Bria Of Elmwood Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Elmwood Park, Illinois.
- Location
- 7733 West Grand Avenue, Elmwood Park, Illinois 60707
- CMS Provider Number
- 145419
- Inspections on file
- 54
- Latest survey
- March 29, 2026
- Citations (last 12 mo.)
- 21 (2 serious)
Citation history
Health deficiencies cited at Bria Of Elmwood Park during CMS and state inspections, most recent first.
Two residents with severe cognitive impairment and complex medical conditions, including dependence on G-tube feeding for all or most nutrition, did not receive enteral nutrition and hydration as ordered. For one resident, hospice and the POA agreed to stop G-tube feeding due to emesis and perceived respiratory distress, but no alternative interventions were tried, the RD was not notified, and the existing POLST directing artificial nutrition and hydration by any means was not revised. For the other resident, surveyors found the feeding pump alarming, the formula carton and tubing completely dry, and the carton dated two days earlier, even though the ordered rate meant it should have been replaced the previous day; there was no documentation explaining the lack of feeding or any provider notification. Facility policies on tube-feeding management, documentation, and adherence to advance directives were not followed.
Surveyors found that staff failed to follow professional standards for medication storage, labeling, and controlled substance documentation, and did not properly document or communicate a major change in a resident’s enteral feeding order. Multiple open insulin vials and pens on several medication carts lacked required open dates, had expired beyond-use dates, or were left in active stock for residents who had been discharged or were deceased. Some insulin and an albuterol inhaler were stored without pharmacy labels or resident names, and loose pills and an expired stock allergy medication were found mixed with active medications. Controlled substance count sheets on several carts had missing nurse signatures for shift counts, and the documented remaining doses for several controlled medications did not match blister card counts; in one case, an oxycodone card had an altered label and was tracked on plain copy paper instead of an individual controlled drug record. In addition, a resident with severe malnutrition, anoxic brain damage, tracheostomy, and gastrostomy status, care planned as NPO and dependent on tube feeding, had the G-tube feeding order discontinued without any documentation in the record or notification of the physician or dietitian by the LPN who received the order.
The facility failed to provide sufficient RN staffing on a high-acuity respiratory unit, resulting in widespread late administration of scheduled medications. Two RNs, including an agency RN who arrived late to the shift, were assigned to 32 residents, many with ventilators, trachs, G-tubes, wounds, epilepsy, diabetes, quadriplegia, and other complex conditions. One RN reported that medications were late every day and that the volume of G-tube medications made timely administration impossible, while a floor manager RN confirmed that most medications scheduled for the morning were not given by the due time. Medication audits showed that half of the unit’s residents received morning medications late, in some cases more than three hours past the scheduled time. The DON acknowledged that such delays constitute timing medication errors but maintained that two nurses were sufficient, while other staff, including an RN, an LPN, and the Infection Preventionist, stated that the unit needed a third nurse due to the acuity and workload.
A resident with severe cognitive impairment, multiple complex medical conditions, and a POLST directing provision of artificial nutrition and hydration via surgically placed tubes was care planned as NPO with enteral feeding for all nutrition needs, yet had no active tube feeding orders and was observed on multiple occasions without any feeding infusing. An RN reported that hospice had discontinued the feeding, the POA stated she had been told feeding could not be restarted despite wanting it continued, and the DON was unaware the feeding had been stopped. The MD acknowledged hospice stopped the feeding due to aspiration risk and stated that the POLST should be revised if G-tube feeding is discontinued, while facility policy affirms residents’ rights to determine life-sustaining treatments, including artificial hydration and nutrition.
A resident with acute respiratory failure, tracheostomy, schizoaffective disorder, epilepsy, and a high fall-risk score had a care plan intervention requiring the bed to be kept in the lowest position. Despite this, nursing documentation and leadership interviews confirmed that the resident’s bed was left in a high position, after which the resident was found on the floor and sent to the hospital. The DON, Restorative Nurse, and Administrator each stated that staff are responsible for implementing care plan interventions and are expected to follow the care plan, consistent with the facility’s policy that the comprehensive care plan drives the care and services provided.
The facility failed to ensure effective nurse-to-nurse handoff communication and documentation during hospital transfers for two residents with complex medical conditions, including ventilator dependence, hospice care, ESRD, and heart failure. In multiple transfers, hospital transfer forms lacked the name of the receiving hospital nurse, progress notes did not document any nurse-to-nurse report, and SBAR forms omitted critical information such as hospice status. The DON stated that nurses are expected to obtain MD orders, complete transfer and SBAR forms, notify family, call and give report to the hospital, and send a face sheet and POS, but staff interviews and record review showed that these steps, particularly the verbal handoff and its documentation, were not consistently completed.
Two residents with high fall-risk scores and multiple comorbidities experienced falls that were not properly documented or evaluated according to facility policy. In both cases, nursing staff documented that the residents were found on the floor and sent to the hospital, but did not complete required fall reports, risk management entries, or post-fall and pain assessments. The DON and Administrator stated that any fall risk score greater than 10 indicates high fall risk and that staff are expected to complete fall risk evaluations and update care plans after each fall, as outlined in the facility’s fall prevention and management policy.
A resident with complex medical conditions, including ventilator dependence and anoxic brain damage, was enrolled in hospice, but the facility did not add hospice orders to the physician order sheet or indicate hospice status on the face sheet. When the resident later had tachycardia and seizure-like activity, an agency RN obtained an order to send the resident to the hospital and provided face sheets and physician orders to EMTs, but was unaware the resident was on hospice and did not communicate hospice status during the transfer. Review of the transfer form showed no documentation of hospice, and leadership acknowledged hospice status should appear in the POS and on the face sheet, in contrast to facility hospice policy and CMS requirements for coordinated hospice care.
The facility failed to honor residents’ rights to receive visitors at any time by enforcing fixed visiting hours ending at 8 p.m., despite a written policy allowing 24-hour open visitation with only quiet hours. Two nonverbal, fully dependent residents with complex conditions, including anoxic brain damage, chronic respiratory failure, tracheostomy and gastrostomy status, had family members who were told by staff, including an LPN, that visiting hours were over and they had to leave at 8 p.m., even when one family member was addressing concerns about tube feeding and another was waiting for incontinence care. Staff consistently described visiting hours as ending at 8 p.m., and the DON acknowledged the use of visiting hours and the need for administrative approval for overnight stays, while there was no documentation that these visitation limits were based on individualized clinical need, resident preference, safety, or roommate rights.
The facility failed to ensure that three nonverbal, fully dependent residents with PEG/GT tubes received enteral nutrition as ordered and that tube feeding intake was accurately documented. A resident’s spouse repeatedly found the feeding pump off or inactive during ordered continuous feeding times, with staff and telehealth documentation confirming missed hours of feeding. For two other residents, surveyors observed that the volume of formula remaining in the feeding containers and the total volume displayed on the pumps did not match the prescribed rates, labeled start times, or ordered daily volumes, and one container lacked a start time label altogether. The DON acknowledged that pumps might not have been reset when new bottles were hung and that there was no dedicated flow sheet to track bottle changes, while records lacked documentation of feeding interruptions, restarts, and total daily volumes despite facility guidelines requiring pump clearing each shift and documentation of tube feeding delivered.
A resident with complex medical conditions was treated for hypokalemia and received potassium supplementation, but staff failed to ensure timely laboratory monitoring and did not act upon a critically high potassium result. An LPN reviewed a critical potassium value of 8.4 mEq/L but did not initiate emergent intervention or escalate the situation as required by facility policy. The lack of timely response and failure to follow protocols resulted in the resident not receiving necessary medical care and subsequently experiencing cardiac arrest and death.
A resident with significant cardiac and vascular conditions had a critically high potassium level identified by lab testing, but the LPN who received the result did not ensure timely provider notification or initiate appropriate clinical intervention. The LPN documented an attempt to notify the NP but did not escalate the issue or provide further care, and the critical result was cleared from the EMR, preventing further action. The resident was later found unresponsive and died, with the facility's failure to follow its policy for critical lab notification resulting in Immediate Jeopardy.
A resident with multiple comorbidities was treated for hypokalemia and received potassium supplementation, but the facility failed to ensure ongoing assessment and timely laboratory monitoring. Orders for potassium were entered incorrectly, resulting in prolonged administration, and there was no documentation of follow-up labs or clinical intervention after a critically high potassium level was identified. The resident was later found unresponsive, with the death certificate listing cardiopulmonary arrest as the cause of death.
A CNA failed to follow infection prevention protocols by not changing gloves or performing hand hygiene while providing care to two residents. The CNA used soiled gloves to handle personal items, clean linens, and touched multiple surfaces, including a linen cart, without proper glove removal or hand hygiene. This breach of protocol was confirmed by facility leadership and was inconsistent with established infection control policies.
A resident with multiple medical conditions left the facility without proper discharge planning or documentation, including the absence of required AMA education, physician notification, and completion of forms. The resident departed without medications or belongings, and the facility was unable to confirm the resident's location or condition after discharge.
A resident with significant cognitive and physical impairments, identified as high risk for falls, experienced multiple unwitnessed falls, including one resulting in a hip fracture. The facility did not implement effective fall prevention interventions or follow proper post-fall procedures, as staff moved the resident after a suspected injury and care plan changes did not address the actual causes of the falls.
Two residents who required staff assistance with personal hygiene did not receive adequate ADL care, as evidenced by observations of poor grooming and resident reports of ignored requests for help. Both residents had documented needs for assistance in their care plans, and facility guidelines required such support.
The facility did not properly transcribe and implement hospital nutrition support orders for a resident readmitted with severe underweight and pressure ulcers, resulting in delayed initiation of prescribed supplements and tube feeding. Additionally, two other residents requiring tube feeding were observed without feedings running during ordered times, with staff confirming interruptions for care and medication that were not promptly resumed. These actions led to significant weight loss and inadequate nutrition support, contrary to physician orders and facility policy.
A resident with paraplegia and multiple diagnoses, who requires maximal assistance for transfers, fell after staff failed to respond to her call light for bathroom assistance. The incident was not documented in the fall log, and no fall risk assessment was completed as required by facility policy. Staff believed the resident's behavior was typical, but there was no supporting documentation or care plan evidence.
A resident with multiple risk factors and a history of abuse allegations did not have their Abuse/Neglect Care Plan updated after a new sexual abuse allegation was reported. Despite facility policy requiring care plan updates after significant changes, including abuse allegations, the care plan remained unchanged following the incident.
A resident with moderate cognitive impairment reported to an LPN that his roommate had inappropriately touched him during the night. The allegation was relayed to the Social Service Coordinator and Administrator, but the Administrator did not immediately report the incident to state authorities or law enforcement as required by facility policy, instead concluding the claim was fabricated. The incident was only reported to authorities several weeks later, despite staff acknowledging that immediate reporting was necessary.
A respiratory technician/student, not yet certified, independently provided respiratory care to residents, including tracheostomy care and ventilator checks, without proper supervision. This occurred despite the residents' complex medical needs and the facility's awareness of the technician's unlicensed status.
A facility failed to provide care according to professional standards, resulting in a resident's prolonged distress due to pneumonia and influenza A. Despite the resident's request for hospital transfer, the nurse on duty refused to call 911. Additionally, unlicensed respiratory technicians were observed performing tasks independently without direct supervision, contrary to the Respiratory Care Practice Act.
A resident with COPD, asthma, and influenza experienced a significant change in condition, feeling unwell and having difficulty breathing. Despite her requests for hospitalization, the facility staff failed to assess her condition or notify her physician, resulting in a delay of care. The resident eventually called 911 herself and was admitted to the hospital with pneumonia and influenza.
The facility failed to employ credentialed respiratory staff, allowing a respiratory technician to perform tasks independently without certification. The technician, initially hired as a student, was observed providing tracheostomy care and administering medications without the necessary supervision. Despite awareness of the lack of certification, the facility did not take corrective action, violating state law requirements for licensed respiratory care practitioners.
During an influenza outbreak, the facility failed to provide appropriate masks, leading to the use of non-medical masks by staff and residents. The Infection Preventionist recommended N95 masks, but non-medical masks were still available and used, contributing to the spread of influenza among residents. The outbreak began on the fourth floor and spread to the first, with several residents testing positive for influenza and other respiratory illnesses. Observations confirmed the presence of non-medical masks throughout the facility, contrary to CDC guidelines for infection control.
Residents with intact cognition reported dissatisfaction with food quality, describing it as uncooked, cold, and bland. Despite complaints to the Dietary Manager, the grievance committee did not effectively address their concerns. A test tray observation revealed food served below proper temperature standards, highlighting the facility's failure to resolve food quality issues.
