Bria Of River Oaks
Inspection history, citations, penalties and survey trends for this long-term care facility in Burnham, Illinois.
- Location
- 14500 South Manistee, Burnham, Illinois 60633
- CMS Provider Number
- 145735
- Inspections on file
- 47
- Latest survey
- September 10, 2025
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Bria Of River Oaks during CMS and state inspections, most recent first.
Multiple rooms were found to have temperatures above the required range, with several residents reporting discomfort due to excessive heat and malfunctioning air conditioning. Staff interviews confirmed that the issue had persisted for weeks, and temperature monitoring and response procedures were not effectively followed.
Air conditioning units on the second and third floors were not functioning properly, resulting in hallway temperatures of 84-85°F and several rooms blowing warm air. A blanket was used to soak up water from a leaking unit. The issue affected 127 residents, and the Corporate Maintenance Director was not informed of the problem until the day of the survey.
A resident with significant physical and mental health needs was physically taken to the floor and restrained by an activity aide/CNA after a dispute over smoking privileges. The resident sustained injuries and reported feeling scared and humiliated. Multiple staff, including security and nursing, failed to intervene or report the incident according to policy, resulting in a failure to protect the resident from abuse and ensure proper documentation and follow-up.
A staff member physically intervened with a resident using a crisis prevention technique that was not consistent with training, and failed to report or document the incident as required. The event was not communicated to the LPNs, DON, or administration, and no assessment or review was conducted, resulting in a lack of proper documentation and failure to follow facility policy.
A resident with a history of epilepsy, dementia, and chronic kidney disease experienced a delay in treatment for a fractured left hip due to inadequate pain assessment. Despite reporting severe pain and inability to move the left leg, the resident was not sent to the hospital until four days later, after an x-ray revealed the fracture. The facility failed to conduct a comprehensive assessment and did not follow its pain management policy, resulting in a significant delay in appropriate treatment.
A resident with a history of epilepsy, dementia, and chronic kidney disease experienced severe pain after a fall, which the facility failed to assess and manage properly. Despite complaints of pain, the facility did not conduct a comprehensive assessment, leading to a delay in diagnosing a left femur fracture. Pain management was inadequate, with inconsistent documentation and communication with healthcare providers.
A resident with chronic conditions was transferred to the hospital due to hyperglycemia and altered mental status, but the facility failed to notify the family, as required by policy. The family, who was the resident's power of attorney, was not informed until the resident was on life support. The nurse claimed to have called the family but did not document the call, leading to a deficiency finding.
A resident with bipolar disorder was injured in a physical altercation with a roommate who has a history of mental health issues. The incident began with a verbal dispute and escalated when the second resident attacked, resulting in a spinal fracture for the first resident. Staff present failed to de-escalate or separate the residents effectively, and security was not immediately available. The facility's policies for abuse prevention and behavior management were not followed.
The facility failed to maintain a clean and safe environment for residents, with issues such as soiled mattresses, unclean clothes, and inadequate window coverings. Observations revealed strong odors and unsanitary conditions in residents' rooms, with staff failing to address these issues promptly. The Maintenance Director acknowledged the use of paper blinds due to residents' destructive behavior, but replacements were not made regularly, leaving windows uncovered.
Two residents at high fall risk experienced falls due to inadequate supervision and monitoring. One resident with dementia and unsteadiness on feet suffered a fracture after falling unsupervised, while another resident with hemiplegia and dementia slid from a wheelchair, sustaining an ear laceration. The facility's fall risk evaluations were not accurately updated, and staff were unaware of the residents' fall risk status, leading to these incidents.
A resident with a history of hemiplegia and dementia sustained an ear laceration after sliding from a wheelchair. Despite hospital discharge instructions for a follow-up with a plastic surgeon, the facility failed to schedule the appointment. The wound care coordinator deemed the wound healed without documented consultation with a physician, and no contact was made with the plastic surgery office. The primary physician admitted to canceling non-life-threatening appointments, but there was no documentation supporting this decision.
The facility failed to provide adequate food portions to all residents, as evidenced by resident complaints and staff observations. Several residents with complex medical conditions reported insufficient meal sizes, and documentation from meetings and grievances highlighted ongoing requests for larger portions. Despite the facility's policy to meet residents' nutritional needs, the issue persisted, affecting all residents receiving meals.
