which led to delayed family notification.
The facility did not follow its Abuse and Neglect Policy by failing to report an allegation of rough handling of a resident to the Administrator immediately. The Director of Nursing was informed of the allegation but did not report it to the Administrator, who was unaware of the incident and would have initiated an investigation if informed. The policy requires immediate reporting to the Administrator and to IDPH within two hours.
A resident with multiple medical conditions fell during a transfer when a CNA failed to follow the facility's protocol requiring two staff members for mechanical lift operations. The CNA attempted the transfer alone, resulting in the lift tipping over and the resident experiencing severe back pain. The facility's policy and training emphasize the need for two staff members to ensure safety during such transfers.
The facility failed to implement adequate fall prevention interventions and supervision, resulting in multiple resident falls and injuries. Residents were not properly assessed for the safe use of assistive devices, leading to incidents such as a resident with hemiplegia falling and fracturing their fibula, and another resident with dementia falling and sustaining a head injury. Additionally, a resident using a motorized wheelchair with visual impairments was not supervised, resulting in fractures. The facility's fall coordinator and director of nursing did not adequately address these issues.
A resident's finances were mismanaged by the facility, resulting in an unauthorized withdrawal of $5,504.06 from the resident's account. The resident's POA did not consent to this transaction, and discrepancies in signatures and billing records were found. The facility failed to provide itemized billing or adequate documentation, leading to a deficiency in financial management.
The facility failed to provide adequate pressure ulcer care, resulting in deficiencies for three residents. A resident developed an infected hand wound due to lack of preventive measures, while another had soiled dressings not replaced promptly. Additionally, two residents had air mattresses set incorrectly, affecting pressure redistribution. These issues highlight the facility's failure to implement an effective pressure sore prevention plan.
A resident at high risk for falls experienced three falls within 30 days due to the facility's failure to implement new fall interventions and complete incident reports. The resident, with diagnoses including dementia and hypertension, was found on the floor multiple times after attempting to go to the bathroom unassisted. Despite being identified as high risk, the care plan lacked updated interventions, and an incident report was not completed for a fall on 8/17/24. The resident was eventually hospitalized with a subacute subdural hematoma after a fall on 9/11/24.
A resident with vascular dementia and severe malnutrition was not adequately hydrated through their prescribed g-tube feeding regimen, leading to dehydration and hospitalization. Despite receiving Jevity 1.2 at 65 ml/hr and 100 ml water flushes every four hours, the resident had a free water deficit of 1.9 liters and elevated sodium levels. Facility staff noted the resident's minimal oral intake and reliance on enteral feeding, but inconsistencies in the administration of prescribed hydration were found.
A resident experienced a fall while trying to go to the bathroom, but the facility failed to notify the family and physician as required by their policy. The assigned nurse did not make the necessary notifications, and another nurse confirmed the lack of communication. The fall nurse found no documentation of notification, despite the facility's policy mandating immediate notification in such cases.
A resident with type II diabetes and hidradenitis suppurativa did not receive proper wound care as per physician orders. The resident's dressing was not secured after a shower, and no dressing was present during an interview. The wound care director confirmed the dressing should have been changed, but it was not, violating the facility's policy to follow physician orders.
A resident reported her purse missing, leading to an investigation that revealed a staff member, not assigned to her unit, had taken it. The purse was found in another resident's room, but the resident's debit card was used for a small transaction. The staff member was arrested for theft and outstanding warrants. The facility's abuse policy failed to prevent this financial abuse.
The facility failed to implement fall prevention interventions for two residents with a history of falls. One resident experienced an unwitnessed fall resulting in fractures and hospitalization due to delayed care plan updates. Another resident was found in a high bed position, contrary to the care plan, increasing fall risk. The facility's fall prevention and care planning policies were not adequately followed, leading to preventable incidents.
The facility failed to label foods being thawed inside the refrigerator, including chicken breast, ham, turkey, ground beef, and a pitcher of orange juice. The Dietary Manager confirmed the items were unlabeled, which is against the facility's policy on food safety and labeling.
The facility failed to properly implement pressure ulcer prevention interventions and follow manufacturer recommendations for a resident with Stage 4 pressure ulcers. The resident was observed on a low air loss mattress with inappropriate bedding and without heel protectors, contrary to physician orders and care plan. Interviews and policy reviews confirmed the expectations, but staff did not adhere to them, leading to the deficiency.
The facility failed to provide appropriate restorative services for a resident with ROM limitations in both upper extremities. The resident was found without the prescribed bilateral hand splints, and no physician order or care plan for the splints was found in the medical records. The resident's care plan and physician orders were updated only after the surveyor's observation, indicating a lack of consistent and timely restorative care.
The facility failed to ensure proper catheter care for a resident, resulting in brownish, yellow-colored sediments inside the catheter tubing. The Unit Manager confirmed that catheter care should be rendered every shift, but there were missing documentation entries for catheter output monitoring and delayed quarterly assessments. The resident had a history of UTIs, and the facility's policies on catheter care were not followed.
The facility failed to implement appropriate PPE use and hand hygiene during high-contact care activities. A CNA was observed emptying a urinary catheter bag without gloves, and another CNA failed to perform hand hygiene before donning new gloves after incontinence care. Both actions were against the facility's policies, affecting two residents with multiple diagnoses.
A facility failed to honor a resident representative's choice for an assisted living transfer. The resident, with multiple health conditions, was transferred to another LTC facility without the daughter's permission. Despite initial rejection, the resident was later accepted and moved to the desired assisted living facility. The facility's Social Service Director was expected to follow up on the family's request within a week.