The facility failed to document the administration of controlled substances for several residents, as required by its policies. An LPN did not record doses of Oxycodone, Clobazam, and Lacosamide on the controlled substance record, despite administering them. Additionally, a newly admitted resident's Oxycodone was not documented on an individual controlled substance form, and the LPN did not inform the DON about the missing documentation.
A respiratory technician/student, unlicensed, administered a medicated breathing treatment to a resident with chronic respiratory failure, violating the facility's policy that requires medications to be administered by licensed personnel. The technician had been working independently without a license, and the facility failed to verify licenses beyond the initial hiring process.
The facility failed to comply with medication storage and labeling policies, affecting several residents. Unlabeled and expired medications were found in medication carts, and insulin was improperly stored, leading to the administration of expired doses. Additionally, expired Tuberculin solutions were not removed from the medication refrigerator, potentially impacting new admissions. These deficiencies highlight lapses in adherence to established protocols.
A facility failed to follow its mechanical lift policy by not keeping the lift's base in the widest position during a resident transfer. The resident, who was morbidly obese and required assistance, was being moved to a dialysis chair when the lift's legs were closed, contrary to policy. The resident became nervous and fidgeted, leading to a fall that resulted in an acute subdural hematoma.
A resident in an LTC facility was physically abused by another resident, resulting in facial lacerations. The altercation began as a verbal argument over the television and escalated when one resident hit the other with a remote control. Both residents were moderately cognitively impaired. Staff intervened, and the aggressor was sent for psychiatric evaluation.
A resident alleged being attacked by another resident over a TV volume dispute, leading to hospitalization for psychiatric evaluation. Despite an investigation by the social service director, the facility failed to report the abuse allegations to the state agency as required. Conflicting accounts from residents and staff, along with missing documentation, highlight the deficiency in compliance with abuse reporting regulations.
A resident did not receive the correct dose of Oxycodone as prescribed, due to an LPN administering it every four hours instead of the ordered eight-hour interval. The resident was not in the facility when the medication was signed out, and there was a lack of documentation in the medication administration record. The LPN did not review the orders or report the error, and the facility failed to adhere to its narcotic medication policy.
A facility failed to follow its narcotic medication policy for a resident prescribed Oxycodone 5 mg. The resident reported not taking the medication every four hours, yet records showed discrepancies, including administration times when the resident was not present. An LPN admitted to administering the medication more frequently than ordered and did not report the error. The facility's documentation was inconsistent with its policy, leading to a deficiency.
The facility failed to provide palatable meals to several residents, who reported the food as flavorless, overcooked, or undercooked. Meals were often served late, with some residents receiving dinner after 9:45 pm. Dietary staff acknowledged the complaints and frequently sent replacement trays or substitutes, indicating a failure to adhere to the facility's policy on providing nourishing and palatable meals.
A facility failed to provide timely dinner meals to 14 residents, with meals being served after 10:00 pm instead of the scheduled 6:30 pm. Residents, including those with diabetes and respiratory issues, expressed dissatisfaction with the late and poor-quality meals. Staff acknowledged the failure to meet the expected meal delivery times.
A resident with multiple health issues missed an oncology appointment due to the facility's failure to provide an escort, despite being aware of the need. The transportation was arranged, but no escort was available, and the facility lacked a specific policy for such situations.
A facility failed to document the administration of narcotic medication in the EMAR for a resident with multiple medical conditions. Despite being signed out on the individual narcotic sign-out sheet, five doses of Hydrocodone-Acetaminophen were not recorded in the EMAR. Interviews revealed that a lapse in following documentation procedures occurred, with a nurse admitting to sometimes forgetting to sign medications under the EMAR. The facility's policies require documentation in both the individual narcotic sign-out sheet and the EMAR.
A resident experienced mental abuse when an activity aide pulled off her wig during a disagreement over a borrowed speaker. The resident, who was alert and oriented, felt humiliated and embarrassed by the incident, which escalated into a physical altercation. The facility's abuse prevention policy was not upheld, leading to a deficiency report.
The facility failed to ensure that all CNAs have current CPR training and certification, as required by its policy. Interviews revealed that CPR training is encouraged but not mandatory, contradicting the facility's policy that all staff are responsible for performing CPR. The Director of Nursing confirmed that some aides lack CPR training, and they are instructed to inform a nurse if a resident is unresponsive, rather than performing CPR themselves.
A respiratory therapy student administered care unsupervised after the licensed therapist left early, affecting 11 residents. The facility lacked policies for student supervision, violating the Respiratory Care Practice Act's proximate supervision requirement.
A resident with multiple health issues experienced diarrhea and weakness, but the facility failed to notify the physician or conduct a proper assessment. The resident was later found unresponsive and deceased, with signs of rigor mortis. The facility's policy requires notifying the physician of significant changes, but this was not done, contributing to the deficiency.
A resident with multiple medical conditions developed untreated diarrhea, leading to cardiac arrest. The CNA reported the issue to the RN, but no further action was taken due to the absence of a medication order. The LPN was unaware of the resident's condition, and no nursing assessment or physician notification occurred. The facility lacked a care plan for diarrhea, contributing to the deficiency.
A male resident with a complex medical history, including respiratory failure and COPD, experienced a critical incident due to lapses in respiratory care. Despite established care plans for ventilator settings and suctioning, the nursing staff and respiratory therapist did not respond promptly to the resident's distress signals. Staffing challenges, including reliance on a single respiratory therapist for over 20 residents with tracheostomies, and unclear protocols regarding suctioning responsibilities contributed to the delay. The resident's distress, including a dislodged tracheostomy tube, led to cardiac arrest and subsequent passing.
A deficiency was identified involving the delayed response of nursing staff to a resident with a tracheostomy, who had a complex medical history including Acute and Chronic Respiratory Failure, Dysphagia, and COPD. Despite the resident's Full Code status, there were documented delays in providing necessary suctioning and monitoring. The resident showed signs of distress, such as gesturing towards the tracheostomy, but received inconsistent and delayed care. Conflicting accounts from staff and discrepancies in monitoring and assessment contributed to the adverse outcomes.
The facility failed to provide timely respiratory tracheostomy care, did not respond to a resident's request for suctioning, and lacked staff with the necessary skills to meet the needs of a resident in respiratory distress, leading to a life-threatening situation.
A facility failed to follow abuse prevention policies, resulting in a resident being physically abused by a respiratory therapist. The resident, who has a tracheotomy and chronic respiratory failure, reported being slapped and forcibly restrained. Despite reporting the incident, the resident continued to see the therapist, leading to feelings of fear and frustration.
A facility failed to follow abuse prevention procedures by not conducting a thorough investigation of an alleged abuse incident involving a staff member and a resident. The resident reported being slapped by the respiratory therapist on two occasions and expressed fear of the staff member's return. The facility did not ensure the staff member was kept away from the resident and did not provide adequate training to staff on abuse prevention and response.
The facility failed to follow their policy for tracheotomy suctioning and did not adhere to physician orders for providing adequate respiratory care for a resident with a tracheotomy. The resident experienced pain and fear due to harsh suctioning by a respiratory therapist, and documentation showed inconsistencies in care. The medical director acknowledged the incident and confirmed that physician orders should always be followed.
Failure to Provide Ordered Enteral Nutrition and Honor POLST for Artificial Nutrition
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered enteral nutrition and hydration, to follow tube-feeding policies, and to honor an existing POLST directive for artificial nutrition and hydration. One resident (R11) had a history of anoxic brain damage, severe protein-calorie malnutrition, acute and chronic respiratory failure, stage 4 sacral pressure ulcer, tracheostomy, and gastrostomy status, and was assessed as severely cognitively impaired and dependent for all ADLs. His care plan documented NPO status with enteral feeding for all nutrition needs, including monitoring tolerance, weight, labs, skin, hydration, and providing additional fluids via feeding tube as ordered. Physician orders included a nutritionist consult after emesis and instructions to check residuals and hold feeding if residuals were ≥100 ml, with MD notification if residuals remained high. However, at the time of surveyor observations, R11 had no active G-tube feeding order, only water flush and medications, and was repeatedly observed in bed with a G-tube plunger at bedside, no feeding pump, and no feeding infusing. Staff interviews revealed that R11’s feeding had been stopped by hospice on a prior date due to episodes of emesis and perceived respiratory distress. The hospice RN stated that R11 had been on 2 cal formula at 50 ml/hr with a total volume of 425 ml and that hospice discussed with the family that feeding could cause respiratory distress; no other interventions such as reducing rate or volume were attempted before stopping feeding entirely, and hospice believed the resident was near end of life. The hospice RN acknowledged telling the POA that at end of life the resident did not need feeding. The POA reported having no clinical experience, relying on hospice’s explanation, and believing that because the resident was at end of life he did not need feeding; she also stated the resident did not receive water except with medications and was not being turned and repositioned every two hours as care-planned. The facility dietitian reported she was not notified that feeding had been stopped, described not feeding at all as “extreme,” and stated that the facility should be following the resident’s POLST form when determining care. R11’s Illinois Department of Public Health POLST form, signed by the POA, documented in section D that artificial nutrition and hydration should be provided by any means, including new or existing surgically placed tubes. The DON stated she was not aware that R11’s feeding had been discontinued and agreed the facility should follow the POLST. The attending physician/medical director acknowledged being aware that hospice had stopped the feeding due to aspiration risk and that the longer the resident was fed, the longer he would live, and stated that if the G-tube feeding was discontinued, the POLST should be readdressed and a new form obtained. The facility’s advance directive/DNR policy stated that life-sustaining treatments include IVs, tubes, and artificial hydration and nutrition to maintain life unless there are specific directions from the resident or family not to, and that changes to advance directives require voiding the old form and initiating a new one. No documentation was presented showing that R11’s POLST had been revised to reflect a decision to withhold artificial nutrition and hydration. A second resident (R1) with acute and chronic respiratory failure, type 2 diabetes, protein-calorie malnutrition, dysphagia, a stage 3 pressure ulcer, traumatic brain injury, epilepsy, encephalopathy, tracheostomy, and gastrostomy status was also affected. R1’s MDS documented severe cognitive impairment and that more than 51% of nutrition was via enteral feeding. The care plan indicated R1 was NPO due to dysphagia, that tube feeding would provide approximately 100% of estimated needs, and that staff should monitor tube-feeding tolerance; it also noted R1’s increased risk of abuse due to fragility, poor cognition, and poor communication, with a goal to remain free from mistreatment. Physician orders specified continuous enteral feeding of 2 Cal HN at 40 ml/hr for 20 hours daily (on at 2 pm, off at 10 am) via G-tube, with Jevity 1.5 as a substitute at 52 ml/hr for 21 hours if needed. During observation, R1 was found in bed, unarousable, with the enteral feeding pump alarming “FEED ERROR.” The feeding carton was completely desiccated, with only a quarter-sized amount of dried, cracking formula inside, and the tubing contained dry residual formula occupying less than 10% of its length. The carton was labeled with a date indicating it had last been hung two days earlier, with no time noted. Nursing staff and the DON confirmed that at the ordered rate of 40 ml/hr, the 1-liter carton would last approximately 25 hours and that another carton should have been hung the previous day. The DON acknowledged that R1 was completely dependent on staff for enteral feeding and hydration. There was no documentation in the medical record between the date the carton was hung and the survey date indicating that feeding had been held, that a provider had been notified, or that any rationale existed for not administering the feeding. Progress notes for R1 documented on a later date that the resident was in bed with head of bed elevated, vital signs stable, medications given, and “GTF ongoing, on at 2pm off at 10am,” with trach and G-tube sites intact and no signs of infection, and that the resident was repositioned every two hours. This documentation did not reflect the observed absence of active feeding or the dry feeding set. The dietitian confirmed that R1 was NPO and that 100% of nutritional needs were delivered via tube feeding, and explained that the current order met 100% of estimated needs. The medical director stated that a patient with diabetes who does not receive ordered enteral feeding could be expected to develop hypoglycemia, dehydration, or electrolyte imbalances. Nursing staff assigned to the unit on the relevant shifts either denied being assigned to R1, did not recall the resident, or stated they did not change tube-feeding cartons, indicating that night shift was responsible for changing sets at midnight and dating them accordingly. The facility’s Tube Feeding Management policy required continuous tube feedings to be based on a 22-hour consumption period or other time frame per RD assessment, with the health care provider notified if the ordered amount was not infused, and required labeling of tube feedings with resident name, rate, total volume, date, and time hung. The policy also required that the pump be cleared at the end of each shift, that tube feeding delivered be documented, and that the health care provider be alerted to any issues or concerns. In R1’s case, the feeding set remained in place well beyond the expected infusion period without replacement, the pump alarmed without effective response, and there was no documentation of the interruption or of provider notification. In R11’s case, enteral feeding was discontinued without updating the POLST or notifying the dietitian, despite the existing POLST directive to provide artificial nutrition and hydration by any means.