The facility failed to provide timely emergency care for two residents, resulting in one resident's death and another's severe injury. A resident with high blood pressure and mental status changes experienced a two-hour delay in receiving emergency care, leading to a critical neurological event. Another resident with low blood sugar was not promptly treated with food or emergency services, resulting in cardiac arrest and hypoxic brain injury. Additionally, the facility did not adequately monitor blood sugar levels for two other residents, leading to severe hypoglycemia in one case.
Facility staff failed to identify and respond to emergency care needs for two residents with significant changes in physical and mental status. One resident with a history of cerebral infarction and diabetes was found vomiting and confused, leading to a delayed 911 call and eventual death from a subdural hematoma. Another resident experienced low blood sugar, received inadequate initial treatment, and later went into cardiac arrest. Additionally, the facility failed to monitor blood sugar levels for residents on diabetic medications and demonstrated improper insulin administration practices.
A resident developed a stage 3 sacrum pressure ulcer due to the facility's failure to provide adequate preventative measures and timely wound care. Despite being at risk, the resident was not given a low air loss mattress, and staff were not educated on pressure ulcer prevention. The Wound Nurse did not document or assess the wounds until prompted by a surveyor, and the Wound Physician confirmed the presence of a stage 3 ulcer and a skin tear, which were not previously identified by the facility staff.
A resident in a LTC facility was physically abused by another resident after being caught going through the aggressor's belongings. The incident resulted in a bleeding laceration on the victim's upper lip, requiring hospital evaluation. Both residents were alert and oriented, with histories of schizophrenia and other medical conditions. The facility's policy prohibits such abuse, yet the incident occurred, highlighting a failure to maintain a secure environment.
The facility failed to maintain a safe and comfortable environment, with observations revealing wall damage in 10 out of 12 resident rooms. Issues included rotted door jambs, large holes behind headboards, and damage at floor-wall junctions. The Maintenance Director acknowledged awareness of these issues and mentioned ongoing renovations.
The facility failed to prevent multiple incidents of resident-on-resident physical abuse, resulting in significant injuries. In one case, a resident with a history of violent behavior struck another resident, causing facial fractures. In another, a resident was hit while entering from the smoking patio. A third incident involved a resident being struck unprovoked in her room. The facility's policy on abuse and neglect was not effectively enforced.
The facility failed to ensure a resident with a stage 4 pressure ulcer was assessed by a Dietician upon admission. Despite a recommendation for a Dietician consult, no order was found, and the Dietician admitted to missing the resident due to being overloaded. The facility's policy requiring high-risk notes and nutrition assessments for such residents was not followed.
Failure to Maintain Safe and Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain safe and comfortable temperature levels within the required range of 71-81 degrees for multiple resident rooms. During observations conducted with the Maintenance Director, several rooms on the second and third floors were found to have temperatures ranging from 81 to 87 degrees. Residents in these rooms reported feeling hot and uncomfortable, with some stating that the air conditioning had been malfunctioning for an extended period. One resident noted that staff had placed a blanket under a leaking air conditioner and promised repairs, while others confirmed that the issue had persisted for weeks without resolution. Interviews with staff revealed that the Maintenance Director had only recently started working at the facility and was aware of ongoing air conditioning issues. The Corporate Maintenance Director stated that he was only made aware of the high temperatures on the day of the survey and that maintenance is typically performed twice a year. Facility policies require temperature monitoring and specific actions when indoor temperatures exceed 80 degrees, but the report indicates that these procedures were not effectively implemented, resulting in prolonged exposure of residents to excessive heat.
Failure to Maintain Functional Air Conditioning Results in Uncomfortable Temperatures
Penalty
Summary
The facility failed to maintain air conditioning units in good repair on the second and third floors, resulting in uncomfortably high temperatures in both hallways and several resident rooms. Observations revealed that the second-floor hallway temperature reached 84°F and the third-floor hallway reached 85°F. Multiple resident rooms on both floors had air conditioning units that were not functioning properly and were blowing warm air. In one room, a blanket was found placed under the air conditioner to soak up water dripping from the unit. These conditions affected a total of 127 residents residing on the second and third floors. Interviews with facility staff indicated that the Maintenance Director had only recently started working at the facility and was in the process of addressing some of the malfunctioning air conditioners. The Corporate Maintenance Director stated that the expected temperature range for resident rooms is 68-78°F and that maintenance is typically performed twice a year. However, the Corporate Maintenance Director was not made aware of the high temperature issue until the day of the survey. The facility's job description for the Maintenance Director includes responsibilities for maintaining equipment and promptly reporting facility damage.