Failure to Timely Report Injury of Unknown Origin Involving Serious Bodily Injury
Penalty
Summary
The facility failed to comply with abuse reporting requirements by not submitting an initial and final report to the State Agency within required timeframes for an injury of unknown origin involving a resident who sustained a serious bodily injury. The resident, an older adult admitted for therapy and medical management with multiple diagnoses including end stage renal disease, difficulty walking, cognitive communication deficit, adult failure to thrive, and a stage 2 sacral pressure ulcer, complained of hip pain. According to the DON, the resident’s daughter reported that the resident’s hip did not look right, and the resident went to therapy but complained of pain to an agency nurse, who notified the unit manager. The unit manager obtained orders for an X-ray and PRN Tylenol. The daughter did not want to wait for the X-ray provider and requested that the resident be sent to the hospital, and the resident was transferred per family request. Progress notes show that the family requested transfer to the hospital for a dislocated hip, and later documentation from the ER indicated the resident was admitted with a right hip fracture. An incident report dated the day after the transfer identified the event as an injury of unknown origin and documented that there had been no fall or injury at the facility since admission and that an investigation was initiated. The initial report listed the date and time staff became aware of the incident as that same morning and indicated it was sent to the State Agency at 11:00 a.m. The final report for the same incident was not sent until a later date, which coincided with the day the surveyor requested the report. When the surveyor discussed this with the Administrator, she stated that she had forgotten to send the final report, despite having completed it. This sequence of events shows the facility did not adhere to its own abuse and retaliation policy, which requires all allegations of abuse, including injuries of unknown origin, to be reported to the State Agency immediately, not exceeding two hours after receipt, with a final investigation submitted within five working days.
Failure to Process Grievance and Arrange Timely Dental Services for Missing Dentures
Penalty
Summary
The deficiency involves the facility’s failure to timely address a resident grievance regarding missing dentures and to ensure provision of dental services as outlined in facility policy. The resident, an adult with diagnoses including lipoprotein deficiency, plasma-protein metabolism disorder, glaucoma, legal blindness, right ear hearing loss, essential hypertension, low BMI, and right foot pain, was cognitively intact with a Brief Interview for Mental Status score of 14. An inventory list dated prior to hospitalization documented upper and lower dentures, while a subsequent inventory list after readmission showed no dentures. Upon readmission, the resident reported the dentures missing, but no grievance form was completed by the staff who received the concern, despite facility policy requiring grievances/concerns to be filed and followed up within 72 hours. The resident reported repeatedly asking to speak with the Administrator, being told the Administrator was on vacation, being redirected to the Assistant Administrator without follow-up, and speaking with Social Services without receiving any response regarding the missing dentures. The facility also failed to ensure timely referral and provision of dental services after the dentures were reported missing. Facility policy required that if dentures are lost or damaged, the resident must be promptly referred for dental services within three days, or the facility must document what was done to ensure the resident could still eat and drink and any extenuating circumstances for delay. Staff interviews confirmed that the Social Services staff reported the missing dentures to administration but did not complete a grievance form, and the Assistant Administrator acknowledged awareness of the concern without initiating the grievance process. The DON stated that residents who report missing dentures are to be referred to dental services, but was unsure why this resident was not seen by dental services before discharge. Although the Activity Director indicated the resident was placed on a monthly sign-up list for dental services, the resident was not actually seen by the dental provider prior to discharge, and the resident reported not seeing any dental services or being informed of any follow-up on the dentures during the stay or after discharge.
Failure to Ensure Functioning Call Light System for Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a working call light system for a resident’s bed, as required by the resident’s care plan and the facility’s call light policy. The resident is an adult male with end stage renal disease, heart transplant status, depression, type 2 diabetes mellitus without complications, and essential hypertension. His care plan, initiated on 12/31/2025, includes an intervention that he be provided a safe environment with a working and reachable call light as part of fall prevention. On 1/2/2026 at 12:41 p.m., the resident was observed sitting in a chair in his room, alert and able to make his needs known, repeatedly calling out for help because he needed assistance getting back to bed. The resident reported that he had been pressing his call light as instructed but was not receiving help because the call light was not working and the light did not come on. The surveyor observed the resident pressing the call light and confirmed that the corridor light above the door did not illuminate, the light on the call light panel was not on, and there was no audible sound. When informed, a restorative aide entered the room, observed the resident pressing the call light, and stated that the light should illuminate outside the door and that residents use the call light to let staff know they need help. An agency LPN attempted to re-plug the call light and determined that the call light for both bed one and bed two was not working and that maintenance would need to be called. The maintenance assistant later examined the call light and stated that when the button is pressed, the light is supposed to come on over the door, and that both call lights for bed one and two go into one unit so if one does not work, the other will not work. He reported that he had previously fixed this call light the Saturday before Christmas, that it had come off the wall, and that it must have come loose again. Upon further inspection, he found the call light was not connected and that a wire needed to be soldered back, confirming that neither call light would work. Staff interviews revealed inconsistent understanding of how residents would obtain help if a call light was not functioning, with both a CNA and an agency LPN acknowledging they would not know a resident needed help without a working call light. The DON and nurse manager described expectations for rounds and for reporting defective call lights, and the assistant administrator and maintenance assistant referenced routine checks and alternative measures such as bells or room changes, but the maintenance log for 12/30 only showed a checked box for a call light request in this resident’s room without documentation of what was fixed or the nature of the concern, despite the facility’s policy requiring that the call system be in proper working order and that nonfunctional call lights be addressed and alternative means provided.
Failure to Promptly Transfer Resident with Sepsis Symptoms
Penalty
Summary
A facility failed to follow its own guidelines for the prompt transfer of a resident exhibiting signs and symptoms of sepsis, resulting in a delay of approximately six hours before the resident was sent to the hospital. The resident, who had a complex medical history including cerebral neoplasm, seizures, spastic hemiplegia, encephalopathy, diabetes, and a history of sepsis, began showing abnormal vital signs and symptoms such as hypoxia, tachycardia, low blood pressure, and altered mental status. Multiple staff members, including a speech therapist and registered nurse, noted these changes and communicated them to the nurse practitioner, who ordered diagnostic tests and treatments but did not assess the resident's vital signs during their visit or address the abnormal findings reported by nursing staff. Despite the facility's policy requiring sepsis screening and prompt action when two or more SIRS criteria are met, no formal sepsis screening was completed, and key laboratory tests such as blood cultures, CMP, coagulation tests, and lactate were not ordered or drawn as required. The resident's family expressed concern and requested hospital transfer, citing a history of sepsis, but the transfer was not initiated until later that evening after further deterioration and abnormal lab results were noted. Documentation and interviews revealed that staff were aware of the resident's change in condition and the potential for sepsis but did not follow the facility's sepsis care guidelines, which call for immediate physician notification, IV fluids, and consideration for hospital transfer unless specific exceptions apply. The delay in recognizing and responding to the resident's sepsis symptoms resulted in the resident being hospitalized and diagnosed with septic shock and pneumonia. Interviews with staff, including the DON, nurse practitioner, and medical director, confirmed that the facility was not equipped to treat sepsis in-house and that the established protocol was not followed. The facility's failure to implement its sepsis guidelines and promptly transfer the resident for higher-level care constituted a deficiency in quality of care.
