Bria Of Forest Edge
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 8001 South Western Avenue, Chicago, Illinois 60620
- CMS Provider Number
- 145864
- Inspections on file
- 43
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Bria Of Forest Edge during CMS and state inspections, most recent first.
A resident was admitted and remained under facility care until transfer to a hospital, but the attending physician did not complete an initial face-to-face visit, any physical assessments, or the required visits every 30 days for the first 90 days. All documented medical visits and assessments were performed by NPs, and there were no physician progress notes in the record. The DON and Assistant Administrator confirmed that the NP, not the physician, saw the resident. The facility’s physician services policy describes steps when a physician does not make required visits and requires progress notes for physician visits, but it does not define a time frame for the attending physician to assess newly admitted residents.
Two residents were involved in an incident where one cognitively intact resident reported that another resident entered her room while she was sleeping, took her phone without consent, and used it to take photos. An RN documented the complaint and noted that the DON was made aware, but both the DON and the Administrator later stated they had no knowledge of any resident taking another resident’s property and that the incident had not been reported to the abuse coordinator or to the state as misappropriation of property, contrary to the facility’s abuse policy.
Staff failed to follow the facility’s abuse/misappropriation reporting policy when a cognitively intact resident reported that another resident entered her room while she slept, took her phone, and used it, and this allegation was documented by an RN but not reported to the DON/abuse coordinator or to the state agency as required. The Administrator later confirmed he had not been informed of the incident, even though the facility policy requires immediate reporting of any allegation or suspicion of abuse, including theft or misappropriation of property, to administration and timely reporting to the state.
Two residents were involved in an incident where one cognitively intact resident reported that a male resident entered her room while she was sleeping, took her phone, and used it to take pictures of himself. The RN documented the allegation in a progress note and indicated that the DON was made aware, but the DON and administrator later stated they had never been notified of any theft or misappropriation involving this resident. No abuse report was made to the abuse coordinator, and no investigation was initiated, despite facility policy requiring that all allegations of misappropriation of resident property be promptly documented and investigated.
Two residents with mental health diagnoses engaged in a physical altercation after one entered the other's room and took food without permission. Staff were not present to intervene, and the incident was not reported or investigated according to facility policy, despite both residents confirming the physical abuse.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a G-tube, as required by their infection control policy. Observations showed a lack of EBP signage, accessible PPE, and proper PPE usage by staff during high-contact care activities. Interviews confirmed that the facility's policy required EBP for residents with indwelling devices, but the resident's health record lacked a care plan or order for EBP, risking cross-contamination among other residents.
A resident at high risk for falls was left unsupervised in the dining room, resulting in a fall that caused a laceration and a C6 vertebrae fracture. The resident was not wearing shoes and required assistance for safe ambulation. Staff interviews revealed that no one was assigned to monitor the dining room, and the facility's policies on fall prevention and supervision were not followed.
The facility failed to ensure dumpster lids were closed and free from overflowing trash, potentially affecting all 194 residents. Observations revealed open lids with visible garbage and flying insects. The Regional Dietary Manager confirmed the lids should be closed, and a broken compactor lid had been reported. The Maintenance Director arranged the garbage to close the lids and stated a new compactor was needed.
The facility failed to maintain a safe and homelike environment, with a leaking ceiling in one room and structural issues like a missing tile and broken door in another. Maintenance issues were not logged, and communication breakdowns led to prolonged deficiencies, compromising residents' living conditions.
The facility failed to document the administration of controlled medications and ensure proper accountability during shift changes, affecting residents on multiple floors. Missing signatures on medication records and accountability forms were noted, with staff acknowledging the lapses. The DON confirmed the expectation for immediate documentation to ensure accurate record-keeping.
The facility failed to properly store Latanoprost eye drops for two residents, as they were found in a medication cart instead of being refrigerated. Additionally, medication refrigerators on the 4th and 6th floors were not maintained within the required temperature range, potentially affecting all residents on those floors. The Director of Nursing confirmed the need for proper temperature control to preserve medication potency.
A facility failed to obtain informed consent for administering Bupropion, a psychotropic medication, to a resident with major depressive disorder and anxiety. The resident, who was cognitively intact, was unaware of taking Bupropion and had only consented to Sertraline. The facility's policy requires informed consent for psychotropic medications, which was not obtained, as confirmed by the psychotropic nurse.
A resident's call light was found out of reach, hanging on a light fixture above their bed, contrary to facility policy. The resident, who was alert and oriented, could not locate the call light. An LPN confirmed the call light's location and acknowledged it should be within reach. The resident had a BIMS score indicating intact cognition and diagnoses including cerebral infarction and paraplegia.
The facility failed to update the PASARR for two residents with mental health diagnoses. One resident was admitted without a mental diagnosis disclosure on the PASARR, despite having multiple mental health conditions. Another resident's PASARR did not reflect their diagnoses of major depressive disorder and anxiety disorder, nor their medication use. The facility's policy requires PASARR updates after admission, which were not completed in these cases.
A facility failed to refer a resident for PASRR rescreening before the expiration of their Short Term Approval, resulting in a four-month stay without a proper plan of care. The resident had multiple medical diagnoses, including Schizoaffective Disorder and Type 2 Diabetes Mellitus. The Assistant Administrator admitted the oversight in resubmitting the PASRR.