Failure to Protect Resident from Physical Abuse and Inadequate Incident Reporting
Penalty
Summary
A staff member, identified as an activity aide/CNA, physically intervened with a resident who was seeking to smoke after refusing a blood draw. The staff member confronted the resident, grabbed him by both arms, took him down to the floor, and held him there. The resident, who has muscle wasting, atrophy, anxiety, and a right ankle contracture, subsequently complained of pain and was observed with an abrasion on his right elbow. He was later sent to the hospital and diagnosed with acute bilateral lower back pain, elbow pain, and thumb pain. The resident reported feeling scared and humiliated by the incident. Multiple staff members, including security and nursing staff, were present or nearby during the incident but did not intervene or respond appropriately to protect the resident or gather information for reporting. The activity aide/CNA did not follow proper Crisis Prevention Intervention (CPI) protocols, as confirmed by the social service director and activity director, and failed to report the incident to the appropriate supervisory staff. The nurse and other staff who were aware of the commotion did not document or escalate the event as required by facility policy. The facility's abuse prevention policy prohibits abuse, neglect, and mistreatment of residents and requires all incidents to be documented and reported. However, the incident was not promptly or properly reported to the administrator, DON, or other relevant authorities. The lack of immediate assessment and documentation, as well as the failure to remove the alleged perpetrator from duty, contributed to the deficiency in protecting the resident from abuse and ensuring a safe environment.
Failure to Document and Report Crisis Prevention Intervention Incident
Penalty
Summary
The facility failed to follow its behavior management policy and document an incident involving the use of crisis prevention intervention (CPI) techniques on a resident. On the morning in question, a staff member (activity aide/CNA) physically intervened with a resident by grabbing both wrists, taking the resident to the floor, and holding them in that position. This action was not reported to the nurses on duty, the acting administrator, or the director of nursing at the time. Multiple staff interviews confirmed that the incident was not communicated through proper channels, and the required documentation in the nursing notes was not completed. The resident did not receive an assessment for injuries following the incident, and the event was not reviewed as per facility policy. The facility's behavior management policy requires staff to use the least restrictive interventions, document resident behavior and symptoms, perform an assessment, and notify family or physician after such incidents. The abuse policy also mandates documentation and internal investigation of all incidents, whether or not abuse is suspected. In this case, the staff member's actions were not consistent with CPI training, and the incident was not documented or reported according to policy, resulting in a failure to safeguard resident-identifiable information and maintain accurate medical records.
Delayed Treatment for Hip Fracture Due to Inadequate Pain Assessment
Penalty
Summary
The facility failed to conduct a comprehensive assessment for a resident with a new onset of left leg pain, resulting in a delay in treatment and hospitalization for a fractured left hip. The resident, who has a medical history of epilepsy, Todd's paralysis, dementia, and chronic kidney disease, reported falling while trying to get into a wheelchair. Despite complaints of severe pain and inability to move the left leg, the resident was not sent to the hospital until four days later, after an x-ray revealed a fracture. The resident first complained of left leg pain on February 17, but the initial assessment focused only on the knee, and an x-ray of the knee was negative. The resident continued to report pain, but the staff did not conduct a thorough assessment to determine the root cause of the pain. The resident's pain was initially attributed to osteoarthritis, and no further imaging was ordered until February 21, when a nurse practitioner ordered an x-ray of the left hip, which revealed a fracture. Throughout this period, the resident's pain was not adequately assessed or documented, and the facility's pain management policy was not followed. The resident's pain scores were not recorded every shift, and comprehensive pain assessments were not completed on February 19 or 20. The lack of a thorough assessment and timely intervention led to a significant delay in the resident receiving appropriate treatment for the hip fracture.