Failure to Maintain Safe and Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain resident room temperatures within the comfortable range of 71 to 81 degrees Fahrenheit, as required by policy. During a facility tour, multiple rooms and hallways were observed with temperatures exceeding 81 degrees, with specific measurements ranging from 81.3 to 81.6 degrees Fahrenheit. Residents reported that their rooms were very hot, especially over the weekend, and that staff were aware of the issue but had not taken effective action to resolve it. One resident stated that she was sweating and uncomfortable, and her family had to bring a portable fan to help alleviate the heat. Another resident reported being moved to a different room only after enduring the heat for several days. Staff interviews confirmed that the building was warm and that the air conditioning system was not functioning properly, particularly in the 100-unit area where individual AC units were not working due to broken fan belts. The Maintenance Director acknowledged the issue and suggested providing portable fans for residents who continued to complain about the heat. A Certified Nurse Assistant also noted that the facility was very hot at the beginning of her shift and that staff were instructed to close windows, but could not recall who gave the directive. Medical records indicated that several affected residents had significant health conditions, including acute respiratory distress, dependence on supplemental oxygen, severe persistent asthma, heart transplant status, and immunodeficiency. Facility policies required maintaining ambient temperatures within a specified range and outlined procedures for extreme heat, including identifying high-risk residents and ensuring proper functioning of air conditioning systems. Job descriptions for maintenance and nursing staff emphasized their responsibility to ensure a safe and comfortable environment for residents.
Failure to Maintain Acceptable Ambient Temperatures Due to Inoperable Cooling System
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment by not ensuring that the cooling system was in proper working order, resulting in ambient temperatures exceeding the facility's policy range of 71 to 80 degrees Fahrenheit. Observations and interviews revealed that the air conditioning system in the 100-unit and 200-unit wings was not functioning adequately, with measured temperatures in the hallways reaching 81.3 and 81.5 degrees Fahrenheit. The Assistant Maintenance Director reported that the entire 100-unit area was hot due to broken fan belts on the roof fans, which led to insufficient cool air circulation. Additionally, the vents were not producing enough cool air, and individual AC units in the 100-unit wing were not working. The Administrator confirmed awareness of the temperature issue and acknowledged that the problem was reported to her. The Maintenance Director also confirmed that the temperatures were elevated and attributed the inadequate cooling to the broken fan belts. Facility policy requires maintaining ambient temperatures within the specified range and activating special procedures during extreme heat, but these measures were not effectively implemented, resulting in uncomfortable conditions for residents, staff, and the public in affected areas.
Failure to Prevent Constipation in Resident on Pain Medication
Penalty
Summary
The facility failed to provide effective bowel management for a resident who was prescribed pain medications known to cause constipation. The resident had multiple diagnoses, including dependence on supplemental oxygen, heart failure, spinal stenosis, type II diabetes, and atrial fibrillation, and was moderately cognitively impaired. Physician orders included tramadol and a fentanyl patch for pain management. Despite these medications, which increase the risk of constipation, the resident's bowel movements were not adequately monitored or managed, as evidenced by documentation showing only small bowel movements on two days and none for the following five days. Staff interviews revealed that the nurse practitioner was not made aware of any constipation concerns, and the assistant director of nursing acknowledged that the resident's hospital stay for fecal impaction was preventable. The resident was ultimately hospitalized with severe fecal impaction, confirmed by CT scan, and required disimpaction and an enema. Facility policy required documentation of bowel movements and physician notification for changes in bowel patterns, but these procedures were not effectively implemented for this resident.
Failure to Prevent and Manage Pressure Ulcers Due to Inadequate Assessment and Equipment Use
Penalty
Summary
The facility failed to consistently and accurately assess, monitor, and implement interventions to prevent skin breakdown for two residents at high risk for pressure ulcers. One resident was admitted with intact skin and a high Braden score risk, but developed a facility-acquired unstageable sacral pressure injury within weeks. There was no documented order or clear record of when a low air loss (LAL) mattress was implemented for this resident, despite its presence at the time of survey. The wound care nurse practitioner and wound care director confirmed the development of the pressure ulcer and noted the use of wound care treatments and nutritional supplements, but the initial preventive interventions and monitoring were not adequately documented or implemented per guidelines. Another resident with a history of surgical dehiscence and a full-thickness ankle wound was observed on an alternating air mattress that was not properly inflated due to the power cord being disconnected from the socket. The mattress was set at an incorrect weight and remained deflated in the upper middle portion, causing discomfort and pain for the resident. Staff were aware of the deflation but did not promptly resolve the issue, and the mattress was not providing the required pressure redistribution as per manufacturer guidelines. These failures in monitoring and equipment management contributed to inadequate pressure ulcer prevention and care for both residents.
Failure to Assess and Obtain Consent for Bed Side Rail Use
Penalty
Summary
The facility failed to follow its own side rail policy and federal requirements regarding the assessment and consent for the use of bed side rails for four residents out of a sample of forty-nine. Observations revealed that these residents had raised upper quarter or half side rails on both sides of their beds. Interviews with staff confirmed that all beds in the facility are equipped with bilateral upper side rails and that side rail assessments are required on admission, quarterly, upon significant change, and annually. However, for the residents in question, there were missing or outdated side rail assessments and, in several cases, no documented consent for side rail use in the medical records. Specifically, one resident had only a single assessment from several years prior, and others had no consent forms or assessments available at all. Further review of the residents' medical records showed that some were totally dependent on staff for activities of daily living and unable to use side rails independently. Despite this, care plans for side rail use were initiated without the required ongoing assessments or proper consent documentation. Staff interviews confirmed that the facility's policy requires alternative devices to be tried first, assessments to be completed, and consent to be obtained and documented before side rails are used. These steps were not consistently followed, resulting in the deficiency.