A resident with a furuncle on the neck did not receive timely wound care, as observed by surveyors. The dressing was not changed for several days, and the wound care nurse failed to document the treatment on time. The facility's policy required dressings to be changed as ordered, but discrepancies in documentation were found.
The facility failed to properly contain respiratory equipment for two residents, leading to potential contamination. A resident with severe cognitive impairment had a nebulizer mask left uncovered, while another with moderate impairment had oxygen tubing and a nasal cannula left exposed. Both an LPN and the DON acknowledged the need for proper containment to prevent contamination.
A resident at the facility did not have a privacy curtain in their room, which is essential for maintaining privacy in shared spaces. The resident, who is cognitively intact and has multiple health conditions, reported never having a privacy curtain during their six-month stay. The absence of hooks on the privacy curtain track was noted, and the housekeeping supervisor confirmed that floor technicians are responsible for ensuring privacy curtains are installed, highlighting a lapse in adhering to the facility's policy on creating a homelike environment.
A resident with a history of mental health issues was involved in a physical altercation with another resident over a financial disagreement. After staff intervened, the resident was taken to the dining room where the former Social Service Director improperly used physical restraint techniques, leading to both falling to the floor. This action violated the facility's abuse prevention policy, and the staff member was discharged for improper use of CPI techniques.
A facility failed to ensure a resident had properly fitting clothes and did not maintain an inventory of personal belongings for four residents. A resident with multiple health issues was found with clothes that were too small and unlabeled. Despite family efforts to provide clothing, items went missing, and the facility lacked inventory lists. Other residents reported similar issues, and the laundry process was hindered by unlabeled clothes. The facility's policies on personal belongings and resident rights were not followed.
A resident with an abnormal mammogram did not have a follow-up appointment scheduled, despite a doctor's order and repeated requests. The resident, who is cognitively intact, expressed concern about her breast health. The DON and APN were aware of the need for follow-up but failed to ensure the appointment was made, contrary to facility policies.
A resident reported feeling threatened by an LPN during medication administration, but the incident was not properly reported or investigated by the facility staff. The resident, who is cognitively intact, informed a Psychiatric Rehabilitation Service Coordinator, who failed to comprehend and report the full extent of the allegation to the appropriate authorities, including the facility's abuse coordinator.
A resident was punched by another resident after entering a bathroom without knocking, but the incident was not reported to the facility's social worker or administrator. The aggressor, with a history of aggressive behavior, was moved to another floor, but the lack of proper documentation and reporting by staff led to a failure in addressing the abuse according to the facility's policy.
The facility failed to report an abuse allegation within the required timeframe. A resident reported being punched by another resident, leading to room relocations. Despite informing a CNA and a complainant, the administrator was not notified, and no report was made to the State Agency. The facility's abuse policy requires immediate reporting to the administrator, which was not followed.
The facility failed to notify residents of their trust fund balances exceeding the $2000 SSI resource limit, affecting 17 residents. The Business Office Manager believed the limit had changed to $17,500 based on a letter, leading to a lack of notification. This misunderstanding could impact residents' Medicaid and SSI eligibility.
The facility failed to maintain the dishwasher in a clean condition and used expired testing strips to determine the concentration of the sanitizing solution in the three-compartment sink. The Dietary Manager was unaware of the expiration, and the Assistant Administrator confirmed the absence of a cleaning schedule, potentially affecting all 190 residents who take food by mouth.
The facility failed to follow its medication administration policy for a resident with COPD, resulting in improper documentation and timing of inhaler medication. The resident reported receiving the inhaler only once a day, and the MAR showed multiple days without recorded administration. An LPN administered the medication earlier than scheduled, and the DON confirmed that proper documentation and timing protocols were not followed.
The facility failed to ensure timely arrival of nursing staff, proper medication administration, and accurate documentation for 37 residents. An LPN was observed arriving late and administering medications past the scheduled time without proper documentation. Multiple residents reported not receiving their medications on time, and the EMAR showed 283 overdue medications. The DON confirmed the presence of blank spaces in the MARs, indicating lapses in medication administration and documentation.
The facility failed to ensure medications were administered as ordered and that residents remained free from significant medication errors. Multiple residents did not receive their medications on time, and documentation was often missing or incomplete. The DON confirmed the presence of blank spaces in the MARs, indicating non-administration or lack of documentation.
Failure to Ensure Required Attending Physician Visits for Newly Admitted Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a newly admitted resident received the required initial face-to-face visit and ongoing visits from the attending physician. The resident was admitted on an unspecified date and remained in the facility until transfer to the hospital on 2/16/26. Record review showed that the attending physician (V10) did not perform an initial visit, did not complete any physical assessments, and did not meet the requirement of one visit every 30 days for the first 90 days of the resident’s stay. All documented medical visits and assessments during this period were completed by nurse practitioners (V8 and V11), rather than by the attending physician. During the survey, the DON (V3) and Assistant Administrator (V2) confirmed that there were no progress notes from the attending physician in the resident’s medical record, and that the nurse practitioner (V11) was the one who saw the resident. The facility’s policy on Physician Services – On Call Coverage states that if a physician does not make required visits, the DON and/or Administrator should be notified, followed by notification of the Medical Director if there is still no response, and that a progress note must be placed in the medical record when a physician visits a resident. However, the policy does not specify a time frame for when newly admitted residents must be physically assessed by the attending physician, and there was no documentation that the attending physician had seen or assessed this resident at any time during the stay.