Failure to Assess and Manage Resident's Pain
Penalty
Summary
The facility failed to adequately assess and manage a resident's new onset of pain, which led to a delay in identifying a serious medical condition. The resident, who had a history of epilepsy, Todd's paralysis, dementia, and chronic kidney disease, experienced a fall while attempting to transfer to a wheelchair. Despite the resident's complaints of severe pain in the left leg, the facility did not conduct a comprehensive assessment to determine the underlying cause of the pain. Initial assessments focused on the left knee, and an x-ray was ordered, which showed no fracture. However, the resident continued to experience significant pain, which was not effectively communicated to the primary care provider. The resident's pain persisted over several days, with staff failing to reassess the situation adequately or notify the primary care provider of the continued pain despite the administration of tramadol. The resident's pain was initially attributed to osteoarthritis, and the facility did not perform a thorough examination to rule out other potential causes. It was not until several days later that an x-ray of the left hip was ordered, revealing a fracture of the left femur. This delay in diagnosis resulted in the resident experiencing increased pain levels for four days before being sent to the hospital for treatment. Interviews with staff revealed a lack of consistent pain assessment and documentation, as well as a failure to follow up on the resident's pain management plan. The facility's policy on pain management was not adhered to, as pain assessments were not conducted every shift, and the resident's pain scores were not consistently documented. The failure to identify and address the resident's pain in a timely manner highlights deficiencies in the facility's pain management practices and communication with healthcare providers.
Failure to Notify Family of Resident's Hospital Transfer
Penalty
Summary
The facility failed to adhere to its discharge and change in condition policies by not notifying a family member of a resident's change in condition and subsequent transfer to the hospital. The resident, an elderly individual with chronic obstructive pulmonary disease, type 2 diabetes, and left eye glaucoma, was assessed by a nurse practitioner for hyperglycemia and altered mental status. The decision was made to transfer the resident to the hospital for further evaluation due to confusion and uncontrolled hyperglycemia. Despite the facility's policy requiring notification of the resident's family in such situations, there was no documentation indicating that the family was informed of the transfer. The resident's family member, who was also the power of attorney, was not notified by the facility and only learned of the hospitalization through the hospital itself. This lack of communication resulted in the family member being unaware of the resident's condition until the resident was on life support. Interviews with facility staff revealed that the nurse responsible for the resident's care claimed to have called and left a message for the family but failed to document the call due to being busy. The facility's policies clearly state that family notification must be documented, including the name of the family member contacted, the phone number called, and the time of the call. The absence of such documentation contributed to the deficiency identified by the surveyors.
Failure to Prevent Resident-to-Resident Altercation
Penalty
Summary
The facility failed to adhere to its abuse prevention and behavior management policies during a resident-to-resident altercation, resulting in a serious injury. A male resident with a history of bipolar disorder, depression, muscle wasting, and atrophy was involved in a verbal and physical altercation with his roommate, who has a history of major depressive disorder, anxiety disorder, cocaine abuse, and suicidal ideations. The altercation began with a verbal exchange over the room's lighting and noise levels, which escalated when the second resident physically attacked the first, leading to a compression fracture of the spine for the first resident. During the incident, staff members present did not effectively intervene to prevent the escalation from verbal to physical aggression. A registered nurse and a certified nursing assistant were in the vicinity but failed to de-escalate the situation or physically separate the residents in a timely manner. The nurse attempted to redirect the aggressive resident verbally but was overpowered when the resident attacked. The certified nursing assistant, who was providing care to another resident, did not intervene physically due to concerns for personal safety and instead called for security, which delayed the response. The facility's administrator acknowledged that staff are trained in Non-Violent Crisis Prevention and Intervention (CPI) techniques and are expected to intervene in such situations. However, the staff did not follow the facility's policies for behavior management and abuse prevention, which include de-escalation, redirection, and environmental control. The administrator also noted that security was not stationed on the floor where the incident occurred, which contributed to the delay in response. The facility's investigation concluded that the aggressive behavior was not substantiated as abuse due to the resident's mental health condition, but the failure to prevent the altercation and protect the residents was evident.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several observations and interviews. Nine residents were affected by the facility's inability to adhere to its housekeeping and maintenance policies. Observations revealed that residents' rooms were not kept clean, with heavily soiled mattresses not being replaced, unclean clothes not being removed promptly, and windows lacking proper coverings. For instance, residents reported that their window covers were torn or missing, and it took an extended period for repairs or replacements to occur. Specific incidents highlighted the severity of the issue. One resident's room was observed with a strong odor due to a large garbage bag left on the bathroom floor, a sheet around the toilet base, and a toilet filled with feces. The odor was so strong that it was intolerable. The resident's mattress was stained and smelled of urine, and their clothing was found wet and covered in gnats. Staff interviews confirmed that the resident had a history of urinating in inappropriate places, and there was a lack of timely intervention to clean and maintain the room. The facility's maintenance and housekeeping staff were aware of the issues but failed to address them promptly. The Maintenance Director acknowledged that residents in the Annex were destructive, leading to the use of paper blinds, which should be replaced regularly if damaged. Despite having an adequate supply of blinds, the facility did not ensure that windows were properly covered, leaving residents without privacy and comfort. The Administrator confirmed that staff should have addressed these issues immediately, but the deficiencies persisted, affecting the residents' quality of life.