Medication Storage, Controlled Substance Documentation, and Enteral Feeding Order Communication Failures
Penalty
Summary
The deficiency involves multiple failures in medication storage, labeling, pharmacy services, and documentation, as well as failure to document and communicate a significant change in a resident’s enteral nutrition order. Surveyors observed numerous open insulin vials and pens on multiple medication carts without required open dates or beyond-use dates, including products for residents who had been discharged or were deceased. Several insulin vials and pens had stickers indicating “Do Not Use After” dates that had already passed, yet remained in the active medication drawers. An albuterol inhaler and several insulin products were found on the carts without pharmacy labels or resident names, and 24 loose pills were scattered in the top drawers of one cart. An expired stock bottle of Geri-Dryl liquid allergy relief was also stored with active medications. Staff interviewed on the units acknowledged that these medications were expired, lacked open dates, or were unlabeled and stated they should not be in use. Record review showed that some of the insulin products belonged to residents who had been discharged or had died weeks earlier, and those medications had not been removed from the active supply or returned to the pharmacy. Current physician orders for several residents confirmed ongoing insulin therapy, yet the corresponding insulin vials or pens on the carts were either expired or missing required dating. Pharmacy and facility policies required that multidose injectable vials be dated upon opening, that shortened expiration dates be applied and observed, that all medications be stored in containers with pharmacy labels, and that expired medications be removed from active stock and destroyed. The DON confirmed that insulin should be dated when opened, discarded after the appropriate time frame, and that medications without labels should not be used. Despite these policies, surveyors found expired, undated, unlabeled, and stock medications commingled with active medications on multiple carts. Additional deficiencies were identified in controlled substance documentation and handling. On several medication carts, controlled substance count sheets had multiple missing nurse initials for shift-to-shift counts on various dates. For several residents, the number of controlled medication doses documented as remaining on the monitoring/control records did not match the actual blister card counts, and nurses stated they had administered doses but had not yet signed them out. One resident’s oxycodone blister card had the original pharmacy label name blacked out and the resident’s name handwritten in marker, and the controlled medication was being documented on a handwritten sheet of copy paper instead of an individual controlled substance record. Facility and pharmacy policies required that each controlled dose be recorded at the time of administration on both the MAR and the controlled substance count sheet, that shift counts be completed and signed by oncoming and off-going nurses, and that controlled medications be dispensed with and tracked on individual controlled drug records. The DON stated it was not appropriate to document controlled counts on blank copy paper and that each controlled medication should have a proper count sheet. The deficiency also includes failure to ensure professional standards in documenting and communicating changes in a resident’s diet order. One resident with anoxic brain damage, severe protein-calorie malnutrition, acute and chronic respiratory failure, stage 4 sacral pressure ulcer, tracheostomy, and gastrostomy status was care planned as NPO and dependent on enteral feeding for all nutrition needs. The resident previously had an order for continuous tube feeding with 2 CalHN, with a substitution order for Jevity 1.5 if needed, but this feeding order was discontinued. At the time of review, the resident had no active G-tube feeding order, only water flush and medication orders. The dietitian reported that she last saw the resident while on G-tube feeding and hydration therapy and stated she was not notified that the feeding had been stopped. The DON stated that hospice orders should be clarified by the floor nurse, who should verify with the physician, notify the dietitian, and document the order in the record. The LPN who received the order to discontinue feeding stated he simply stopped the feeding, did not document the change in the resident’s record, did not write a progress note, and did not notify the physician or dietitian, despite job descriptions requiring nurses to document nursing care and pertinent data according to facility policies and procedures.
Insufficient RN Staffing on Respiratory Unit Leading to Widespread Late Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient licensed nursing staff on the third-floor respiratory (ventilator) unit to meet resident needs, resulting in widespread late medication administration. The third floor housed 32 residents, all dependent on staff for all or some daily needs, including 16 residents on ventilators, 29 with tracheostomies, 22 with gastrostomy tubes, and 15 with wounds. Facility staffing records from 3/9/26–3/25/26 show that only two licensed nurses were scheduled per shift on this high-acuity respiratory unit, consistent with the facility assessment and staffing plan that identified two licensed nurses per unit and per shift. On the date reviewed, the schedule showed two RNs (one agency) assigned to the third floor, and the DON confirmed there had been a call-off and that one RN came in to cover until the agency nurse arrived. On the morning in question, one RN reported still having several residents left to receive their medications and stated that medications would be late, explaining that the volume of residents with gastrostomy tubes made medication administration time-consuming due to required checks and preparation. This RN stated that medications were late every day on that floor and that a third nurse was needed. A floor manager RN reported being asked to come in temporarily to help until the agency RN arrived and acknowledged that most residents’ medications, scheduled for 9:00 a.m. and due by 10:00 a.m., were not given by the due time; the floor manager passed medications for only two residents and then stayed to help the agency nurse. The agency RN stated that they had just arrived, were receiving report, had 19 residents assigned, and still had 17 residents needing their morning medications after the due time, confirming that these medications would be late. Medication Administration Audit reports for the third floor on the same date showed that 16 of 32 residents received medications late, affecting residents assigned to both RNs. Multiple residents with complex conditions, including respiratory failure, ventilator dependence, tracheostomies, gastrostomy tubes, epilepsy, diabetes, pressure ulcers, quadriplegia, hemiplegia, anoxic brain damage, COPD, and other serious diagnoses, had scheduled morning medications administered from 21 minutes to more than three hours past the scheduled times. The DON acknowledged that medications are expected to be given within one hour before or after the scheduled time, affirmed that administration more than one hour past the scheduled time is a timing medication error requiring physician notification, and nonetheless stated a belief that two nurses were sufficient for the unit. Additional staff who regularly worked on the respiratory unit, including an RN, an LPN, and the Infection Preventionist, reported that there were not enough nurses on the third floor, described the residents as very acute with extensive ventilator, trach, and tube-feeding needs, and stated that the workload made it difficult to do more than pass medications and impeded timely completion of other nursing tasks. These observations and records demonstrate that the facility did not ensure sufficient nursing staff with appropriate competencies to meet the assessed needs of all residents on the respiratory unit, contrary to its own staffing, medication administration, and resident rights policies.
Failure to Follow POLST Regarding Artificial Nutrition and Hydration
Penalty
Summary
The facility failed to follow a resident’s advance directive, specifically the Illinois POLST form, regarding the provision of artificial nutrition and hydration. The resident, who had anoxic brain damage, severe protein-calorie malnutrition, acute and chronic respiratory failure, a stage 4 sacral pressure ulcer, tracheostomy and gastrostomy status, and a history of sudden cardiac arrest, was cognitively severely impaired and dependent on staff for all ADLs. The POLST form directed that artificial nutrition and hydration be provided by any means, including new or existing surgically placed tubes. The resident’s care plan documented NPO status with enteral feeding for all nutrition needs, with interventions to adjust tube feeding as needed and monitor tolerance, weight, labs, skin, and hydration. However, record review showed that the resident had no active G-tube feeding orders, only water flushes and medications, and that a prior continuous tube feeding order had been discontinued on a specified date. During observations on two separate days, the resident was seen in bed, unresponsive to questions, with a G-tube plunger at the bedside but no feeding pump or feeding infusing. When questioned, an RN stated she was unsure of the feeding orders and later reported that hospice had discontinued the feeding. The resident’s family member/POA reported being told by hospice that feeding could not be restarted because the resident was at end of life and, lacking clinical experience, accepted this explanation, although she stated she wanted the resident to continue receiving feeding. The DON stated she was unaware that the feeding had been discontinued and affirmed that the facility should follow the POLST. The physician acknowledged knowing that hospice had stopped the feeding due to aspiration risk and that the resident’s wife was said to be okay with it, and further stated that if G-tube feeding is discontinued, the POLST should be readdressed and a new one obtained. The facility’s advance directive/DNR policy states that residents have the right to determine in advance what life-sustaining treatment will be provided, including artificial hydration and nutrition, and that such directions enable staff to know how to treat residents in advance of an emergency.
Failure to Implement Fall-Prevention Care Plan Intervention
Penalty
Summary
The deficiency involves the facility’s failure to implement a care plan intervention for a resident assessed as high risk for falls. The resident is an adult male with medical diagnoses including acute respiratory failure, tracheostomy, schizoaffective disorder, and epilepsy, and a BIMS score of 10/15. A fall assessment dated 5-17-2025 scored the resident at 15, indicating high fall risk. The resident’s care plan dated 7-3-2025 included an intervention to keep the bed in the lowest position. However, nursing notes dated 12-25-2025 documented that the resident’s bed was left in an elevated position, and the nurse observed the resident lying on his left side, after which he was sent emergently to a local hospital for evaluation. During interviews, the DON stated that on 12-25-2025 at 5:50 AM, the resident was observed on the floor after the bed had been left in a high position, and that the care plan required the bed to be in a low position due to the resident’s high fall risk. The DON reported not knowing who left the bed in the high position and stated an expectation that nursing staff implement care plan interventions. The Restorative Nurse confirmed that staff are responsible for implementing care plan interventions and did not know why the bed was left high. The Administrator also stated an expectation that nursing staff follow and implement the care plan to ensure the resident’s safety. The facility’s Comprehensive Care Plan policy dated 3-2025 states that the comprehensive care plan should drive the care and services provided for the resident.
Failure to Ensure Effective Nurse-to-Nurse Handoff Communication During Hospital Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure effective nurse-to-nurse communication and documentation during resident transfers to an acute care hospital, contrary to professional nursing standards and facility policy. For one resident with acute and chronic respiratory failure with hypoxia, ventilator dependence, anoxic brain damage, epilepsy, and a history of cardiac arrest, the record for a transfer for a GI bleed showed no documentation of a report being called to the hospital. The Hospital Transfer Form completed by the DON left blank the section for documenting to whom report was called, and the DON stated she did not call the hospital but only helped fill out forms. When requested, the facility could not provide any documentation or other evidence that a nurse-to-nurse report or verbal handoff occurred for that transfer. For the same resident’s later transfer for tachycardia and seizure-like activity, the RN who initiated the transfer stated she believed she had called report to the receiving hospital but could not recall to whom she gave report, and there was no documentation in the medical record of a nurse-to-nurse report or verbal handoff. The RN documented notifying the family and giving information to paramedics, including face sheets and physician orders, but did not document communication with the hospital. The resident had a hospice consent signed several days prior to this transfer, but the SBAR form completed by the RN did not indicate that the resident was on hospice and did not document any communication to the hospital. The facility was unable to provide evidence that a verbal handoff or nurse-to-nurse report was completed at the time of this transfer. A second resident with end stage renal disease, dialysis dependence, acute pulmonary edema, heart failure, hypoxemia, anemia in chronic kidney disease, type 2 diabetes, and peripheral vascular disease was transferred to the hospital on two occasions without documented nurse-to-nurse communication. For one transfer, the hospital transfer sheet completed by an RN did not document who received report at the hospital, and there were no nurse progress notes or other nursing documentation regarding handoff or hospital transfer. For a later transfer, initiated when the resident called 911 stating he did not feel well, the LPN documented that the resident was escorted to the emergency room and that a message was left for the next of kin, but the hospital transfer sheet did not document to whom report was called. The LPN stated she typically did not call the hospital when the resident self-initiated 911 calls, relied on paramedics and the hospital’s prior familiarity with the resident, and did not send physician orders in those situations. The DON described an expectation that nurses obtain physician orders, complete transfer and SBAR forms, notify family, call and give report to the hospital nurse, send a face sheet and physician orders, and document these actions in progress notes, which was not demonstrated in these cases.