Failure to Properly Label, Store, and Discard Insulin and Medications
Penalty
Summary
The facility failed to comply with its medication labeling and storage policies by not discarding medications belonging to discharged residents and by not ensuring that open and expiration dates were labeled on insulin pens and vials. During observations, multiple instances were found where insulin bottles and pens for several residents were opened but not dated, and in one case, insulin for a discharged resident remained on the medication cart instead of being discarded. Staff interviews confirmed that facility policy requires opened insulin to be dated and medications for discharged residents to be removed from the cart, but these procedures were not followed. Specifically, insulin bottles and pens for residents with Type 2 Diabetes Mellitus were found on medication carts without open or expiration dates, and in one case, insulin for a resident who had been discharged was still present and not discarded. Staff, including nurses and the assistant director of nursing, acknowledged that insulin should be dated upon opening and discarded after expiration, but these requirements were not met for several residents reviewed. The facility's own policy states that all opened medication vials should be labeled with the date opened and discarded within a specified timeframe, but this was not consistently implemented.
Failure to Follow Infection Control and PPE Protocols During Resident Care
Penalty
Summary
The facility failed to adhere to its infection prevention and control policy by not performing appropriate hand hygiene and not donning required personal protective equipment (PPE) before entering and after exiting resident rooms under enhanced barrier precautions (EBP). Multiple staff members, including nurses, nurse practitioners, and a wound care director, were observed entering EBP rooms and providing direct resident care without donning gowns as required. For example, a nurse entered a resident's room, donned only gloves, and performed gastrostomy tube care without a gown. Nurse practitioners conducted a head-to-toe skin assessment on a new admission without wearing gowns, and the wound care director initially entered a resident's room and removed a dressing without any PPE before later donning PPE for wound care. Additionally, an outside laboratory employee entered an EBP resident room to collect a blood specimen, donned only gloves, and did not perform hand hygiene or wear a gown while touching various surfaces and performing the procedure. The infection prevention nurse confirmed that staff are expected to observe signage for required PPE, don gowns for direct care, and perform hand hygiene before and after entering resident rooms. The facility's policy, revised 7/31/24, specifies that gloves and gowns are required for high-contact care activities and that hand hygiene must be performed before and after direct patient contact.
Failure to Obtain Consent and Post Signage for Electronic Monitoring
Penalty
Summary
The facility failed to follow its own electronic monitoring policy by not posting required signage at facility entry points and at the entrance to the resident's room where electronic monitoring was in use. Additionally, the facility did not obtain informed consent from the residents or their representatives before initiating video and audio monitoring in the room shared by two residents. Both residents were unaware of the presence of the electronic monitoring device, and neither had been informed or given consent for the monitoring. One resident's power of attorney was only contacted after the device was already in place and was not fully informed about the extent of the audio recording, believing it would be voice-activated rather than continuous. Documentation related to the electronic monitoring was incomplete and did not include required information such as the names of residents, dates of consent, or the presence of staff during consent discussions. There was also no evidence that the device was turned off during exams or provision of care, as required by policy. The care plan for one resident did not address the use of electronic monitoring, and the consent form lacked signatures and documentation from the roommate. These failures affected both residents in the room and did not comply with the facility's policy or regulatory requirements for resident rights and privacy.
Call Light Accessibility Not Maintained for Dependent Resident
Penalty
Summary
A deficiency was identified when a dependent resident was observed resting in bed with the call light hanging down to the floor and out of reach. The resident, who was alert and able to communicate, stated she did not know where her call light was and was seen feeling around for it but was unable to reach it. The call light remained out of reach during a subsequent observation. The Assistant Director of Nursing confirmed that call lights should be accessible to residents, as they are used to request assistance from nursing staff. The facility's policy requires prompt response to call lights and ensures the call system is in proper working order.
Inaccurate MDS Coding for Special Treatments and Prognosis
Penalty
Summary
Facility staff failed to accurately code the Minimum Data Set (MDS) assessments for three residents, resulting in inaccurate documentation of their care needs and treatments. One resident, who was alert and oriented, reported not having received dialysis in over two years and had a new kidney, yet her MDS indicated she was receiving dialysis at the facility. Review of her physician orders confirmed there were no orders for dialysis treatment. Another resident, admitted with anemia, dementia, adult failure to thrive, and malnutrition, was on hospice care with documentation supporting a prognosis of less than six months. However, the MDS was coded to indicate the resident did not have a terminal prognosis, despite the presence of appropriate documentation in the medical record prior to MDS completion. A third resident's MDS was coded to reflect ongoing hospice care, even though the resident had been removed from hospice and had a payor source change. Social service notes confirmed the last hospice coverage date, and staff interviews revealed that the MDS should have been updated to reflect the change in hospice status. The failure to accurately code the MDS assessments was confirmed through record review and staff interviews, affecting the accuracy of resident assessments and care planning.
Failure to Update and Implement Resident Transfer Care Plan
Penalty
Summary
The facility failed to ensure that care plans accurately reflected a resident's current care needs for safe transfer status, specifically regarding the use of a mechanical lift. A certified nursing assistant (CNA) assisted a resident, who was recovering from a hip fracture, to stand and transfer to the toilet without applying a gait belt or using a mechanical lift, despite the resident requiring verbal and physical cueing. The CNA stated that they followed care card instructions and were aware of the resident's recent hip fracture. Another CNA reported transferring the same resident from bed to wheelchair without any equipment or gait belt, recalling the resident as a stand and pivot with one-person assist for transfers. The restorative nurse confirmed that prior to the resident's fall, the transfer status was stand and pivot with one assist, but following the hip fracture, the resident should have been transferred using a mechanical lift. The care plan, dated after the hip fracture, indicated the need for two staff and a full-body mechanical lift for transfers, but did not document the previous transfer status or the use of a gait belt. The MDS assessment identified the resident as using a walker and requiring partial to moderate staff assistance for transfers. These inconsistencies between the care plan, staff actions, and resident needs led to the deficiency.
Failure to Provide Timely Incontinence Care and Repositioning
Penalty
Summary
Staff failed to provide incontinence care and turning/repositioning at least every two hours for a resident who was totally dependent on staff for activities of daily living. During a two-hour observation period, there was a persistent malodor coming from the resident's room, and no incontinence care or repositioning was provided. A nurse entered the room to provide gastrostomy tube care but did not check for incontinence needs. At the end of the observation, the resident was found with a urine-saturated brief, a wet flat sheet with brown discoloration, and a mattress with pooled liquid under the buttocks. The resident's sacral pressure ulcer dressing was also saturated with urine. Staff interviews confirmed that the resident was unable to assist with ADLs and was fully dependent on staff. The wound care director stated that staff are expected to turn and reposition residents and provide incontinence care every two hours and as needed. The resident's medical records indicated a low BIMS score and total dependence on staff for care. Despite these needs, the required care was not provided during the observed period.