Failure to Report and Investigate Misappropriation of Resident Property
Penalty
Summary
Facility staff failed to follow the abuse policy regarding misappropriation of property when a cognitively intact resident reported that another resident took her personal phone without consent. The resident, who had a BIMS score of 15 indicating she was cognitively intact, stated that a male resident entered her room while she was sleeping, unplugged her phone, took it, and used it to take facial pictures of himself. A progress note dated 12/11/2025 by an RN documented that the resident complained a male resident came into her room and took her phone while she was sleeping, that she recovered the phone from the other resident, and that she called the police. The note also documented that the DON was made aware and that security deescalated the situation, with social services to follow up. Despite this documentation, both the DON and the Administrator stated during interviews that they had no knowledge of any incident involving another resident taking this resident’s phone or other personal property. The DON stated he had never heard of anyone going into the resident’s room and taking her things and that the RN who wrote the note had not notified him of any theft by any resident. The Administrator, who is the abuse coordinator, stated that staff are expected to report abuse, including theft, to him and that he had not been informed of any incident of misappropriation of this resident’s property. When shown the RN’s progress note, the Administrator acknowledged that the described incident constituted misappropriation of property and stated that, had he been notified, he would have reported it to the state agency and initiated an investigation. The facility’s abuse policy affirms residents’ rights to be free from misappropriation of property and defines misappropriation as the deliberate wrongful use of a resident’s belongings without consent, but this policy was not followed in this case.
Failure to Timely Report Allegation of Misappropriation of Resident Property
Penalty
Summary
Facility staff failed to follow the abuse/misappropriation reporting policy when an allegation of theft of resident property was documented but not reported to the abuse coordinator or to the Illinois Department of Public Health (IDPH). A cognitively intact resident (BIMS score 15) reported that a male resident entered her room while she was sleeping, unplugged her phone, took it, and used it to take facial pictures of himself. This allegation was documented in a nursing progress note by an RN, which also stated that the resident recovered her phone from the other resident, called the police, the DON was made aware, facility security de-escalated the situation, and social services would follow up. Despite this documentation, the DON later stated he had never heard of anyone going into this resident’s room and taking her things and that the RN had never notified him of any theft by any resident. The Administrator, who serves as the abuse coordinator, stated that his expectation is that staff report all abuse, including theft and misappropriation of property, to him so he can follow the abuse policy and initiate an investigation, and that he had not been informed of any incident involving this resident’s personal property. When shown the RN’s progress note, the Administrator acknowledged that the described incident constituted misappropriation of property and confirmed he had not been notified by the RN or any staff member. The facility’s abuse policy requires employees to immediately report any incident, allegation, or suspicion of abuse, neglect, mistreatment, or misappropriation of resident property to the Administrator or an immediate supervisor, and further requires reporting to IDPH within specified time frames. In this case, the allegation involving two residents was not reported as required, resulting in a failure to timely notify the abuse coordinator and IDPH of suspected misappropriation of resident property for two of three residents reviewed for misappropriation in the sample.
Failure to Report and Investigate Alleged Misappropriation of Resident Property
Penalty
Summary
Facility staff failed to follow the abuse/misappropriation policy requiring immediate reporting and investigation of alleged misappropriation of resident property. A cognitively intact resident (BIMS score 15) reported in a 12/11/2025 progress note, documented by an RN, that a male resident entered her room while she was sleeping, took her phone, and that she subsequently recovered the phone and called the police. The note further documented that the DON was made aware and that facility security de-escalated the situation, with social services to follow up. Despite this documentation, there was no evidence that the allegation of misappropriation of property was reported to the abuse coordinator/administrator or that an investigation was initiated as required by the facility’s abuse policy. During the survey, the resident reiterated that another resident had come into her room a few weeks earlier, unplugged her phone, took it, and took facial pictures of himself on her phone, and that she immediately informed the nurse who retrieved the phone. The alleged perpetrating resident denied entering other residents’ rooms or taking phones. The DON stated he was familiar with the resident but had never heard of anyone entering her room and taking her belongings, and stated that the RN had not notified him of any theft. The administrator, designated as the abuse coordinator, also stated he had not been informed of any incident involving the resident’s property and confirmed that, based on the RN’s progress note shown to him by the surveyor, the incident constituted misappropriation of property that should have been reported and investigated under the facility’s abuse policy. The facility’s written policy requires that all allegations of misappropriation of resident property be documented and result in an investigation, including interviews and record review, which did not occur in this case.