Failure to Complete Fall Documentation and Post-Fall Assessments for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall prevention and management policy for two high fall-risk residents by not completing required fall risk evaluations and post-fall assessments, and by failing to document at least one fall event. One resident, a male with acute respiratory failure, tracheostomy, schizoaffective disorder, and epilepsy, had multiple fall risk assessments with scores greater than 10, indicating high risk for falls. His fall risk scores included 15, 13, 25, 25, and 23 on various dates. A progress note documented that he rolled out of bed and was sent to a local hospital for evaluation, but there were no fall or pain assessments completed after this fall, despite the facility policy requiring a fall risk evaluation after each fall. The second resident, a male with hemiplegia, hemiparesis, diabetes, vascular dementia with anxiety, and tracheostomy, also had multiple fall risk assessments with scores greater than 10, indicating high risk for falls, including scores of 14, 22, 24, and 22. A progress note documented that he was found sitting on his buttocks on a floor mat next to the bed and was sent to a local hospital for evaluation. The DON stated there was no completed fall report for this fall and no documented post-fall assessments for falls on two separate dates. The restorative nurse confirmed that the nurse documented the resident on the floor but did not complete a fall report, risk management, or fall assessment. The Administrator and DON both stated their expectation that staff complete risk management, fall assessments, and required documentation after every fall, consistent with the facility’s Fall Prevention and Management policy, which requires a fall risk evaluation on admission, readmission, quarterly, and after each fall, and completion of a fall incident report in the risk management portal.
Failure to Integrate and Communicate Hospice Status in Resident Care and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to coordinate and integrate hospice services into a resident’s plan of care after hospice enrollment. A male resident with acute and chronic respiratory failure with hypoxia, ventilator dependence, anoxic brain damage, epilepsy, and a history of cardiac arrest had a hospice consent signed on 12/27/25 initiating hospice services. Despite this, review of the resident’s most current physician order sheet (POS) showed no physician orders for hospice, and the resident’s face sheet contained no indication of hospice status. The facility was unable to provide documentation demonstrating that hospice enrollment was incorporated into the resident’s active orders or clearly communicated to nursing staff responsible for the resident’s care. On 01/02/26, the resident experienced a change in condition characterized by a heart rate between 130–150 and seizure-like movements or activity. The RN on duty, working through an agency, notified the manager on duty, contacted the MD, obtained a telehealth consultation, and received an order to send the resident out via 911. The resident was transported to the hospital by EMTs. The RN documented that three copies of the face sheet and the physician orders were printed and given to the paramedics. The RN later stated she did not know the resident was on hospice at the time of transfer and indicated that hospice status would have been important to communicate to the hospital. Review of the SNF to Hospital Transfer Form for the 01/02/26 transfer showed that report was called in to the ER, but there was no indication on the form that the resident was on hospice. The DON stated that if a resident is on hospice, this should be reflected in the POS and on the face sheet, and that once hospice consent is signed, social services should enter the hospice order into the POS and usually inform the nurse on the unit. The facility’s hospice policy requires a documented communication process between the facility and hospice provider and specifies that the facility must immediately notify hospice of a need to transfer the resident. CMS regulations cited in the report require the facility to coordinate hospice services with the hospice provider and ensure hospice care is integrated into the resident’s plan of care, which did not occur in this case.
Failure to Honor 24-Hour Visitation Rights and Improper Enforcement of Visiting Hours
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to receive visitors of their choosing at the time of their choosing, as required by resident rights regulations and the facility’s own visitation policy. The facility maintained and enforced fixed visiting hours, generally from either 8 a.m. or 10 a.m. until 8 p.m., and staff reported that visitors were expected to leave after 8 p.m. Staff, including CNAs and LPNs, consistently described visiting hours ending at 8 p.m., and one LPN stated that no one was allowed after 8 p.m. except for hospice or critically ill patients. The DON stated that, for the sake of residents and to have some normalcy, the facility had visiting hours and that overnight stays required approval from the administrator or DON, usually for hospice, new admissions, or family comfort. Two residents who were nonverbal and fully dependent on staff for care were directly affected by this practice. One resident, an older adult admitted in March 2025 with anoxic brain damage, acute and chronic respiratory failure, severe protein-calorie malnutrition, a stage 4 sacral pressure ulcer, tracheostomy status, anemia, and gastrostomy status, was unable to self-advocate. The resident’s family member reported typically visiting around 5:45–6 p.m. and stated that on one evening staff told her at 8 p.m. that visiting hours were over and it was time for her to leave. She reported refusing to leave until the resident’s tube feeding was turned back on, and stated that being asked to leave at 8 p.m. was consistent with how visiting hours had “always been.” Another resident, an older adult admitted in November 2025 with anoxic brain damage, chronic respiratory failure, tracheostomy status, compression of the brain, dependence on supplemental oxygen, and gastrostomy status, was also nonverbal and fully dependent on staff. This resident’s family member reported that at 8 p.m. “on the dot” staff came and told her she had to leave because visiting hours were over, even though she was waiting for staff to come and clean the resident. She identified the LPN who told her to leave as the nurse working that evening. The family member also stated that the roommate’s wife had no objection to her presence and had even shared her phone number. No documentation was found to show that the visitation limits imposed on these residents’ visitors were based on individualized clinical need, resident preference, safety concerns, or the rights of others. The facility’s written visitation guidelines, last reviewed in September 2025, stated that residents have the right to receive visitors 24 hours a day and that open visitation is permitted at all times, with only “quiet hours” between 8 p.m. and 8 a.m., and that any restrictions must be reasonable, temporary, least restrictive, explained, and documented.
Failure to Provide Ordered Enteral Nutrition and Accurately Document Tube Feeding Intake
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents who were unable to maintain adequate nutrition independently received enteral nutrition as ordered and that accurate records of daily enteral intake were maintained. Three nonverbal, fully dependent residents with gastrostomy tubes and significant medical conditions, including anoxic brain damage, respiratory failure, severe protein-calorie malnutrition, tracheostomy status, and pressure ulcers, were affected. For one resident, the spouse reported that the feeding tube pump was off when she arrived around 6:00 PM, despite orders for continuous tube feeding from 2:00 PM to 11:00 AM. Nursing documentation and an incident narrative confirmed that the feeding tube had been turned off for several hours, resulting in missed scheduled tube feeding, and that the issue was brought to staff attention by the spouse. The telehealth physician note further documented that the spouse was upset that feeds were not running between 2:00 PM and 6:00 PM and that feeds were only started once the notification was made. The same resident’s family member reported that this problem had occurred multiple times over a period of weeks, including around Thanksgiving and Christmas, stating that the resident had not been fed for 6 to 8 hours on separate occasions. The family member also reported another recent visit when the pump was beeping and displayed “INACTIVE,” and the nurse present, identified as agency staff, could not explain why the feeding was not running. A CNA stated that when he goes in to provide care, the feeding is often paused and the nurse is notified to turn it back on. At the time of surveyor observation, the resident’s feeding pump was running at the ordered rate of 50 mL/hr with a labeled start time of 6:00 AM, but the amount of formula remaining in the container and the total volume displayed on the pump did not match what should have infused based on the documented start time and rate. For the second resident, who was also nonverbal and fully dependent with diagnoses including respiratory failure, hemiplegia, severe protein-calorie malnutrition, anoxic brain damage, tracheostomy status, and gastrostomy status, the physician’s order specified Jevity 1.5 at 80 mL/hr continuous for 20 hours, on at 2:00 PM and off at 10:00 AM or until 1600 mL was infused, with water flushes every 6 hours. During surveyor observation, the feeding pump was running at 80 mL/hr, but the feeding container lacked a start time label, and approximately 900 mL remained in a 1000 mL container when, based on the ordered rate and start time, only about 100 mL should have remained. The total fed volume on the pump (209 mL) also did not correspond to the actual volume in the container, and the absence of a start time made it unclear when the feeding had been started or whether it had been running continuously as ordered. For the third resident, who was nonverbal, fully dependent, and had diagnoses including anoxic brain damage, chronic respiratory failure, tracheostomy status, compression of the brain, dependence on supplemental oxygen, and gastrostomy status, the physician’s order specified Vital 1.5 at 70 mL/hr continuous for 21 hours, on at 2:00 PM and off at 11:00 AM, with a total daily volume of 1470 mL and water flushes every 6 hours. Surveyors observed the feeding pump running at 70 mL/hr with a labeled start time of 3:00 AM, and approximately 600 mL remaining in a 900 mL container. Based on the ordered rate and the labeled start time, the container should have contained about 480 mL, but the observed volume did not match this calculation. The total fed volume displayed on the pump was 2836 mL, which exceeded the ordered daily volume of 1470 mL and did not correspond to the labeled start time. The DON acknowledged that staff may not have reset the pump when hanging a new bottle and confirmed that nurses should reset the machine at that time. Across all three residents, review of the medical records showed no documentation of when tube feedings were interrupted, stopped, or restarted, and there was no accurate record of the total daily volume of tube feeding delivered. The DON stated that there was no flow sheet to track bottle changes and that documentation was limited to the MAR, which for one resident showed tube feedings as administered but without times for when feedings were started or total volume received. The facility’s own tube feeding guideline required that the pump be cleared at the end of each shift and that tube feeding delivered be documented, but the observed discrepancies between ordered rates, labeled start times, pump volumes, and actual formula remaining, along with missing documentation of interruptions and total intake, demonstrate that these procedures were not followed for the residents reviewed.
Failure to Monitor and Respond to Critical Potassium Levels
Penalty
Summary
A resident with multiple complex medical diagnoses, including chronic obstructive pulmonary disease, hypertension, heart disease, and aortic aneurysms, was admitted to the facility and was being treated for hypokalemia (low potassium). The resident's potassium levels were monitored through laboratory testing, which revealed several critically low values. Orders were given for potassium supplementation, but there was inconsistent documentation regarding the administration of these supplements and a lack of timely repeat laboratory monitoring to assess the effectiveness of the interventions. Despite ongoing potassium supplementation, there was no evidence that the facility ensured ongoing and timely laboratory monitoring of potassium levels in accordance with professional standards of practice. Subsequently, a laboratory result indicated a critically high potassium level of 8.4 mEq/L, which was flagged as critical and verified by repeat testing. The nurse who reviewed this result documented that the lab was relayed to the nurse practitioner via phone and that they were awaiting a response. However, there was no further documentation of any actions taken, no confirmation that the provider was made aware of the critical value, and no evidence of nursing assessment or clinical intervention. The nurse did not initiate emergent medical care or escalate the situation as required by facility policy, and the critical lab result was cleared in the electronic medical record, preventing further follow-up by subsequent staff. Interviews with facility staff revealed that the nurse failed to follow established protocols for reporting and acting upon critical laboratory values, including contacting the provider, medical director, or telehealth services when a response was not received. The facility's policy required that critical lab results be communicated to a licensed practitioner within one hour and that escalation procedures be followed if the provider could not be reached. The lack of timely intervention and failure to act upon the critically abnormal potassium level resulted in the resident not receiving necessary medical intervention. Four days after the critical lab result, the resident was found unresponsive and subsequently expired in the facility.
Removal Plan
- The DON checked and verified all residents with time sensitive critical medication, recognizing therapeutic laboratory level, conducting routine labs per doctor's order, following facility protocols for reporting results, and escalating life-threatening findings promptly.
- All Nurses staff were provided with education by the DON/Designee. The training included ensuring time sensitive critical medication have therapeutic laboratory level, have routine labs per doctor's order, following facility protocols for reporting results, and escalating life-threatening findings promptly.
- The Medical Director, Administrator and DON reviewed the facility's policies which include Policy of Critical Lab Result Reporting, Critical Medications Requiring Laboratory Monitoring.
- New hires will be in-serviced by the DON, ADON or Designee. All staff members who are currently on vacation, or are not available, will also receive the same education upon their return to work. The staff members will also be provided with the same educational materials.
- The facility will utilize the same process of providing education to ensure that Agency staff will receive the same training as the facility staff prior to the start of their shift. The Administrator/DON will send the same training materials to the staffing agency. Additionally, the agency staff will be provided with the same training as mentioned above. An agency staff will not start the shift without finishing the training first.
- The DON/ADON/designee will conduct audits to identify any potential concerns related to this plan of removal.
- The DON/ADON/Designee will also conduct staff (nurses and agency) interview, with at least five employees, to gauge knowledge retention and determine if additional training is required.
- During the weekends, the assigned Nursing Supervisor/Designee will conduct the audit, ensuring time sensitive critical medication, recognizing therapeutic laboratory level, conduct routine labs per doctor's order, following facility protocols for reporting results, and escalating life-threatening findings promptly. Any identified concern will be addressed immediately.
- To ensure compliance, the results of the audit will be reviewed during the meeting which is attended by the clinical leadership which includes the DON, ADON, MDS, IP, Restorative, and the Administrator/Designee.