Failure to Follow Transfer Protocols and Use Gait Belt Results in Resident Fall and Fracture
Penalty
Summary
The facility failed to follow established transfer protocols and policies for a resident who required assistance, resulting in a significant injury. Specifically, staff did not use a gait belt during a bed-to-wheelchair transfer and did not adhere to the identified mechanical lift transfer status for a resident recovering from a hip fracture. The resident, who had a recent decline in cognitive status and was identified as needing increased assistance, was transferred without the required equipment or support, leading to a fall and an acute right femoral fracture that required surgical intervention. Observations and interviews revealed that staff members were aware of the facility's policy requiring the use of gait belts for assisted transfers, and that all CNAs were issued gait belts and trained on their use. Despite this, the staff involved in the incident did not utilize a gait belt or mechanical lift as indicated in the resident's care plan and transfer status. The resident was left alone on the toilet without supervision, and during another transfer, was assisted by only one staff member without the appropriate safety equipment, contrary to the care plan and facility guidelines. Documentation review showed inconsistencies in the resident's fall risk assessments and care planning. The care plan did not specify the use of a gait belt or the required level of assistance prior to the incident, and the only fall risk evaluation available was completed on the day of the fall, identifying the resident as high risk. The facility's fall prevention program and employee handbook both require individualized assessment and the use of safety interventions, including gait belts, but these were not implemented as required for this resident.
Failure to Ensure Physician Order and Proper Functioning of Oxygen Therapy
Penalty
Summary
A resident with a history of dependence on supplemental oxygen, heart failure, and atrial fibrillation was admitted to the facility. During observation, the resident was found in bed with a nasal cannula in place, but the oxygen concentrator was turned off. When staff were notified, the Assistant Director of Nursing attempted to turn on the concentrator, which began to beep and was not functioning properly. The concentrator was then replaced with a new one. The Assistant Director of Nursing stated she had not been previously informed of any issues with the concentrator. Further review revealed that there was no current physician order for the resident's oxygen use. The last order for oxygen had been discontinued when the resident was hospitalized, and was not renewed upon readmission, despite the ongoing need for supplemental oxygen. The facility's policy requires a physician order for oxygen therapy, including specific details such as liter flow and delivery device, and mandates equipment checks and proper setup prior to administration. These requirements were not followed, resulting in the deficiency.
Failure to Monitor and Document Antibiotic Use for Resident with C. diff History
Penalty
Summary
The facility failed to develop and implement protocols and a system to monitor antibiotic use for a resident with a history of Clostridium difficile who was currently receiving antibiotics. Interviews with the Infection Prevention (IP) Nurse revealed that although the resident was removed from contact isolation due to the absence of symptoms, there was an expectation for nurses to monitor and document antibiotic assessments and any side effects. However, it was acknowledged that there was no policy in place requiring nurses to document these assessments, and documentation was not being completed as expected. Review of the resident's records showed that the only monitoring documented was related to the use of Doxycycline and Amoxicillin for underarm skin microbiota. The resident's bowel movements were noted to be loose or putty-like over several days, but there was no consistent documentation of daily antibiotic assessments or monitoring for adverse effects as outlined in the care plan. The care plan did include interventions to monitor for side effects of antibiotics every shift, but these were not being followed or documented by staff.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
A deficiency was identified when a resident was observed in a room that was not maintained in a clean and homelike condition. Over multiple days, surveyors observed dry substances on the tube feeding machine, floor, walls, bedside table, and bed framing in the resident's room. These substances, some of which appeared to be related to tube feeding, remained present despite the passage of time and daily cleaning schedules. The housekeeper supervisor acknowledged awareness of the substances and stated that such conditions should not exist, noting that nurses should address spills promptly before they dry and harden. Additionally, the resident reported receiving a bed bath but indicated that her bed linens, including the pillowcase, had not been changed. The pillowcase was observed to be stained and smelled of urine, and the bed sheets were also found to be soiled with yellow/brown stains. The resident expressed discomfort with the situation, and a registered nurse confirmed that the linens should have been changed during the bed bath. Facility policy requires daily cleaning and sanitizing of resident rooms and bathrooms, but these standards were not met in this instance.
Failure to Document Fall and Notify Family
Penalty
Summary
The facility failed to document a resident's fall in the electronic health record and did not notify the family of the incident. This deficiency affected a resident who was a hospice patient with multiple diagnoses, including senile degeneration of the brain, shortness of breath, dysphagia, and a history of falling. On the day of the incident, the resident was found on the floor next to her bed by a nurse during rounds. The nurse on duty, who was an agency nurse at the time, was informed of the fall by another nurse and assessed the resident. However, the nurse did not fill out the risk management forms, notify the family, or document the incident in the resident's medical record. The Director of Nursing confirmed that the nurse should have notified the doctor and the family within the same shift and completed the risk management documentation. The facility's policies require that an incident report be completed for each fall and that the resident's legal representative or family be notified of any significant change in the resident's condition. The failure to follow these protocols resulted in a lack of documentation and delayed family notification, as the family was informed of the fall the following day.
Failure to Report Allegation of Rough Handling
Penalty
Summary
The facility failed to adhere to its Abuse and Neglect Policy by not reporting an allegation of rough handling of a resident to the Administrator immediately. On December 3, 2024, the surveyor informed the Director of Nursing (V1) and the Assistant Director of Nursing (V2) about allegations of night shift staff rough handling a resident (R1). However, V1 did not report this incident to the Administrator (V17) as required by the policy. On December 5, 2024, V17 stated that she was unaware of the rough handling allegation received on December 3, 2024, and would have initiated an investigation immediately if informed. V1 acknowledged the failure to report the incident to V17 and stated she would inform the Administrator about the allegation immediately. The facility's policy mandates that all allegations of abuse must be reported to the Administrator immediately and to the Illinois Department of Public Health (IDPH) within two hours of receiving the allegation.