Failure to Prevent and Report Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse, resulting in both residents physically assaulting each other. One resident, with diagnoses including schizophrenia, schizoaffective disorder, and major depressive disorder, reported that another resident entered his room without permission and began taking his food. When confronted, the second resident allegedly struck the first on the head, prompting the first resident to retaliate by punching the second resident multiple times. The first resident also reported feeling unsafe due to a lack of staff presence and stated that staff did not intervene or prevent the incident. The second resident, who also had a history of mental health diagnoses such as schizoaffective disorder and bipolar disorder, confirmed the altercation but stated that he had been given permission to take the food. He reported being punched first and then defending himself by striking back. Both residents had intact cognitive function according to their most recent assessments. Staff documentation and interviews indicated that the incident was not witnessed by staff, and there was no immediate intervention during the altercation. Despite the facility's abuse policy requiring immediate reporting and investigation of abuse allegations, the incident was not reported to the administrator or investigated as required. The psychosocial rehabilitative services director was aware of the altercation but did not report it, as he had not witnessed the event and staff present did not provide details. Social service notes only documented a verbal disagreement, and there was no evidence of a thorough investigation or appropriate follow-up in response to the physical altercation.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies, specifically regarding Enhanced Barrier Precautions (EBP) for a resident with a G-tube. Observations revealed that there was no signage indicating EBP outside the resident's room, and Personal Protective Equipment (PPE) was not made available or accessible outside the room. Additionally, a trash can for discarding PPE was not positioned near the exit of the resident's room. During care activities, staff did not wear the appropriate PPE, such as gowns, when providing high-contact care to the resident, who required extensive assistance with activities of daily living and had multiple medical conditions, including a G-tube. Interviews with staff, including the Infection Preventionist nurse and the Director of Nursing, confirmed that the facility's policy required EBP for residents with indwelling medical devices like G-tubes. The policy also mandated the use of gowns and gloves during high-contact care activities and the posting of EBP signage. However, the resident's health record lacked a care plan or order for EBP, and staff were not following the necessary precautions, potentially risking cross-contamination among the 48 residents on the 4th floor.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision to a resident, identified as R194, who was at high risk for falls. This lack of supervision resulted in R194 sustaining a fall in the dining room, leading to a laceration above the left eyebrow and an acute interior column fracture of the C6 vertebrae. The incident required R194 to be transferred to a local hospital for treatment, where they received stitches and were instructed to wear a neck brace for eight weeks. On the day of the incident, R194 was ambulated to the dining room by a Certified Nursing Assistant (CNA) without wearing shoes, only friction socks. The Licensed Practical Nurse (LPN) on duty, V16, was administering medications and did not have a direct line of sight to the dining room. Both V16 and the CNA, V24, acknowledged that no staff was specifically assigned to monitor the dining room at the time, and the area was chaotic with staff attending to other residents. This lack of supervision allowed R194, who had an unsteady gait and required assistance for safe ambulation, to fall and sustain injuries. Interviews with staff, including the Director of Nursing (DON), confirmed that R194 was known to be at high risk for falls and required monitoring when in the dining room. The facility's policies on fall prevention and supervision were not adequately followed, as no staff was present to supervise R194, leading to the fall and subsequent injuries. The facility's documentation and staff interviews highlighted the absence of a systemic approach to ensure adequate supervision and prevent such accidents.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that the dumpster lids were closed and free from overflowing trash, which has the potential to affect all 194 residents residing at the facility. During an observation, the surveyor noted that the metal lid for the trash compactor and two lids for the dumpster were open, with bags of garbage, boxes, and food waste products visible inside. Flying insects were observed in the vicinity of the open compactor and dumpster. The Regional Dietary Manager confirmed that the dumpster lids should be closed to prevent pests from entering the trash and acknowledged that the trash compactor lid was broken, with a work order completed for its repair. Further investigation revealed that the trash compactor lid had been broken for about a month, and a work order dated 9/19/24 indicated that dietary staff reported the issue. The Maintenance Director confirmed that the trash company had been contacted for service. On a subsequent observation, the surveyor found the dumpster lids open again, with trash and boxes preventing closure. A large stone was used to keep the trash compactor lid closed. The Maintenance Director stated that the trash company had assessed the compactor and determined that a new one was needed, but the delivery date was unknown. The facility's policy on garbage disposal emphasizes the importance of collecting and disposing of garbage in a safe and efficient manner.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several deficiencies observed during the survey. In one instance, the ceiling in a room shared by three residents was leaking, and a trash can was used as a catch bin. The leak was reported to have started after maintenance work on a vent, but no work order was logged for the issue, and the ceiling remained covered with plastic days later. The Director of Nursing was unaware of the problem, indicating a breakdown in communication and maintenance procedures. Additionally, the facility failed to address structural issues in another resident's room, where a missing ceramic tile under the sink and a broken closet door were observed. These issues were not reported in the maintenance log, and the Maintenance Director was unaware of them. The missing tile was noted to potentially allow mice to enter, as residents reported seeing mice in the bathroom. The facility's pest control records confirmed the presence of rodents, but no action was taken to repair the tile or door. The facility's policies and procedures emphasize the importance of maintaining a homelike environment and addressing maintenance issues promptly. However, the lack of communication and failure to log maintenance requests in the TELS system or work order book resulted in prolonged deficiencies that compromised the residents' living conditions. The facility's preventive maintenance plan and job descriptions outline responsibilities for repairs, but these were not effectively implemented in the observed cases.