- Any identified concern will be addressed immediately and will also be discussed during the weekly Adhoc QAPI.
- All results of the audits and unit rounds will be reported to the QAPI committee. An Ad-hoc QAPI meeting will be held to review results of the audits and rounds to determine if additional interventions are necessary to ensure compliance.
- The Administrator, DON and Designee will monitor completion of this plan of removal.
Failure to Communicate Critical Lab Result Leads to Resident Death
Penalty
Summary
A facility failed to ensure that laboratory results, specifically a critical potassium level, were communicated to the ordering provider in accordance with its policy and procedures. One resident, an elderly female with multiple cardiac and vascular comorbidities, had a laboratory result indicating a critically elevated potassium level of 8.4 mEq/L, which was flagged as critical and verified by repeat testing. The result was reviewed by an LPN, who documented that the lab was relayed to the nurse practitioner via phone and that a response was awaited. However, there was no further documentation of actions taken, confirmation that the provider was made aware, or evidence of nursing assessment or clinical intervention in response to the critical value. Interviews with facility staff revealed that the LPN may have attempted to notify the provider by text or voicemail but did not receive a response and subsequently cleared the lab notification in the electronic medical record. This action prevented other staff from seeing the critical result. The LPN did not escalate the issue to the medical director or telehealth, as required by facility policy, nor did she initiate emergent care or further monitoring. Other nurses and leadership confirmed that the expectation was for critical labs to be communicated immediately and for escalation if the provider could not be reached, especially for life-threatening values such as a potassium of 8.4 mEq/L. The resident was found unresponsive in the facility four days after the critical lab result was obtained and subsequently expired. The death certificate listed cardiopulmonary arrest as the cause of death, with other comorbidities. Facility policy required that critical lab results be communicated to a licensed practitioner within one hour, with repeated attempts and escalation to the medical director if necessary. The failure to follow these procedures resulted in the deficiency and was cited as Immediate Jeopardy.
Removal Plan
- DON had 1:1 in-service with (V4) and all LPN's and RN's regarding timely notification to MD for any abnormal labs and to escalate to medical director if MD/NP did not answer the call; in-services are ongoing. V4 termed.
- DON/designee completed an in-service to all nurses including agency nurses regarding timely notification to MD for any abnormal labs and to escalate to medical director if MD/NP did not answer the call.
- All newly employed nurses will have orientation including change in condition policy review and the expected appropriate documentation; in-service is ongoing.
- DON had 1:1 in-service with ADON to ensure accurate monitoring of critical labs and potassium.
- A QA tool was developed to identify 5 residents, 3 times a week, for 4 weeks regarding timely notification to MD for any abnormal labs and to escalate to medical director if MD/NP did not answer the call.
- A QA tool was developed to identify 5 residents, 3 times a week, for 4 weeks regarding potassium order per MD order.
- The Medical Director was made aware and in agreement with the abatement and an in-service was conducted with her Nurse practitioner regarding critical labs.
Failure to Monitor and Respond to Potassium Supplementation
Penalty
Summary
A resident with multiple significant medical diagnoses, including chronic obstructive pulmonary disease, hypertension, and heart disease, was admitted to the facility and treated for hypokalemia (low potassium). The resident initially had a potassium level of 3.0 mEq/L, which was flagged as abnormal, and was prescribed a one-time dose of potassium. However, there was no documentation that this dose was administered, nor was there any evidence of follow-up laboratory orders or monitoring after this intervention. Subsequent labs showed a critically low potassium level of 2.0 mEq/L, prompting a new order for potassium supplementation over three days and a repeat basic metabolic panel (BMP) the following morning. Despite these interventions, there was a lack of consistent documentation and follow-up regarding the administration of potassium and the monitoring of potassium levels. The resident continued to receive potassium supplementation, with orders entered incorrectly, resulting in the resident receiving potassium for a longer duration than intended. The medication administration record showed that the resident received 34 doses of potassium over an extended period, rather than the intended three days. During this time, there was no evidence that the facility ensured ongoing and timely laboratory monitoring of potassium levels, nor was there ongoing assessment for the continued need for potassium supplementation. Repeat potassium levels were not obtained until 13 days after the initial critical low value, at which point the resident was found to have a critically high potassium level of 8.4 mEq/L. Upon discovery of the critically elevated potassium level, there was no documentation of nursing assessment, clinical intervention, or initiation of emergent medical care. The nurse who reviewed the lab result documented relaying the information to the nurse practitioner but did not document any further actions or confirmation that the provider was made aware of the critical value. The resident was found unresponsive in the facility four days after the critically high potassium result was obtained, and the death certificate listed cardiopulmonary arrest as the cause of death, with other comorbidities. Facility policy required ongoing laboratory monitoring and prompt reporting of critical values for medications like potassium, but these procedures were not followed in this case.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
A deficiency was identified when a Certified Nurse's Aide (CNA) failed to follow standard infection prevention and control protocols during the provision of morning care for two residents. The CNA was observed assisting one resident with a bed bath, using gloved hands to wash the resident and then using the same soiled gloves to handle the resident's personal items, such as a phone, and to touch various surfaces in the room, including pillows that had been on the floor and the door knobs. The CNA also used the same soiled gloves to pick up clean linen from the hallway linen cart and to handle clean clothing and apply lotion to the resident, without performing any hand hygiene or changing gloves throughout the entire care episode. The CNA continued to use the same soiled gloves to handle soiled linens, which were placed on the bare floor, and to interact with the roommate's belongings and bed linens. At no point during the observed care did the CNA remove the soiled gloves or perform hand hygiene, despite moving between different residents' belongings and clean and soiled items. The CNA acknowledged after the observation that gloves should have been changed and hand hygiene performed, and that soiled linens should have been contained in plastic bags rather than placed on the floor. Interviews with the Infection Control Nurse and the Director of Nursing confirmed that facility policy requires staff to perform hand hygiene before and after resident contact, change gloves between tasks, and avoid touching clean linen carts or moving between residents with soiled gloves. The facility's infection control policies, reviewed and current, specify these requirements for all staff to prevent the spread of infection. The observed failure to adhere to these protocols affected the two residents involved and had the potential to impact all residents on the floor.
Failure to Follow Discharge and AMA Policies for Resident Leaving Facility
Penalty
Summary
The facility failed to follow its discharge and Against Medical Advice (AMA) policies when discharging a resident who left the facility without proper documentation or preparation. The resident, who had multiple medical diagnoses including epilepsy, dysphagia, anxiety disorder, and depression, was cognitively intact but required staff supervision or assistance for all activities of daily living. Despite the resident expressing a desire to leave and being denied a community pass due to not following curfew rules, the facility did not ensure that the discharge process was properly documented or that the resident was adequately prepared for a safe transition. There was no evidence that the resident or their responsible party was educated on the risks of leaving AMA, nor was there documentation that the attending physician was notified and given the opportunity to educate the resident as required by policy. The facility was unable to provide a signed AMA form or documentation that the form was presented and refused, as outlined in their procedures. Additionally, the resident left without his medications or personal belongings, which were instead packed and sent to storage. Attempts to contact the resident after discharge were unsuccessful, and the facility did not know the resident's current location or condition. Interviews with staff confirmed that the required steps for AMA discharge, including documentation of education, physician notification, and proper completion of forms, were not followed. The lack of adherence to policy resulted in the resident being discharged to an unknown location without assurance of safety or continuity of care.
Failure to Prevent Falls and Follow Post-Fall Protocols for High-Risk Resident
Penalty
Summary
A resident with multiple diagnoses, including muscle weakness, abnormal posture, profound intellectual disabilities, dementia, and osteoarthritis, was assessed as high risk for falls. Despite this, the facility failed to prevent multiple fall incidents for this resident. The resident experienced two unwitnessed falls, one of which resulted in a closed right hip fracture. The care plan interventions following the first fall included promoting call light use and therapy evaluation, but the root cause of the fall was not clearly identified, and the intervention did not address the actual cause, as the resident was unable to use the call light effectively due to her condition. During the second fall incident, staff found the resident on the floor next to her bed, exhibiting pain and inability to extend her right leg. The nurse performed a head-to-toe assessment and range of motion, noting facial grimacing and abnormal leg positioning. Despite the resident's nonverbal status and clear signs of injury, staff assisted in transferring her back to bed using a Hoyer lift and a blanket, contrary to facility expectations for handling suspected injuries. The resident was later sent to the hospital and diagnosed with a right hip fracture. The facility's post-fall procedures were not properly followed, as staff moved the resident before paramedics arrived, potentially exacerbating her injury. Additionally, the interventions added to the care plan after the first fall were not effective in preventing subsequent incidents, and the root cause analysis did not result in meaningful changes to the resident's environment or supervision. The lack of effective fall prevention strategies and failure to adhere to post-fall protocols contributed to the resident's repeated falls and injury.
Failure to Provide ADL Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) to residents who were dependent on staff for personal hygiene. One male resident with severe cognitive impairment was observed with an unkempt and dirty beard, discolored facial hair around his mouth, food debris in his beard, and long, dirty fingernails. His Minimum Data Set (MDS) indicated a need for substantial to maximal assistance with personal hygiene, and his care plan documented the requirement for staff assistance with ADLs. Another male resident, who was cognitively intact but unable to walk, was observed with long facial hair and reported that he had repeatedly requested assistance with shaving during his two-month stay, but his requests were ignored. His MDS documented a need for partial to moderate assistance with personal hygiene, and his care plan also indicated the need for staff support with ADLs. The Director of Nursing confirmed that CNAs are responsible for providing hygiene care to residents requiring assistance. The facility's ADL guidelines require a care-planned and implemented program of assistance and instruction in ADL skills.
Failure to Follow Nutrition Support Orders for Tube-Fed Residents
Penalty
Summary
The facility failed to properly transcribe and implement hospital nutrition support orders for one resident who was readmitted, and did not follow physician orders for three residents requiring nutrition support. For the readmitted resident, hospital discharge records specified a continuous tube feeding regimen and nutritional supplements, but the facility delayed starting the supplements and did not initiate the continuous feeding as ordered. This resident, who was severely underweight and had multiple pressure ulcers, experienced a significant weight loss over a short period. For two other residents, observations revealed that tube feedings were not running during times when physician orders indicated they should be. Staff interviews confirmed that tube feedings were sometimes stopped for ADL care or medication administration and not always restarted promptly. One resident experienced a severe weight loss over six months, and the dietitian recommended increasing tube feeding to promote weight stability, but the feeding schedule was not consistently followed as ordered. Facility policy required that physician orders be followed as written and that continuous tube feedings be administered according to the specified schedule or as assessed by the dietitian. However, staff practices, including stopping feedings for care or medication and not resuming them as required, led to residents not receiving adequate nutrition support as ordered. These failures were confirmed through observation, record review, and staff interviews.
Failure to Provide Adequate Supervision and Follow Fall Policy
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and follow its fall prevention policy for one resident with paraplegia, PTSD, conversion disorder with seizures, depression, UTI, and osteoporosis. The resident, who is cognitively intact and requires maximal assistance for transfers and toileting, reported that after a medical procedure, she was in pain and felt weak. She activated her call light to request assistance to use the bathroom, but no staff responded for an extended period. As a result, she attempted to go to the bathroom independently, became weak, and fell in the bathroom. She then crawled to her wheelchair and pushed it into the hallway to get staff attention. The facility's fall report log did not document this incident, and no fall risk management assessment was initiated until prompted by the surveyor. The agency LPN and other staff believed the resident's behavior of placing herself on the floor was typical, but there was no documentation or care plan evidence to support this claim. The facility's fall prevention policy requires that all falls be reviewed and a fall risk evaluation be completed, which was not done in this case. The DON confirmed that the expected procedure following a fall was not followed, and there was a lack of documentation regarding the resident's alleged behaviors.
Failure to Update Abuse/Neglect Care Plan After Abuse Allegation
Penalty
Summary
The facility failed to update and revise the Abuse/Neglect Care Plan for a resident after a sexual abuse allegation was reported. Interviews with the Social Service Director, MDS Coordinator, and Social Service Coordinator confirmed that the care plan should be updated whenever there is an allegation of abuse, and that the Social Service Department is responsible for these updates. Despite this, the resident's abuse/neglect comprehensive care plan was last updated over a year prior to the reported incident, and was not revised following the new allegation. Record review showed that the resident had multiple risk factors, including diagnoses of aphasia, dementia, bipolar disorder, and a history of cerebrovascular disease. The care plan did note previous allegations of verbal aggression and sexual abuse from a peer, but was not updated to reflect the most recent incident. Facility policy requires that care plans be reviewed and updated quarterly, annually, and with any significant change, including abuse allegations, but this was not followed in this case.