Failure to Follow Mechanical Lift Protocol Leads to Resident Fall
Penalty
Summary
The facility failed to adhere to its protocol for operating a full body mechanical lift, which requires the presence of two staff members during resident transfers. This deficiency was highlighted when a CNA attempted to transfer a resident alone, resulting in the mechanical lift tipping over and the resident falling to the floor while still attached to the sling. The incident occurred as the CNA was preparing the resident for dialysis, and the lift tipped over during the transfer process. The resident involved in the incident had multiple medical conditions, including orthopedic aftercare, heart failure, atrial fibrillation, peripheral vascular disease, chronic kidney disease, end-stage renal disease, and a displaced fracture of the left femur. Following the fall, the resident complained of severe back pain and reported hitting her head. The CNA admitted to not following the protocol of having a second person assist during the transfer, acknowledging that they had been trained to always have two people present. Interviews with other staff members, including a restorative nurse and the director of nursing, confirmed that the facility's policy mandates two staff members for mechanical lift transfers to ensure resident safety. The CNA involved had received training on this protocol, and the facility's mechanical lifts had passed inspection prior to the incident. Despite this, the CNA proceeded with the transfer alone, leading to the resident's fall and subsequent pain.
Inadequate Fall Prevention and Supervision Leads to Resident Injuries
Penalty
Summary
The facility failed to implement adequate fall prevention interventions and supervision for residents, resulting in multiple incidents of falls and injuries. Six residents were affected, with some sustaining serious injuries such as lacerations, fractures, and head injuries. The facility did not ensure that residents were properly assessed for the safe use of assistive devices, such as walkers and motorized wheelchairs, which contributed to the incidents. One resident with a history of hemiplegia and cognitive impairment was not properly assessed for the use of a walker, leading to a fall that resulted in a fibula fracture. The fall coordinator admitted that the resident's ambulation status was not evaluated, and the walker was removed only after the incident. Another resident with dementia and a history of falls attempted to go to the bathroom without assistance, resulting in a fall and head injury. The facility's fall coordinator did not adequately investigate the resident's fall history or implement effective interventions. Additionally, a resident using a motorized wheelchair, who had visual impairments, was not provided with the necessary supervision, leading to an incident where the resident ran over their own foot, resulting in fractures. The physical therapist noted the resident's visual limitations but did not communicate this to the facility staff. The facility's director of nursing acknowledged that the resident did not have a care plan for the motorized wheelchair, and the resident's visual impairment was not adequately addressed.
Financial Mismanagement of Resident's Account
Penalty
Summary
The facility failed to properly manage the finances of a resident, identified as R3, resulting in a significant financial discrepancy. R3, who had diagnoses including Cerebral Infarction, Depressive Disorder, Diabetes, Heart Disease, and Dementia, had been residing at the facility since 2016 and passed away recently. The facility collected $5,504.06 from R3's managed account without providing an itemized record of services for the amount taken. This action was taken without the consent of R3's Power of Attorney (POA), V19, who claimed that neither she nor the other POA had authorized the withdrawal. The Business Office Manager (BOM), V13, disclosed that the withdrawal was made to cover an outstanding balance, but V19 denied signing any authorization for this transaction. V19 also stated that she had not been informed of any outstanding balance when R3's account was closed. The facility's investigation revealed discrepancies in the signatures on the withdrawal documents, which did not match V19's known signature. Despite V19's request for an explanation and itemized billing, the facility failed to provide adequate documentation or a clear account of the financial transactions. Further complicating the issue, the facility's records showed inconsistencies in the amounts owed and paid, particularly concerning R3's dental and vision plans. The BOM admitted that the facility lacked a policy for handling large financial transactions and that authorization is required for any fund withdrawal. Despite these requirements, the facility did not present collection letters or itemized billing statements during the survey, and the withdrawal consent document's authenticity was questioned. The facility's failure to manage R3's finances transparently and with proper authorization led to this deficiency.
Deficiencies in Pressure Ulcer Care and Mattress Settings
Penalty
Summary
The facility failed to develop an effective pressure sore prevention plan, which resulted in multiple deficiencies in the care of residents with pressure ulcers. Resident R2, diagnosed with vascular dementia and adult failure to thrive, developed an infected pressure wound on her left hand due to contracted fingernails pressing into her palm. Despite being on restorative services for range of motion, there was no treatment or preventive measures such as splints or carrots to prevent contraction. The wound was not documented or treated by the wound nurse practitioner, and the Director of Nursing was unaware of the wound until reviewing hospital records. Resident R3, with a history of peripheral vascular disease, diabetes, and multiple pressure ulcers, was found with soiled dressings that were not replaced in a timely manner. The wound director acknowledged that the nurse on the floor should have changed the dressing when it was soiled. Additionally, R3's air mattress was improperly set at a weight much higher than the resident's actual weight, which could affect the effectiveness of pressure redistribution. The wound nurse practitioner confirmed that mattress settings should be adjusted according to the resident's weight. Resident R4 also had an air mattress set incorrectly, at a weight higher than the resident's actual weight. This resident was at high risk for skin breakdown, as indicated by a Braden scale score. The facility's failure to ensure proper mattress settings and timely wound care interventions contributed to the deficiencies observed during the survey.
Failure to Implement Fall Interventions and Complete Incident Reports
Penalty
Summary
The facility failed to adhere to its fall policy by not implementing new and effective fall interventions and not completing an incident report or fall investigation following a fall for a resident identified as high risk for falls. This deficiency affected a resident who sustained three falls within 30 days, ultimately resulting in a transfer to the hospital with a diagnosis of a subacute subdural hematoma. The resident was admitted with diagnoses including unspecified dementia, hypertension, anemia, and atrial fibrillation, and required partial moderate assistance for toilet transfers. The resident's incident report on 8/12/24 documented a fall where the resident was found on the floor after attempting to go to the bathroom without assistance, highlighting issues such as improper footwear and unsafe transfer. Despite being identified as high risk for falls, the resident's care plan did not include new interventions after subsequent falls on 8/17/24 and 9/11/24. The fall on 8/17/24 was not documented in an incident report, and no new interventions were implemented, despite the resident being found on the floor by staff. On 9/11/24, the resident fell again while attempting to get up from the toilet, resulting in a skin tear and a head injury, leading to a hospital transfer. The facility's policy required that residents be assessed for fall risk, interventions be put in place, and incident reports be completed for each fall. However, these procedures were not consistently followed, contributing to the resident's repeated falls and subsequent hospitalization.