Controlled Medication Documentation and Accountability Failures
Penalty
Summary
The facility failed to ensure proper documentation and accountability for the administration of controlled medications, affecting multiple residents across different floors. Specifically, there were missing signatures on the Controlled Drug Receipt Record/Disposition form for a resident receiving Tramadol, indicating that the medication administration was not properly documented. Additionally, the Shift Change Accountability Record for Controlled Substances Forms on the 3rd floor, 4th floor B-wing, and 6th floor B-wing had missing signatures, which are required to confirm the handover of correct medication counts between outgoing and incoming nurses. These deficiencies were observed during various tasks, including medication reconciliation and storage and labeling checks, with several nurses acknowledging the missing signatures. The Director of Nursing confirmed the expectation for staff to sign the accountability forms immediately after counting controlled medications to ensure accurate record-keeping. The facility's policy mandates that controlled substances be counted each shift, and both nurses involved in the count must sign the count sheet to verify the accuracy of the documented quantities.
Improper Medication Storage and Temperature Control
Penalty
Summary
The facility failed to adhere to proper medication storage protocols, as evidenced by the improper storage of Latanoprost eye drops for two residents, R84 and R100. During a survey, it was observed that the Latanoprost eye drops, which should be refrigerated to maintain potency, were found in a brown bag in the medication cart instead of being stored in a refrigerator. The Licensed Practice Nurse (LPN) acknowledged that the medication should not be in the cart and should be refrigerated as per the pharmacy's instructions. This oversight in medication storage has the potential to affect all residents on the 3rd and 6th floors. Additionally, the facility failed to maintain the required temperature range for medication refrigerators, which is crucial for preserving medication potency. On the 6th floor, the medication refrigerator was found to have a temperature of 60F, with ice buildup in the freezer section, while the 4th floor refrigerator was recorded at 48F on consecutive days. The Director of Nursing confirmed that the refrigerator temperature should be between 36F and 46F and that staff should report any deviations to maintenance for repair. The facility's policy and the Latanoprost package insert both specify the need for refrigeration of unopened bottles, highlighting a failure to follow established guidelines.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent for the administration of a psychotropic medication, specifically Bupropion, for a resident identified as R103. R103, who has diagnoses of major depressive disorder and anxiety disorder, was cognitively intact as per the Minimum Data Set. The resident's medication records indicated that Bupropion was prescribed and administered daily without the resident's knowledge or consent. The resident was only aware of taking Sertraline, another antidepressant, and expressed surprise upon learning about the Bupropion medication. The facility's policy mandates informed consent for psychotropic medications, which was not obtained in this case. The psychotropic nurse, identified as V3, confirmed that informed consent is crucial for psychotropic medications due to their potential impact on cognitive function. Upon reviewing the resident's records, V3 acknowledged that the consent for Bupropion was missing, and the resident had not been informed of the medication's risks and benefits. The facility's policy requires that residents or their representatives be informed and provide consent for psychotropic medications, with verbal consent documented if written consent cannot be immediately obtained. This protocol was not followed, resulting in the deficiency noted in the report.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, as required by their policy. During an observation, a surveyor found the call light string hanging on top of the light fixture above the resident's bed, out of reach. The resident, who was alert and oriented, was unable to locate the call light string when asked by the surveyor. The Licensed Practical Nurse (LPN) confirmed that the call light string was on top of the light fixture and acknowledged that it should be within the resident's reach. The resident involved had a diagnosis that included cerebral infarction, morbid obesity, hemiplegia, and paraplegia, but had an intact cognitive status with a Brief Interview for Mental Status (BIMS) score of 14. The Director of Nursing (DON) stated that the purpose of the call light is for residents to signal staff for help, and it should be within reach at all times. The facility's policy, revised in September 2022, also mandates that call lights be accessible to residents at all times.
Failure to Update PASARR for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to refer two residents, R34 and R103, to the appropriate state-designated authority for a new Level I PASARR evaluation and determination. Resident R34 was admitted to the facility without a mental diagnosis disclosure on the Level I PASARR, despite having medical diagnoses including Schizoaffective Disorder, Bipolar Disorder, Brief Psychotic Disorder, Depression, and Impulsiveness. The facility's policy requires that the PASARR screening be provided prior to admission to ensure appropriate care and placement decisions. However, the Assistant Administrator acknowledged that even if the PASARR is completed at the hospital, the facility should verify its accuracy. Resident R103 was diagnosed with major depressive disorder and anxiety disorder, with active orders for antidepressant medications. However, R103's Level I PASARR did not reflect these mental health diagnoses or medication use. The Assistant Administrator, covering for the social services director, confirmed familiarity with the PASARR process and acknowledged the discrepancies in R103's PASARR. The facility's policy states that if a resident requires a PASARR update after admission, the facility should contact the state agency to update the PASARR, which was not done in these cases.
Failure to Timely Rescreen Resident for PASRR
Penalty
Summary
The facility failed to refer a resident to the state agency for Preadmission Screening and Resident Review (PASRR) rescreening before the expiration of the resident's Short Term Approval without Specialized Services determination. This deficiency affected one resident, identified as R178, out of a total sample size of 77 residents. The resident's PASRR, dated November 6, 2023, indicated that the Short Term Approval would end on February 4, 2020, and required a new Level I screen to be submitted no later than 10 days before this date if continued stay was necessary. However, the PASRR Level I rescreen for the resident was not completed until June 7, 2024, resulting in the resident staying at the facility for four months without the proper plan of care. The resident's medical diagnoses included Schizoaffective Disorder Bipolar Type, Type 2 Diabetes Mellitus, Asthma, Unspecified Psychosis Not Due to A Substance or Known Physiological Condition, and Depression. The Assistant Administrator acknowledged that the PASRR was not resubmitted in a timely manner.