Failure to Immediately Report Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The facility failed to immediately report an allegation of resident-to-resident sexual abuse to the Illinois Department of Public Health (IDPH) and local law enforcement. The incident involved a resident who reported to an LPN that his roommate had inappropriately touched him in the lower back and buttocks area during the night. The LPN relayed this information to the Social Service Coordinator, who then informed the Administrator. Despite being made aware of the allegation on the same day it was reported, the Administrator did not notify IDPH or the police at that time, as he concluded after interviews that the allegation was fabricated. Interviews with facility staff, including the Director of Nursing and Social Service Director, confirmed that the proper protocol for such allegations is to report them immediately to the state and law enforcement. The Social Service Coordinator documented the allegation in a progress note and reported it to the Administrator, but no external reporting occurred until several weeks later, when the facility finally contacted the police and submitted an initial report to IDPH. The police confirmed that they were not notified at the time of the alleged incident. The resident involved had a history of cognitive impairment, with a Brief Interview for Mental Status (BIMS) score indicating moderate impairment, and diagnoses including aphasia, dementia, and bipolar disorder. The facility's own abuse prevention policy requires immediate reporting of any abuse allegations to both state authorities and law enforcement, particularly in cases of sexual abuse between residents. Despite these requirements, the facility delayed reporting the incident, failing to follow established protocols.
Unlicensed Respiratory Care Provided by Technician/Student
Penalty
Summary
The facility failed to provide credentialed certified respiratory staff as required by state law, resulting in unlicensed personnel performing respiratory care for residents. Specifically, a respiratory technician/student, who was not yet certified, was observed independently providing tracheostomy care and other respiratory treatments to residents. This included tasks such as suctioning, tracheostomy care, ventilator checks, assessments, and medication administration, which should have been performed by a licensed respiratory therapist. The deficiency involved three residents who required respiratory care. One resident, a female with chronic respiratory failure and other complex medical conditions, had physician orders for tracheostomy tube care and oxygen therapy. Another resident, also a female with chronic respiratory failure and tracheostomy status, had similar orders. The third resident, a male with respiratory failure and other health issues, was on ventilator settings that required professional oversight. Despite these needs, the unlicensed technician/student was assigned to provide care without proper supervision or certification. Interviews with facility staff revealed that the respiratory technician/student had been working independently since January 2023, despite not having completed the necessary certification program. The facility's respiratory therapy director and human resources director were aware of the technician's unlicensed status but did not take appropriate action to ensure compliance with state regulations. The facility's records and staff lists inaccurately represented the technician as a licensed respiratory therapist, further contributing to the deficiency.
Removal Plan
- Affected resident corrective actions: R67, R79, and R149 were provided with respiratory care and assessment by a licensed RT. Respiratory assessments on all current 18 residents were completed by a licensed RT with no concerns identified.
- The Medical Director and responsible parties of ventilator residents were notified of the alleged deficiency.
- The two unlicensed respiratory staff (Staff A and Staff B) were immediately removed from the schedule and will be terminated from their role as respiratory aides.
- Education was provided to the Respiratory Program Director, Director of Human Resources, and Administrator to ensure newly hired credentialed staff have a valid and active license.
- Verification of valid and active licenses for all respiratory therapists was completed by the Regional Director of Operations and the President of Clinical Services.
- Quarterly review of RT licenses by the Human Resources Director to ensure compliance.
- Development of a biweekly schedule and on-call schedule by the Director of RT and/or Regional RT to ensure a licensed RT is available.
- Review of the Respiratory Therapist to Patient ratio on a daily basis by the facility Administrator and Director of Nursing.
- Education provided to the Director of Nursing and Director of Staffing to ensure outside agency staff have valid and active licenses before working.
- Administrator will review newly hired licensed professional staff employee files to ensure valid and active licenses before the first day of work.
- Human Resource Director will send out communication on renewing licenses and remove any RT from the schedule if not renewed one week prior to expiration.
- Director of Human Resources will conduct audits on newly hired licensed professionals to identify non-compliance, with results reported to the QAPI committee.
- Administrator and Director of Human Resources will monitor the completion of the plan of removal.
Failure to Provide Professional Standards of Care and Supervision
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for a resident experiencing a change in condition. A resident, who had a history of chronic obstructive pulmonary disease, acute respiratory failure, and other respiratory issues, experienced physical distress and anxiety due to a lack of appropriate medical intervention. Despite the resident's request to be taken to the hospital, the nurse on duty refused to call 911, insisting that the resident could be treated at the facility. The resident eventually called 911 herself and was diagnosed with pneumonia and influenza A at the hospital. The facility also failed to ensure that respiratory care was provided by licensed professionals. Two unlicensed respiratory technicians, who were still students, were observed independently performing tasks such as tracheostomy care, administering medications, and conducting assessments without direct supervision. The facility's administration was aware of the technicians' unlicensed status but allowed them to continue working independently, contrary to the requirements of the Respiratory Care Practice Act. The facility's failure to adhere to professional standards of care resulted in prolonged distress for the resident and potential risks to other residents receiving respiratory care. The lack of proper documentation and oversight of unlicensed personnel further contributed to the deficiencies identified during the survey.
Failure to Timely Assess and Respond to Resident's Change in Condition
Penalty
Summary
The facility failed to timely assess and respond to a significant change in condition for a resident, resulting in a delay of care. The resident, an elderly female with chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypoxia, asthma, and influenza, experienced a significant change in her condition. On the night of January 12, 2025, she began feeling unwell, experiencing drowsiness and difficulty breathing due to excessive phlegm. Despite her requests to be sent to the emergency room, the nurse on duty refused to call 911, stating there was nothing wrong with her and that she could be treated at the facility. The following morning, the resident continued to feel unwell and again requested to be sent to the hospital, but the nurse refused once more. The resident eventually called 911 herself and was taken to the hospital, where she was admitted with pneumonia and influenza. The facility's Director of Nursing (DON) mentioned that the resident frequently called 911, and the local emergency services had warned the facility about potential fines for abusing the service. However, there was no documentation of a head-to-toe physical assessment or monitoring of the resident's respiratory status on the days in question, nor was there any notification to the resident's physician or nurse practitioner about her change in condition. The facility's failure to assess the resident's condition and notify her physician was a violation of their Change in Resident Condition policy. The resident's care plan specifically noted the need to monitor her respiratory status due to her existing medical conditions, yet no such monitoring was documented. The lack of timely assessment and response to the resident's significant change in condition resulted in prolonged physical distress, pain, and anxiety for the resident before she was admitted to the hospital for treatment.
Unlicensed Respiratory Care Staff Performing Independent Duties
Penalty
Summary
The facility failed to employ credentialed certified respiratory staff as required by state law, impacting the care provided to residents requiring respiratory care. Observations and interviews revealed that a respiratory technician, identified as V5, was performing tasks independently without the necessary certification. V5 was observed providing tracheostomy care, administering medications, and conducting assessments for residents, despite not being a certified respiratory therapist. V5 has been working independently since January 2023, although initially hired as a student in January 2022. The facility's Human Resources Director, V6, acknowledged that V5 does not have a respiratory therapy license and was aware of this since October 2024. Despite this knowledge, no action was taken to rectify the situation. The Regional Respiratory Program Director, V7, stated that V5 was supposed to work under supervision, but observations indicated otherwise. V5's responsibilities included tasks typically performed by licensed respiratory therapists, such as suctioning, tracheostomy care, and responding to respiratory emergencies, without the required supervision. The facility's job description for respiratory therapists requires a graduate of an accredited program and a current license, which V5 and another technician, V10, do not possess. The Respiratory Care Practice Act mandates that individuals performing respiratory care must be licensed and supervised, which was not adhered to in this case. The facility's failure to ensure that V5 and V10 were appropriately credentialed and supervised poses a risk to the residents requiring respiratory care.
Inadequate Mask Provision During Influenza Outbreak
Penalty
Summary
The facility failed to adequately protect its residents during an influenza outbreak by not providing appropriate masks to individuals entering the facility. The Infection Preventionist (V3) recommended that staff wear face shields and N95 masks for contact and droplet precautions, but noted that non-medical masks were being used instead. Despite informing the Director of Nursing (V2) and the Administrator (V1) about the issue, non-medical masks continued to be available on every floor, and some staff were observed wearing them. The outbreak began on the fourth floor and spread to the first floor, with 34 residents testing positive for influenza, two residents positive for pneumonia and influenza, and two residents positive for RSV. The facility's Control Supply Director (V11) ordered non-medical masks instead of surgical masks, possibly due to a supply issue, and was unsure who directed him on what type of masks to order. The Medical Director (V9) stated that N95 masks were necessary to completely prevent an influenza outbreak. Observations by the surveyor revealed numerous boxes of non-medical masks throughout the facility, and staff were seen wearing them, including a respiratory therapist providing care to a resident. The facility's contact tracing list confirmed the spread of influenza among residents, and the CDC guidelines emphasize the importance of using appropriate PPE, such as surgical masks, to prevent transmission in healthcare settings. The use of non-medical masks, which are not suitable for healthcare environments, contributed to the deficiency in infection control during the outbreak.
Failure to Address Food Quality Complaints
Penalty
Summary
The facility failed to implement an effective grievance council to address residents' complaints about food quality, affecting four residents and potentially impacting 128 out of 150 residents. The residents, who have intact cognition, expressed dissatisfaction with the food, describing it as uncooked, cold, and bland. They reported that when they requested alternatives, they were told it was not in the budget. Despite these complaints, the grievance committee did not address their concerns effectively. During a resident council meeting, several residents voiced their dissatisfaction with the food quality, stating that their complaints to the Dietary Manager, V14, were not adequately resolved. Although V14 offered substitutes or reheated meals, residents felt that the food quality had declined since their arrival at the facility. The Medical Director, V9, and the Social Service Director, V18, were unaware of the specific grievances related to food quality, indicating a lack of communication and follow-up on resident concerns. A test tray observation revealed that the food served did not meet proper temperature standards, with burgers at 105 degrees Fahrenheit and other items also below recommended serving temperatures. The Dietary Manager, V14, was unaware of the proper serving temperatures for food safety, further highlighting the facility's failure to address food quality issues. The facility's grievance policy requires prompt resolution of grievances, but this was not effectively implemented, potentially affecting all residents receiving meal trays.
Failure to Document Controlled Substance Administration
Penalty
Summary
The facility failed to adhere to its medication administration and documentation policies, affecting four residents. Specifically, the staff did not properly document the administration of controlled substances on the controlled substance record for three residents. For instance, the controlled substance record for one resident's Oxycodone was left blank, despite the medication administration record indicating it was administered. Similarly, another resident's Clobazam and Lacosamide doses were not documented on the controlled substance record, although the medication administration record showed they were given. Additionally, the facility did not ensure that a newly admitted resident's Oxycodone controlled medication was documented on an individual controlled substance form. Instead, the medication was handwritten on a piece of paper, and there was no formal controlled substance record for this resident. The LPN responsible for administering the medication acknowledged the lack of documentation and indicated that the necessary forms might be in the nursing office, but did not inform the Director of Nursing about the missing controlled substance form. The facility's policies require that all controlled substances be documented at the time of administration, including the date, time, and signature of the administering nurse, as well as the number of doses remaining. These policies are in place to ensure safe and accurate medication administration, yet the facility failed to comply with these guidelines, leading to incomplete and inaccurate records for the affected residents.