Resident Dehydration Due to Inadequate G-Tube Hydration
Penalty
Summary
The facility failed to ensure that a resident, who was prescribed a mechanical soft diet with thin liquids and gastrostomy tube feeding, received adequate hydration to prevent dehydration. This deficiency affected a resident diagnosed with vascular dementia, metabolic encephalopathy, severe protein-calorie malnutrition, and adult failure to thrive. The resident was on a continuous enteral feed of Jevity 1.2 at 65 ml/hr, with an additional 100 ml water flush every four hours, totaling 1439 ml of water daily. Despite this regimen, the resident was found to have a free water deficit of 1.9 liters, elevated sodium levels, and fecal impaction upon hospital admission. Interviews with facility staff, including dietitians and a wound nurse practitioner, revealed that the resident was considered a dual feeder, receiving both g-tube feeding and a mechanical soft diet. However, the resident's oral intake was minimal, and all nutrition and hydration were primarily provided through the enteral feed and water flushes. The dietitian noted that the enteral feeding was calculated to meet the resident's caloric and protein needs, and additional water should have been provided if the resident had conditions like fever or wounds with exudate, which were not documented. The resident's medical records indicated inconsistencies in the administration of the prescribed enteral feeding and water flushes. Specifically, there was no documentation of the administration of 100 ml of water at 2200 hours and the Jevity feed on a particular date. The resident's nutritional assessment highlighted severe protein-calorie malnutrition and a high risk of malnutrition, with no dietary interventions implemented at the time. The resident was eventually transferred to the hospital for worsening wounds and was diagnosed with hypovolemic hypernatremia due to inadequate g-tube replenishment.
Failure to Notify Family and Physician After Resident Fall
Penalty
Summary
The facility failed to adhere to its notification policy for changes in a resident's condition, specifically following a fall incident involving one resident. The incident occurred when the resident attempted to go to the bathroom but could not find his urinal, resulting in him sitting on the floor between the bed and the wall. Despite the fall being documented in the resident's fall risk evaluation, there was no notification made to the resident's family or physician, as required by the facility's policy. Interviews with the staff involved revealed that the nurse assigned to the resident during the morning shift did not make any notifications to the family, doctor, or falls coordinator. Another nurse who assisted during the incident confirmed that she did not notify anyone and that the responsibility lay with the assigned nurse. The fall nurse also confirmed the absence of any documentation regarding the notification of the physician or family. The facility's policy mandates immediate notification to the resident, physician, and family in the event of an accident involving injury or a significant change in the resident's status, which was not followed in this case.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to follow physician orders for wound treatment for a resident with a diagnosis of type II diabetes and hidradenitis suppurativa, who also had bilateral below-knee amputations. The resident was admitted with a high risk for skin breakdown, as indicated by a Braden scale score of nine. During an observation, it was noted that the resident's dressing for a non-pressure wound on the right underarm was not secured after a shower, and no dressing was present at the time of the interview. The wound care director confirmed that the dressing should have been changed when it was soiled or within two hours after removal, as per the physician's orders. The resident's wound care notes and physician orders specified the use of Dakin's solution for cleansing and the application of Hydrofera Blue and silver alginate for different wound sites, with daily changes required. However, during the survey, it was observed that the wound care was not performed as ordered, with the resident's right axillary and flank sites lacking proper dressing. The facility's policy mandates adherence to physician orders for treatments and care plans, which was not followed in this instance, leading to the deficiency.
Failure to Prevent Financial Abuse and Theft
Penalty
Summary
The facility failed to prevent financial abuse and theft involving a resident, identified as R1, who reported her purse missing. R1, a female resident with a Brief Interview of Mental Status (BIMs) score of 12/15, has diagnoses including osteoarthritis, obstructive sleep apnea, depression, pulmonary hypertension, and difficulty in walking. On a Monday morning, R1 reported to the Activity Director that her purse was missing, which led to the Assistant Administrator being informed. The Assistant Administrator spoke with R1, who explained that she last saw her purse over the weekend. After a search, the purse was found in another resident's room, but R1's debit card was missing, and a small transaction was noted. The facility's investigation revealed that a staff member, identified as V17, was involved in the theft. Video footage showed V17 entering R1's room, although he was not assigned to that unit. V17 was seen taking the purse and later returning it to another resident's room. The police were notified, and V17 was arrested for the theft and for having outstanding warrants from another state. The facility's staffing records confirmed that V17 was not assigned to R1's room on the day of the incident. The facility's abuse policy outlines the prevention of various types of abuse, including theft and financial abuse. Despite this policy, the incident occurred, highlighting a failure in preventing the misappropriation of property. The facility's response included notifying the police and conducting an internal investigation, which led to the identification and arrest of the staff member involved.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions for two residents with a history of falls. One resident, admitted for rehabilitation with a history of falls and a fracture, attempted to get out of bed unassisted and experienced an unwitnessed fall, resulting in acute fractures that required hospitalization. The resident's fall care plan was not updated until after the incident, despite an initial assessment indicating a high risk for falls. The facility's protocol for fall prevention was not followed, leading to the resident's injury and subsequent hospitalization. Another resident was observed in a high bed position, contrary to the care plan intervention that required the bed to be in the lowest position to prevent falls. The resident, who had a history of falls and was at high risk, was found in a slanting position in bed with the bed controls out of reach. The staff failed to ensure the bed was in the correct position after the resident's breakfast, which was a necessary intervention to prevent falls. The facility's policies on fall prevention and care planning were not adequately implemented. The fall risk assessments and individualized care plans were either delayed or not properly followed, resulting in preventable incidents. The staff's failure to adhere to these protocols directly contributed to the residents' falls and injuries, highlighting significant lapses in the facility's fall prevention management.