Failure to Provide Timely Wound Care and Documentation
Penalty
Summary
The facility failed to ensure timely wound care treatment and documentation for a resident with a furuncle on the neck. The resident, who is cognitively intact, was observed with a soiled and undated dressing on two consecutive days, indicating that the dressing had not been changed for about three days. The wound care nurse admitted to not dating the dressing changes and stated that the facility's policy did not require it. The nurse also acknowledged that the dressing needed to be changed and that failing to do so could lead to infection. The resident's treatment orders required dressing changes on specific days and as needed, but the Treatment Administration Record showed discrepancies in the documentation. The wound care nurse documented treatments for previous days only on a later date, indicating a lapse in timely documentation. The Director of Nursing confirmed that dressings should be changed according to orders and when soiled to prevent infections. The facility's policy and the wound care nurse's job description emphasized the importance of following physician orders and documenting care rendered.
Failure to Contain Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper containment of respiratory equipment for two residents, leading to potential contamination issues. Resident R88, who has severe cognitive impairment and multiple chronic conditions including COPD and CHF, was observed with a nebulizer mask left uncovered on a plastic bin and bedside table on separate occasions. This was acknowledged by a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), who both confirmed that the mask should be stored in a plastic bag to prevent contamination and maintain infection control standards. Similarly, Resident R6, who has moderate cognitive impairment and a history of COPD exacerbation, was observed with oxygen tubing and a nasal cannula left uncovered on top of an oxygen concentrator machine. This was also brought to the attention of an LPN and the DON, who reiterated the importance of containing the equipment in a plastic bag when not in use to prevent debris and contamination. These observations highlight a lapse in following proper respiratory care protocols for residents requiring such equipment.
Privacy Curtain Deficiency for Resident
Penalty
Summary
The facility failed to provide a privacy curtain for a resident, identified as R62, which is necessary to ensure privacy in shared rooms. R62, who has been at the facility for six months, reported never having a privacy curtain and expressed a desire for one, especially for privacy while sleeping. The resident is cognitively intact, as indicated by a Brief Mental Status Interview (BIMS) score of 15, and has multiple diagnoses, including prediabetes, alcohol abuse with alcohol-induced psychotic disorder, and essential hypertension. During the survey, it was observed that R62's room lacked a privacy curtain, and the housekeeper, V15, confirmed the absence of hooks on the privacy curtain track, preventing the installation of a curtain. The housekeeping supervisor, V36, stated that floor technicians are responsible for ensuring privacy curtains are in place and acknowledged the importance of privacy curtains in maintaining residents' privacy and dignity. The facility's policy emphasizes creating a homelike environment that accommodates residents' needs and preferences, which was not adhered to in this instance.
Resident Abuse Due to Improper Use of CPI Techniques
Penalty
Summary
The facility failed to protect a resident, identified as R394, from physical abuse by a staff member, specifically the former Social Service Director, V44. The incident occurred following a disagreement between R394 and another resident, R116, which escalated into a physical altercation. After staff intervened and separated the residents, R394 was escorted to the dining room. During an attempt to redirect R394, who was being verbally aggressive, V44 used physical restraint techniques, which led to both V44 and R394 falling to the floor. This action was deemed improper use of Crisis Prevention Intervention (CPI) techniques. R394, who has a medical history including chronic obstructive pulmonary disease, anxiety disorder, bipolar disorder, and schizophrenia, was involved in a verbal and physical altercation with R116 over a financial disagreement. The situation escalated when R394, upset over a damaged cellphone, was pushed by R116, leading to a physical confrontation. Staff intervened, and R394 was taken to the dining room where the incident with V44 occurred. Despite attempts to deescalate the situation verbally, V44 resorted to physical restraint, which was not in line with CPI protocols. The facility's policy on abuse prevention emphasizes the residents' right to be free from abuse, neglect, and mistreatment. However, the actions of V44, who was later discharged for improper use of CPI, violated this policy. The incident was reported to the police, and an investigation was conducted by the facility. The report highlights the need for staff to prioritize verbal de-escalation techniques and adhere to established protocols to prevent similar incidents in the future.
Failure to Maintain Inventory of Residents' Personal Belongings
Penalty
Summary
The facility failed to ensure that a resident, R2, had clothes that fit properly and did not maintain an inventory of personal belongings for four residents, R2, R3, R4, and R5. This deficiency was identified through observations, interviews, and record reviews. R2, who has multiple diagnoses including major depressive disorder, anxiety disorder, and morbid obesity, was found to have clothes that were too small and not labeled with a name. The facility had previously experienced a flood, which resulted in the misplacement of many residents' clothes, including R2's. R2's family member, V13, reported purchasing clothes for R2, which were labeled and documented in an email to the facility's social worker, V11. However, these items were missing, and the facility did not have an inventory list for R2 or the other residents. The social service director, V4, acknowledged the lack of inventory lists and stated that social services were responsible for keeping track of residents' belongings. Despite promises to replace missing items, R2's clothes had not been replaced, and the facility failed to maintain proper documentation of personal belongings. Interviews with other residents, R3, R4, and R5, revealed similar issues with missing clothes and the absence of inventory lists. The laundry supervisor, V10, noted that clothes often arrived unlabeled, making it difficult to return them to the correct residents. A large bin of unlabeled clothes was observed, indicating a systemic issue with inventory management. The facility's policies on personal belongings and resident rights emphasize the importance of maintaining an inventory to ensure residents can retain and use their personal possessions, which was not adhered to in this case.