Unlicensed Staff Administers Medication
Penalty
Summary
The facility failed to ensure that medications were administered by licensed personnel, as required by their policy. A respiratory technician/student, who was not licensed, independently administered a medicated breathing treatment to a resident with chronic respiratory failure. The resident, an elderly female with multiple complex medical conditions including chronic respiratory failure, neurocognitive disorder, and quadriplegia, was observed receiving the treatment from the unlicensed staff member. The technician had been working independently since January 2023, despite not having completed the necessary respiratory program or obtained a license. The facility's human resources director acknowledged that the technician was unlicensed and that there was no follow-up on license verification after the initial hiring process. The facility's policy clearly states that medications should only be administered by licensed personnel, yet this protocol was not followed. The technician's employee badge did not indicate their student status, and the facility's medication administration guidelines were not adhered to, leading to a significant medication error.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to its medication storage and labeling policies, resulting in several deficiencies. During a review of the medication cart on the first floor, it was found that two open bottles of eye drops, Simbrinza and Gentamycin Sulfate Ophthalmic Solution, were not labeled with a resident's name. The Simbrinza was discontinued by the physician on 11/7/2024, and the Gentamycin was discontinued on 1/17/2025, yet both remained in the cart without proper labeling. The LPN on duty could not confirm the ownership of these medications, indicating a lapse in following the facility's medication labeling policy. On the second floor, an open vial of Novolog insulin with an expiration date of 12/17/2024 was found in the medication cart, along with another expired and unlabeled vial. The LPN admitted to administering doses from the expired vial, which should have been removed from the cart. This oversight highlights a failure to adhere to the facility's policy on medication expiration and storage, as insulin should be used within 28 days of opening and stored in a refrigerator until opened. Additionally, on the third floor, an unopened insulin vial meant for a resident with Type 2 Diabetes Mellitus was found in the medication cart instead of being refrigerated as required. The facility also failed to remove expired Tuberculin testing solutions from the medication refrigerator, which could potentially affect all newly admitted residents on the first floor. These findings demonstrate a pattern of non-compliance with medication storage and labeling protocols, posing a risk to resident safety.
Failure to Follow Mechanical Lift Policy Results in Resident Injury
Penalty
Summary
The facility failed to adhere to its mechanical lift policy, which mandates keeping the base of the lift in the widest position during transfers. This oversight occurred during the transfer of a resident diagnosed with morbid obesity and requiring assistance with personal care. The resident, who was unable to self-transfer due to decreased muscle tone and comorbidities, was being moved from bed to a dialysis chair using a mechanical lift. During the transfer, the CNAs did not have enough space in the resident's room and moved the resident into the hallway. As the resident was being lowered into the chair, the lift's legs were closed, contrary to the policy. The resident, who was top-heavy and nervous, began to fidget and move his hands outside the sling, causing instability. As the CNAs attempted to position the resident in the chair, the resident's movements led to the chair and the resident falling backward, resulting in the resident hitting his head on the floor. The incident resulted in the resident sustaining an acute subdural hematoma. The CNAs involved could not recall if the lift's legs were open or closed, but the Director of Nursing confirmed that the lift's legs were closed during the transfer, which was against the facility's policy.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to prevent and protect a resident from resident-to-resident physical abuse, resulting in one resident hitting another in the face with a remote control. This incident involved two residents, both of whom were moderately cognitively impaired. The altercation began as a verbal argument over the television in their shared room, which escalated into physical violence. The resident who was struck sustained facial lacerations that required medical attention. The incident was reported by the affected resident, who initially stated that there was no physical altercation, but later confirmed being hit with the remote control. Staff members, including a CNA and LPN, observed the aftermath of the incident, noting blood on the affected resident's face. The facility's Director of Nursing and other staff were notified, and the resident who committed the act of aggression was sent to the hospital for a psychiatric evaluation. The facility's abuse policy emphasizes the right of residents to be free from abuse and outlines measures to prevent such occurrences. However, the incident highlights a failure in implementing these measures effectively, as the altercation was not prevented despite the facility's commitment to creating a secure environment. The report indicates that education on TV volume levels and encouraging residents to participate in activities outside their rooms could have potentially prevented the incident.
Failure to Report Allegations of Resident Abuse
Penalty
Summary
The facility failed to report allegations of physical abuse involving a resident, identified as R1, who claimed to have been attacked by another resident, R3. The incident reportedly occurred when R1 asked another resident to lower the volume of their television, leading to an altercation. R1 was sent to the hospital for a psychiatric evaluation following the incident. Despite the facility's social service director, V7, being aware of the altercation and conducting an investigation, there was no documentation to show that the facility reported the allegations to the state agency as required. Interviews with staff and residents revealed conflicting accounts of the incident. R1 alleged that R3 attacked him from behind, while R3 claimed that R1 was the aggressor and that he intervened to prevent R1 from attacking another resident, R4. R3 stated that he held R1 in a bear hug until staff arrived. The facility's registered nurse, V6, reported that R3 admitted to putting R1 in a choke hold, but there was no evidence that this information was reported to the state agency. The facility's administrator, V1, was out of state at the time of the incident and relied on V7 to handle the investigation and reporting. The facility's policy requires that any allegations of abuse be reported to the state agency within two hours if they result in serious bodily injury, or within 24 hours if they do not. However, there was no documentation to confirm that the initial or final reports were submitted to the state agency. The administrator, V1, acknowledged the lack of documentation and was unable to provide proof of submission. The failure to report the allegations as required constitutes a deficiency in the facility's compliance with abuse reporting regulations.
Medication Administration Error and Documentation Failure
Penalty
Summary
The facility failed to ensure that a resident received the correct dose of medication as prescribed, specifically Oxycodone 5 mg every eight hours as needed. The deficiency was identified when a resident, who was alert and oriented, reported that he did not take Oxycodone every four hours and only took it after returning from being out on pass due to increased pain from movement. The resident's sign-out log confirmed he was not in the facility at the time the medication was signed out, indicating a discrepancy in medication administration. The controlled drug log showed multiple instances where Oxycodone was signed out without corresponding documentation in the medication administration record, suggesting a lack of proper documentation and adherence to prescribed orders. Further investigation revealed that an LPN admitted to administering Oxycodone every four hours without reviewing the medication administration record or physician orders, which specified an eight-hour interval. The LPN acknowledged realizing the error but did not report it to the Director of Nursing. The facility's policy on narcotic medications requires documentation of administration and proper handling, which was not followed in this case. The Director of Nursing confirmed that staff had been in-serviced on documenting controlled substances, but the facility failed to present documentation of proper administration during the survey period.
Failure to Document and Administer Oxycodone Correctly
Penalty
Summary
The facility failed to adhere to its narcotic medication policy, specifically concerning the administration and documentation of Oxycodone 5 mg for a resident. The resident, who was alert and oriented, reported that he did not take Oxycodone every four hours and only used it occasionally, particularly after returning from being out on pass. However, the facility's records showed discrepancies in the administration of the medication. The resident's controlled drug log indicated that Oxycodone was signed out at times when the resident was not present in the facility, such as on 11/18/24 at 4:50 pm, when the resident was out on pass. Additionally, there were multiple instances where the medication administration record lacked documentation of the nurse's initials, indicating that the medication was administered. The Director of Nursing acknowledged that the staff had been in-serviced on documenting controlled substances, but the facility failed to present documentation showing that the resident was administered Oxycodone as per the physician's orders. An LPN admitted to administering Oxycodone every four hours without reviewing the medication administration record or physician orders, which specified administration every eight hours. This LPN also failed to report the medication error to the Director of Nursing. The facility's policy on narcotic medications requires that every dose be accounted for and documented, but this was not consistently followed, leading to the deficiency.
Deficiency in Meal Palatability and Timeliness
Penalty
Summary
The facility failed to provide palatable meals to residents, affecting six individuals who reported dissatisfaction with the food quality. These residents, all with intact cognition as per their BIMS scores, expressed concerns about the food being flavorless, overcooked, or undercooked. Specific incidents included meals being served late, with some residents receiving their dinner trays after 9:45 pm, and the food, particularly chicken, being described as hard and dry. This led residents to supplement their meals with personal snacks or food ordered from outside the facility. Interviews with dietary staff, including the Dietary Manager, cooks, and aides, revealed awareness of the complaints regarding food quality. Staff acknowledged receiving concerns about the food being overcooked or burned and mentioned frequently sending replacement trays or substitutes upon request. Despite these acknowledgments, the facility's policy on providing nourishing and palatable meals was not adhered to, as evidenced by the residents' consistent dissatisfaction and the staff's recognition of the ongoing issues.
Delayed Dinner Service for Residents
Penalty
Summary
The facility failed to provide dinner meals to residents at the designated mealtimes, affecting 14 residents. On the evening of November 13, 2024, several residents reported receiving their dinner trays significantly later than the scheduled time of 6:30 pm, with some not receiving their meals until after 10:00 pm. This delay in meal service was confirmed by multiple residents, who expressed dissatisfaction and distress over the late and poor-quality meals, such as overcooked chicken. The residents involved in this deficiency included individuals with various medical conditions such as diabetes, obesity, respiratory failure, and cognitive impairments. Despite having intact cognition as per their BIMS scores, residents expressed their dissatisfaction with the meal service, highlighting the impact of the delay on their well-being. For instance, one resident mentioned feeling sad and unhappy due to the late meal service, while another had to rely on personal snacks from a roommate due to the inedible state of the provided meal. Interviews with facility staff, including the Dietary Manager, Director of Nursing, and a cook, revealed an acknowledgment of the failure to adhere to the scheduled meal times. The Dietary Manager and Director of Nursing both stated that the expectation was for meals to be delivered between 6:15 and 6:30 pm, which was not met on the specified date. The cook admitted to sending the dinner trays after 9:30 pm, thus failing to maintain the facility's policy of providing meals within a 14-hour window between dinner and breakfast.
Failure to Provide Escort for Resident's Medical Appointment
Penalty
Summary
The facility failed to arrange appropriate transportation for a resident, leading to a missed oncology appointment. The resident, a male with a history of acute respiratory failure, emphysema, malignant neoplasm of the larynx, COPD, severe protein-calorie malnutrition, and behavioral disturbances, required an escort due to his behavior and elopement risk. On the day of the appointment, the transportation was arranged, but no escort was available to accompany the resident, making it unsafe for him to attend the appointment alone. The transportation coordinator, who usually accompanies residents, was on a scheduled day off and had informed the scheduler and the Director of Nursing (DON) about the need for an escort. Despite the transportation being set up, the facility did not provide an escort, resulting in the appointment being missed. The facility's appointment log incorrectly documented that no escort was needed, although the transportation coordinator confirmed that the facility was aware of the requirement. Interviews with the DON and the scheduler revealed that while the facility offers escort services, they do not guarantee them and have no specific policy or protocol for providing escorts. The facility was unable to provide any policy or documentation regarding transportation arrangements during the survey.
Failure to Document Narcotic Administration in EMAR
Penalty
Summary
The facility failed to adhere to its narcotic and medication administration policy by not documenting the administration of narcotic medication in the electronic medical record (EMR) for a resident. This deficiency was identified during a review of medication administration for a resident who had multiple medical conditions, including a history of left perinephric hematoma, intervertebral disc degeneration, hypertension, atrial fibrillation, benign prostatic hyperplasia, chronic myelomonocytic leukemia, monoclonal gammopathy, idiopathic gout, non-Hodgkin lymphoma, b-cell lymphoma, and chronic kidney disease. The resident had physician orders for Hydrocodone-Acetaminophen to be administered as needed for moderate pain, but five doses were not documented in the EMAR, although they were signed out on the individual narcotic sign-out sheet. Interviews with facility staff revealed that there was a lapse in following the established procedures for documenting narcotic administration. A Licensed Practical Nurse admitted to sometimes forgetting to sign medications under the EMAR, only signing the individual narcotic sign-out sheet. The Director of Nursing and the Vice President of Clinical Operations both confirmed that the facility's policy requires documentation in both the individual narcotic sign-out sheet and the EMAR. The facility's policies on narcotic medication and medication administration were provided, which outline the steps for proper documentation, including checking the medication administration record prior to administering medication and documenting each medication as it is prepared.
Staff-to-Resident Mental Abuse Incident
Penalty
Summary
The facility failed to prevent an incident of staff-to-resident mental abuse involving a resident, identified as R5, and an activity aide, identified as V9. The incident occurred after a disagreement over a borrowed portable speaker, during which V9 pulled off R5's wig in a hallway where other staff were present. R5, who was alert and oriented with a BIMS score of 15, reported feeling humiliated and embarrassed by the incident. The altercation escalated with R5 throwing a cup at V9 and grabbing V9's shirt, which required intervention from other staff members to separate them. The facility's abuse prevention policy, dated February 2017, emphasizes the residents' right to be free from abuse and mistreatment by anyone, including facility staff. Despite this policy, the incident occurred, and the facility's administrator, V7, and a nurse, V37, were involved in the investigation. V7 stated that V9's actions were not willful, and V37, who witnessed part of the altercation, did not believe V9 intended to harm R5. However, the incident was reported as a deficiency due to the failure to protect the resident from mental abuse, as outlined in the facility's policy and residents' rights.