Failure to Label Thawed Foods in Refrigerator
Penalty
Summary
The facility failed to label foods being thawed inside the refrigerator, which has the potential to affect all 159 residents currently residing in the facility. During an initial kitchen tour, the surveyor observed unlabeled food items, including chicken breast, ham, turkey, ground beef, and a pitcher of orange juice, being thawed in the refrigerator. The Dietary Manager confirmed that these items were indeed unlabeled and acknowledged that they should have been labeled according to the facility's policy. The facility's policy on food safety and labeling requires that all thawed foods be labeled with specific information, including the item name, preparation date, use-by date, and employee initials. The policy also outlines approved methods for thawing food, such as in refrigerators operating at less than 40°F, under cold running water, in a microwave, or as part of the cooking process. Despite these clear guidelines, the facility did not adhere to the labeling requirements, leading to the observed deficiency.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to ensure the proper implementation of pressure ulcer prevention interventions and adherence to manufacturer recommendations for using a low air loss (LAL) mattress for a resident with Stage 4 pressure ulcers. During an observation, the resident was found lying on a LAL mattress with a flat sheet and a thick bath blanket folded in quarters over it, contrary to the manufacturer's guidelines. Additionally, the resident's bilateral heels, which had dressings but no heel protectors, were placed on pillows but not elevated off the bed as required by the physician's orders and the care plan. The resident had multiple pressure ulcers, including a Stage 4 ulcer on the sacral region and ulcers on both heels, among other areas, indicating a high risk for skin impairment as per the Braden scale assessment. The resident's medical history included severe conditions such as osteomyelitis of the vertebra, sacral and sacrococcygeal region, Stage 4 pressure ulcer of the sacral region, pressure ulcer-induced deep tissue damage, Stage 2 pressure ulcer, unstageable pressure ulcer of the right ankle, sepsis, and metabolic encephalopathy. The wound care physician's most recent assessment detailed the extent and condition of the resident's pressure ulcers, highlighting the need for stringent adherence to prescribed interventions and manufacturer guidelines for the LAL mattress. Despite these requirements, the facility staff did not follow the necessary protocols, leading to the deficiency. Interviews with the Unit Manager, Director of Nursing, and Wound Care Director confirmed that the facility staff were expected to implement physician orders, wound care plan interventions, and follow the manufacturer's recommendations for using the LAL mattress. The facility's policies on wound care guidelines, skin care regimen, and specialized mattress usage were also reviewed, all of which emphasized the importance of proper pressure ulcer prevention and treatment measures. However, the observed practices did not align with these policies, resulting in the identified deficiency.
Failure to Provide Appropriate Restorative Services for Resident with ROM Limitations
Penalty
Summary
The facility failed to ensure appropriate restorative services for a resident with limitations in range of motion (ROM) in both upper extremities. During an observation, the resident was found without the prescribed bilateral hand splints, and only one splint was located in the room. The resident confirmed that she had only been using the left hand splint and required assistance to move both hands and arms. The restorative nurse confirmed that the resident was on a program for bilateral hand splints but found no physician order or care plan for the splints in the resident's medical records. The resident's restorative assessments indicated limitations in ROM, but only the left hand splint was documented, and the resident had not been re-evaluated by occupational therapy since January 2023. The therapy director mentioned that an order for bilateral hand splints was received but was pending insurance approval. The resident's medical history includes primary generalized osteoarthritis, intervertebral disc degeneration, and chronic respiratory failure with hypoxia. The facility's policy on restorative nursing programs requires comprehensive assessments and appropriate services, but no specific policy or procedure for splint application was provided. The resident's care plan and physician orders were updated only after the surveyor's observation, indicating a lack of consistent and timely restorative care. The facility's policy on restorative nursing programs requires comprehensive assessments and appropriate services, but no specific policy or procedure for splint application was provided. The resident's care plan and physician orders were updated only after the surveyor's observation, indicating a lack of consistent and timely restorative care.
Deficiency in Catheter Care Management
Penalty
Summary
The facility failed to ensure ongoing assessment and implementation of catheter care for a resident with an indwelling urinary catheter. On observation, the resident was found with brownish, yellow-colored sediments inside the catheter tubing, indicating a lack of proper catheter care. The Unit Manager/Infection Coordinator confirmed that catheter care should be rendered every shift to prevent catheter-associated urinary tract infections and that any changes in urine color or sediment formation should be reported to the physician. However, the resident's catheter tubing had not been changed promptly, and there were missing documentation entries for catheter output monitoring on several shifts. Additionally, the resident's quarterly catheter assessments were not conducted in a timely manner, with both assessments being signed on the same day, and no prior quarterly assessment was done before March 11, 2024, despite the resident being admitted earlier. The resident had a history of urinary tract infections and was on antibiotics for a UTI upon readmission from the hospital. The facility's policies on urinary catheter care and indwelling catheters were not followed, as evidenced by the lack of timely catheter changes and proper documentation. The facility's policy states that catheters should be changed based on clinical indications such as infection or obstruction, and the use of indwelling catheters should be assessed at least quarterly. The failure to adhere to these policies resulted in the observed deficiency in catheter care management for the resident.
Inadequate PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to implement appropriate use of Personal Protective Equipment (PPE) during high-contact care activities for a resident with a urinary catheter and on Enhanced Barrier Precaution (EBP). Specifically, a Certified Nursing Assistant (CNA) was observed emptying a urinary catheter bag without wearing gloves. The CNA acknowledged the mistake, and both the Infection Control Nurse and the Director of Nursing confirmed that gown and gloves should be used during such tasks. The resident involved had multiple diagnoses, including malignant neoplasm of the prostate, Pseudomonas aeruginosa, and a stage 3 pressure ulcer, necessitating the use of EBP to prevent further infection. Additionally, another CNA was observed failing to perform hand hygiene before donning a new pair of gloves after providing incontinence care and changing bed linens for a resident. The CNA admitted to forgetting to perform hand hygiene, and the Assistant Director of Nursing confirmed that hand hygiene should be performed after removing gloves and before putting on a new pair. The resident involved had multiple diagnoses, including hemiplegia, mixed receptive-expressive language disorder, dementia, and muscle wasting and atrophy. The facility's hand hygiene policy, revised in July 2024, mandates hand hygiene after removing gloves, which was not followed in this instance.
Failure to Honor Resident Representative's Choice
Penalty
Summary
The facility failed to honor the resident representative's right to choose a long-term care facility for their family member. The resident, an elderly female with a medical history including type 2 diabetes, depression, dementia, and chronic kidney disease, was admitted to the facility for physical therapy following a hospitalization. Her daughter, who is the surrogate decision-maker, requested that her mother be transferred to an assisted living facility upon discharge. However, the resident was transferred to another long-term care facility without the daughter's permission, which led to dissatisfaction. The Social Service Director at the facility had reached out to the assisted living facility as per the daughter's request, and an assessment was conducted. Initially, the assisted living facility representative deemed the resident inappropriate for their facility. Despite this, the resident was eventually accepted and transferred to the assisted living facility. The facility administrator confirmed that the referral process was followed, but the resident was transferred to a different long-term care facility before the assisted living facility could complete their assessment. The administrator also noted that the expectation was for the Social Service Director to follow up with the family's request within a week.
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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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