Failure to Schedule Follow-Up for Abnormal Mammogram
Penalty
Summary
The facility failed to ensure a diagnostic appointment was scheduled for a resident who had an abnormal mammogram and a doctor's order for a follow-up appointment. This deficiency affected one of the three residents reviewed for nursing care. The resident, who is cognitively intact with a BIMS score of 15, expressed concern about not knowing the status of her breast health after an abnormal mammogram in February. Despite mentioning her concerns to several nurses, the follow-up appointment was not scheduled. The Director of Nursing (DON) acknowledged the importance of follow-up appointments to prevent worsening conditions and ensure early treatment. The Advanced Practice Nurse (APN) was aware of the abnormal mammogram and had entered an order for a diagnostic mammogram and ultrasound, but was unaware that the appointment had not been scheduled. Facility policies require physician orders to be followed as written and appointments to be verified by staff, but these procedures were not adhered to in this case.
Failure to Report and Investigate Alleged Mental Abuse
Penalty
Summary
The facility failed to report and investigate an allegation of mental abuse involving a resident, identified as R2, who reported that a nurse, identified as V7, threatened him during a medication administration. R2, who is cognitively intact with a BIMS score of 15/15, reported the incident to V5, the Psychiatric Rehabilitation Service Coordinator, stating that V7 threatened to "beat the $h!+ out of" him after R2 pointed out a missing pill. V5, who had been recently in-serviced on abuse reporting, acknowledged that R2 reported feeling uncomfortable with V7 but did not recall the specific threat and did not report the incident to her supervisor, V6, or the facility's abuse coordinator, V1. V5 admitted that she might not have comprehended the full extent of R2's report due to being preoccupied as she was leaving the facility. V6, the Psychiatric Rehabilitation Service Director, stated he was never informed of any issues between R2 and V7. V1, the facility administrator and abuse coordinator, confirmed that he had not received any allegations of abuse regarding R2 until the surveyor's inquiry. The facility's policy requires immediate reporting of any abuse allegations to the administrator, which was not followed in this case, leading to a failure in addressing the potential abuse and ensuring the resident's safety.
Failure to Report and Address Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident where one resident punched another in the face. The incident occurred when the resident entered another resident's bathroom without knocking, leading to the physical altercation. Despite the resident reporting the incident to a Certified Nursing Assistant (CNA) and a complainant, the abuse was not reported to the facility's social worker or the administrator, who is the designated abuse coordinator. The administrator was unaware of the incident until notified by the surveyor, indicating a breakdown in the facility's abuse reporting protocol. The resident who was punched did not sustain any injuries but was moved to another room, while the aggressor was relocated to a different floor. The aggressor has a documented history of aggressive and inappropriate behavior, as noted in their social service care plan. Despite the facility's policy affirming residents' rights to be free from abuse, the incident was not properly documented or reported by the staff involved, including the CNA and the Licensed Practical Nurse (LPN) on duty at the time. This lack of communication and documentation contributed to the facility's failure to address the abuse promptly and effectively.
Failure to Report Abuse Allegation Timely
Penalty
Summary
The facility failed to adhere to its abuse policy and procedure by not reporting an abuse allegation to the abuse coordinator and the State Agency within the required two-hour timeframe. This deficiency involved two residents, where one resident reported being punched in the face by another resident after entering the latter's bathroom without knocking. Although the incident did not result in any injury, the affected resident was moved to another room, and the alleged perpetrator was relocated to a different floor. Despite the incident being reported to a Certified Nursing Assistant (CNA) and a complainant, the facility's administrator was not informed, and no report was made to the State Agency. Interviews revealed that the CNA was informed of the incident by the affected resident and subsequently notified a Licensed Practical Nurse (LPN) on duty. However, the LPN stated that no report of the physical assault was made to them. The facility's administrator was only made aware of the incident during a surveyor's visit, and a review of the facility's reportable incidents showed no record of the allegation. The facility's abuse policy mandates immediate reporting of any abuse allegations to the administrator, which was not followed in this case.
Failure to Notify Residents of Trust Fund Balances
Penalty
Summary
The facility failed to notify residents of their trust fund balances before they exceeded the $2000.00 resource limit for Social Security Administration (SSI) for individuals. This oversight affected 17 residents who were reviewed for trust fund balances, with amounts ranging from $2036.95 to $14,942.58, all exceeding the SSI resource limit. The facility's Business Office Manager, V3, stated that they believed the resource limit had changed to $17,500.00 based on a letter from All Assistance Program Providers, which led to the decision not to notify residents or their families about the balances. The facility's Resident Trust Fund Policy and Procedure, which was undated, documented that residents should not have more than $17,500.00 in their trust fund accounts. However, the Social Security spotlight on Resources 2024 edition still indicated that the resource limit for SSI benefits was $2000 for an individual. This discrepancy in understanding and communication resulted in the facility not providing the required notifications, potentially affecting the Medicaid and SSI eligibility of the residents involved.