Deficiency in CPR Training for CNAs
Penalty
Summary
The facility failed to ensure that all healthcare personnel, specifically Certified Nursing Aides (CNAs), have current basic life support cardiopulmonary resuscitation (CPR) training and certification. During interviews and record reviews, it was revealed that none of the ten CNAs reviewed had current CPR certification. The facility's Administrator, V7, stated that CPR training is encouraged but not required for CNAs. Similarly, V11 from Human Resources confirmed that not all CNAs are required to be CPR trained, despite the facility's policy indicating that all staff are responsible for performing CPR. The Director of Nursing, V8, acknowledged that some aides working at the facility lack CPR training and certification, and reiterated that they are not required to have it. The facility's CPR policy, dated 2015, mandates that all staff are responsible for performing CPR according to American Heart Association guidelines. However, the current practice contradicts this policy, as CNAs without CPR training are instructed to inform a nurse if they find a resident unresponsive, rather than performing CPR themselves. This discrepancy between policy and practice raises concerns about the facility's preparedness to handle emergencies involving unresponsive residents.
Unsupervised Respiratory Care by Student
Penalty
Summary
The facility failed to have a licensed respiratory therapist on duty for the entire shift on August 8, 2024, affecting 11 residents who required respiratory care. A respiratory aide, who was also a respiratory therapy student, was observed administering respiratory care unsupervised. The aide confirmed that the licensed respiratory therapist left early, a practice that was reportedly common. The respiratory therapy supervisor was unaware of the situation and stated that students should not work unsupervised and must be accompanied by a licensed therapist. The facility did not provide any policy or procedures regarding the supervision of respiratory therapy students. The facility's assessment tool indicated the need for two respiratory therapists per shift but did not include information about respiratory therapy students. The Respiratory Care Practice Act requires proximate supervision, meaning a licensed individual must be physically close enough to assist if needed. The facility's failure to adhere to these requirements led to the deficiency.
Failure to Notify Physician of Resident's Acute Change in Condition
Penalty
Summary
The facility failed to notify the attending physician of an acute change in condition for a resident who experienced loose stools and weakness. The resident, who had a history of osteomyelitis, adjustment disorder, anemia, hypertension, hypotension, lymphedema, stage four pressure ulcer, and adult failure to thrive, was found in cardiac arrest by emergency medical services. The resident had been last checked by a CNA around 2:00 AM, who noted diarrhea and weakness but did not report these symptoms to the nurse or physician. The CNA mentioned the diarrhea to another nurse, who did not take further action as there was no order for Imodium. The resident was found unresponsive and cold to the touch at 4:00 AM, with signs of rigor mortis, indicating they had been deceased for some time. The paramedics confirmed the resident's condition and noted that the facility staff could not provide a timeline of when the resident was last checked. The facility's policy requires notifying the physician of significant changes in a resident's condition, but there was no documentation of such notification or a nursing assessment related to the resident's diarrhea. The Director of Nursing stated that staff are expected to perform rounds every few hours and notify the physician if a resident experiences new or persistent diarrhea. However, the resident's care plan did not include a plan for diarrhea, and there was no record of anti-diarrhea medication being administered. The facility's failure to notify the physician and assess the resident's condition contributed to the deficiency, as the resident's acute change in condition was not addressed in a timely manner.
Failure to Assess and Treat Resident's Diarrhea
Penalty
Summary
The facility failed to conduct a comprehensive assessment for a resident who developed new loose stools, which remained untreated. The resident, who had a history of multiple medical conditions including osteomyelitis, anemia, hypertension, and a stage four pressure ulcer, was found in cardiac arrest by emergency services. The resident had been left unattended for an extended period, with dried fluids on the linens, indicating a lack of timely care and monitoring. Interviews with staff revealed that the Certified Nursing Assistant (CNA) noticed the resident had diarrhea during the night shift but did not wake the resident for further assessment. The CNA reported the diarrhea to the Registered Nurse (RN) on duty, who did not take further action as there was no standing order for anti-diarrheal medication. The Licensed Practical Nurse (LPN) on the following shift was unaware of the resident's condition and did not conduct an assessment, as she was not informed of any issues during the shift handover. The Director of Nursing (DON) stated that staff are expected to conduct rounds every few hours and assess any new conditions such as diarrhea. However, there was no documentation of a nursing assessment or physician notification regarding the resident's condition. The lack of a care plan for diarrhea and the absence of any as-needed medication orders for diarrhea contributed to the failure to address the resident's symptoms, ultimately leading to the resident's untreated condition and subsequent cardiac arrest.
Respiratory Care Deficiency Leading to Critical Incident
Penalty
Summary
The report details a deficiency in the facility's response to a resident (R2) requiring respiratory care, ultimately leading to a critical incident. R2, a [AGE] year old male with a complex medical history including Acute and Chronic Respiratory Failure, Dysphagia, COPD, and Heart Failure, was ventilator-dependent and had a tracheostomy. Despite clear care plans and orders for ventilator settings and suctioning, there were lapses in providing necessary respiratory care. The facility's nursing staff and respiratory therapist failed to respond promptly to R2's distress signals, including agitation and pointing to his tracheostomy, indicating a need for suctioning. The deficiency was exacerbated by staffing challenges, as highlighted by the respiratory therapist mentioning limited resources and high workload. The facility's reliance on a single respiratory therapist during the day for over 20 residents with tracheostomies may have contributed to delays in responding to urgent respiratory needs. Additionally, the lack of clear protocols or policies regarding suctioning responsibilities between nurses and respiratory therapists further complicated the situation. The failure to promptly address R2's respiratory distress, including a dislodged tracheostomy tube, ultimately led to a critical event resulting in cardiac arrest and the resident's passing.
Delayed Respiratory Care for Resident with Tracheostomy
Penalty
Summary
The deficiency identified in the report pertains to the failure of the facility nursing staff to provide timely respiratory care to a resident with a tracheostomy, leading to adverse outcomes. The resident in question, R2, had a complex medical history including diagnoses of Acute and Chronic Respiratory Failure, Dysphagia, Chronic Obstructive Pulmonary Disease, and other conditions. Despite the resident's code status being Full Code, there were documented instances where the nursing staff did not respond promptly to the resident's needs, particularly in relation to suctioning and monitoring after tracheostomy care. The events leading to the deficiency included instances where the resident exhibited signs of distress, such as gesturing and pointing to the tracheostomy, indicating the need for suctioning. However, there were delays in providing the necessary care, with conflicting accounts from staff regarding the resident's condition and the actions taken. The report highlighted a lack of consistent monitoring and assessment of the resident's respiratory status, as well as discrepancies in the responses of different healthcare professionals involved in the resident's care.
Failure to Provide Timely Respiratory Tracheostomy Care
Penalty
Summary
The facility failed to provide care in accordance with professional standards of quality by not providing timely respiratory tracheostomy care, not responding to a resident's request for respiratory suctioning, and not having staff with the necessary skills to adequately meet the needs of a resident in respiratory distress. On the morning of 02/19/2024, a resident with a tracheostomy (R2) gestured for suctioning, but the Licensed Practical Nurse (LPN) did not immediately provide the care and instead informed the Respiratory Therapist (RT). The RT did not promptly attend to the resident, and later, the resident was found unresponsive with a dislodged tracheostomy tube, leading to a code blue situation and emergency resuscitation efforts by the staff and EMS. The resident was not connected to a ventilator at the time, which meant no alarms were triggered to alert staff of the distress. The facility's policy did not include specific monitoring protocols for residents with tracheostomies who were not on ventilators, relying instead on physical rounds and checks by nurses, CNAs, and respiratory therapists. Interviews with staff revealed inconsistencies in understanding and executing the responsibilities for suctioning and monitoring residents with tracheostomies. The Director of Nursing (DON) and Respiratory Therapy Director both indicated that nurses and respiratory therapists are expected to suction residents in need, but there was a lack of clear communication and immediate action in this case. The facility's policy on oxygen therapy did not provide adequate guidance on monitoring residents with tracheostomies who are not connected to ventilators, contributing to the failure to prevent the life-threatening situation for R2.
Failure to Prevent Abuse by Staff Member
Penalty
Summary
The facility failed to follow their abuse prevention policy and procedures, resulting in a resident being physically abused by a respiratory therapist. The incident occurred when the respiratory therapist pushed the resident onto the bed, forcibly restrained him, and roughly suctioned him after a physical struggle. The resident reported the incident to his nurse and family member, expressing fear, anger, and frustration with the facility for not preventing further contact with the staff member after the report. The resident, who is alert and oriented, has a diagnosis of tracheotomy, gastrostomy, acute and chronic respiratory failure with hypoxia, and alcoholic liver disease. He recounted the incident to the surveyor, stating that the respiratory therapist slapped him for coughing on two separate occasions. The resident felt unsafe as he continued to see the respiratory therapist in the facility after reporting the abuse. The administrator confirmed that the incident was reported on Christmas day, and the respiratory therapist was suspended over the phone but was still present in the facility afterward. The respiratory therapist admitted to struggling with the resident and pushing him onto the bed for suctioning, but denied slapping him. The therapist described the resident as uncooperative and difficult to manage. The facility's administration did not take immediate and effective actions to ensure the resident's safety and psychosocial well-being, as the resident continued to see the respiratory therapist after the incident. The facility's failure to act promptly and appropriately led to the resident feeling unsafe and unsupported.
Failure to Follow Abuse Prevention Procedures
Penalty
Summary
The facility failed to follow their abuse prevention investigation procedures by not conducting a thorough investigation of an alleged abuse incident involving a staff member and a resident. The incident was reported to the administrator on Christmas day, but the alleged abuse occurred on Christmas Eve. The administrator interviewed the accused staff member over the phone and suspended him, but did not ensure that the staff member was kept away from the resident. The resident consistently reported being slapped by the respiratory therapist, and the resident's sister requested that the staff member not be allowed to care for the resident again. However, the administrator did not take adequate steps to ensure the resident's safety, stating that the staff member would only enter the resident's room with another person in case of an emergency, despite the respiratory office being in close proximity to the resident's room and no supervisor being present at night to enforce this rule. The resident, who is alert and oriented, reported being slapped by the respiratory therapist on two separate occasions and expressed fear of the staff member's return. The resident's sister also expressed concerns about the staff member's continued access to the resident. The respiratory therapist admitted to struggling with the resident during care, forcibly restraining the resident, and suctioning the resident in a hard manner. Despite these admissions, the facility did not conduct a thorough investigation or provide adequate training to staff on abuse prevention and response. The facility's social service director was not informed of the initial incident and did not conduct a psychosocial assessment of the resident until prompted by the administrator. The medical director acknowledged that the facility's response to the incident was inadequate and that abuse prevention would be included in future quality assurance meetings. The facility's policy on abuse prevention emphasizes the importance of creating a resident-sensitive and secure environment, but the facility failed to adhere to its own procedures in this case, leading to the resident's continued fear and distress.
Failure to Follow Tracheotomy Suctioning Policy and Physician Orders
Penalty
Summary
The facility failed to follow their policy for tracheotomy suctioning and did not adhere to physician orders for providing adequate and appropriate respiratory and tracheal suctioning for a resident. This resulted in the resident not receiving sufficient suctioning to maintain a clear tracheal airway and experiencing pain and fear due to harsh and non-gentle suctioning by a respiratory therapist. The resident, who is alert and oriented, has a diagnosis of tracheotomy, gastrostomy, acute and chronic respiratory failure with hypoxia, and alcoholic liver disease. Observations revealed the resident's tracheotomy was filled with phlegm, and the resident struggled to communicate due to the mucus accumulation. Staff interviews indicated that suctioning was performed once per shift and as needed, but documentation showed inconsistencies and multiple days without recorded suctioning or tracheal care, contrary to physician orders and facility policy. During an interview, a respiratory therapist admitted to forcibly restraining the resident and performing suctioning in a hard manner, causing the resident to become upset. The therapist did not seek assistance or return at a different time to provide care. Another observation showed the resident's tracheotomy with thick mucus buildup and discolored sponge, indicating inadequate suctioning. The resident confirmed that suctioning was performed only once in the morning and that he needed additional suctioning. The facility's policy on tracheal suctioning emphasizes the importance of gentle and reassuring care, allowing the resident to catch their breath between suctioning episodes and providing oxygenation as needed. However, these standards were not met in the care provided to the resident. The medical director acknowledged the incident and stated that the administration did not act effectively to maintain the resident's safety and psychosocial well-being. The medical director also confirmed that physician orders should always be followed and that the resident had not been examined by a doctor since the original incident. The failure to provide adequate and appropriate respiratory care, as well as the harsh treatment by the respiratory therapist, highlights significant deficiencies in the facility's adherence to professional standards of practice and physician orders for tracheal suctioning care.
Latest citations in Illinois
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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