Failure to Maintain Clean Dishwasher and Valid Testing Strips
Penalty
Summary
The facility failed to maintain dishwasher equipment in a clean condition and failed to ensure the availability of valid testing strips for determining the concentration of the sanitizing solution in the three-compartment sink. During an observation, the Dietary Manager (V3) was asked about the method used to determine the concentration of the sanitizing solution. V3 produced expired testing strips, which had expired more than two years ago. V3 admitted that he was unaware of the expiration and acknowledged that expired strips should not be used. Additionally, the metal surface of the dishwasher was observed to have an accumulation of whitish grey dirt, indicating a lack of regular cleaning. V3 mentioned that an outside vendor performs maintenance every other month but was unsure about the daily cleaning schedule, which is supposed to be done by the kitchen staff. The Assistant Administrator (V1) was informed about the situation and confirmed that there was no established cleaning schedule for the dishwasher. The facility's policy on equipment cleanliness states that all foodservice equipment should be clean, sanitary, and maintained according to the manufacturer's directions. However, the observations and interviews revealed that these procedures were not being followed, potentially affecting all 190 residents who take food by mouth. Only one resident in the facility does not take food by mouth, highlighting the widespread impact of this deficiency.
Failure to Follow Medication Administration Policy for Resident with COPD
Penalty
Summary
The facility failed to follow its medication administration policy for a resident diagnosed with chronic obstructive pulmonary disease (COPD). Specifically, the facility did not document the administration of inhaler medication as ordered by the physician, did not observe the proper timing for administering the inhaler, and did not follow the respiratory care plan. The resident, who was supposed to receive Albuterol Sulfate HFA Inhalation Aerosol Solution every four hours, reported receiving the inhaler only once a day. The Medication Administration Record (MAR) for the resident showed multiple days where the medication was not recorded as administered. During the survey, it was observed that a Licensed Practical Nurse (LPN) administered the inhaler medication earlier than scheduled and did not adhere to the one-hour before and after rule. The Director of Nursing (DON) confirmed that nurses are required to document every medication administration on the MAR and follow the five rights of medication administration. The facility's policy on medication administration emphasizes the importance of administering medications at the proper time, in the prescribed dose, and documenting each administration. However, these protocols were not followed, leading to a deficiency in pharmaceutical services for the resident with COPD.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure timely arrival of nursing staff, proper medication administration, and accurate documentation for 37 residents. On the day of the survey, a Licensed Practical Nurse (LPN) was observed arriving 30 minutes late for her shift and administering medications past the scheduled time. The LPN did not have a list of residents who had received or not received their medications and was observed with multiple unlabeled medication cups on the medication cart. The Electronic Medication Administration Record (EMAR) showed 283 overdue medications, and the LPN admitted to not documenting the administration of medications properly. Several residents, including those with cognitive impairments, reported not receiving their medications on time or at all. One resident confirmed that medications were left at the bedside, and another resident mentioned that the facility sometimes ran out of medications, causing delays. The surveyor observed blank spaces in the Medication Administration Records (MAR) for multiple residents, indicating that medications were not documented as administered on several occasions. The Director of Nursing (DON) reviewed the MARs and confirmed the presence of blank spaces, which should have been coded to indicate the reason for non-administration. The facility's Medication Administration policy requires that any deviation from the physician's order be documented and the physician notified. The failure to follow these procedures led to significant lapses in medication administration and documentation, affecting the care of 37 residents on the 6th floor.
Failure to Administer and Document Medications as Ordered
Penalty
Summary
The facility failed to ensure medications were administered as ordered and that residents remained free from significant medication errors. On multiple occasions, medications for four residents were either not documented as administered or were administered late. For instance, on 3/21/24, it was found that a resident did not receive their 9am medications, which included significant medications such as Cymbalta, Gabapentin, Hydrochlorothiazide, Losartan Potassium, Meloxicam, and Topiramate. The Licensed Practical Nurse (LPN) admitted to not documenting the administration of these medications. Another resident reported not receiving their medications on a previous day, and their Medication Administration Record (MAR) confirmed missing documentation for several days. The Director of Nursing (DON) reviewed the MARs and confirmed the presence of blank spaces, indicating that the medications were not documented as administered or the reason for non-administration was not recorded. Additionally, another resident's medications, including Levothyroxine, Humalog, Amlodipine Besylate, Metformin, and Nuedexta, were not documented as administered on multiple occasions. The LPN admitted to leaving the documentation open as a reminder to reorder the medication. A third resident did not receive their 9am medications, which included Amiodarone, Furosemide, Bupropion, Apixaban, Gabapentin, Lidocaine patch, Metoprolol, and Sertraline, and reported that the facility often ran out of medications. The MAR confirmed missing documentation for several medications on different days. The facility's Medication Administration policy requires that medications be administered at the proper time and any deviations be documented, which was not adhered to in these cases.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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