Inadequate Supervision and Monitoring of High Fall-Risk Residents
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring for residents at high risk of falls, resulting in two incidents involving residents R1 and R2. R1, a resident with dementia, schizophrenia, and unsteadiness on feet, suffered a left arm fracture after falling in the hallway unsupervised. Despite being alert and oriented, R1 reported feeling pushed by an 'evil spirit' and was able to walk back to their room without assistance. The facility's fall risk evaluation for R1 was not updated accurately, and R1 was not listed as a high fall risk until after the incident. Staff interviews revealed a lack of awareness and communication regarding R1's fall risk status, and the fall binder used to track high fall-risk residents was not consistently updated or accessible. R2, a resident with hemiplegia, epilepsy, and vascular dementia, was on 1:1 monitoring due to their high fall risk. During a meal, R2 slid out of their wheelchair, resulting in a laceration to the right ear. The CNA assigned to monitor R2 reported that R2 made a sudden movement, causing the wheelchair to move, and the CNA attempted to lower R2 to the floor. However, R2's ear was injured during the fall. The facility's investigation noted that R2 was on 1:1 monitoring, but the CNA was responsible for multiple residents, and there was no clear documentation of the specific monitoring requirements for R2. The facility's policies on fall prevention and management were not effectively implemented, as evidenced by the lack of accurate fall risk assessments and communication among staff. The fall risk evaluations for R1 were not scored correctly, leading to a failure to identify R1 as a high fall risk. Additionally, the fall binder, which was intended to inform staff of high fall-risk residents, was not consistently updated or utilized by staff. These deficiencies in supervision and monitoring contributed to the incidents involving R1 and R2, highlighting a need for improved communication and adherence to fall prevention protocols.
Failure to Schedule Follow-Up for Ear Laceration
Penalty
Summary
The facility failed to follow hospital discharge instructions by not scheduling a follow-up appointment for a resident with an ear laceration. The resident, who has a history of hemiplegia, epilepsy, aphasia, and vascular dementia, sustained a skin tear on the right ear after sliding out of a wheelchair. The resident was sent to the hospital, where plastic surgery recommended follow-up care, including a potential skin graft evaluation. However, the facility did not schedule the necessary follow-up appointment with a plastic surgeon as instructed. Interviews and record reviews revealed that the wound care coordinator decided not to send the resident to the follow-up appointment, considering the wound healed. This decision was made without documented consultation with the physician or nurse practitioner. The wound care coordinator and the Director of Nursing acknowledged the importance of follow-up appointments and the need for proper documentation of any decisions to cancel such appointments. However, there was no documentation indicating that the facility contacted the plastic surgery office or that the primary physician was involved in the decision to cancel the appointment. The facility's failure to ensure the resident attended the follow-up appointment resulted in a lack of evaluation for potential reconstructive surgery. The primary physician admitted to canceling specialty appointments if deemed non-life-threatening, but there was no documentation supporting this decision for the resident's ear laceration. The facility's policy on skin tears and other non-pressure ulcers requires appropriate documentation, which was not completed in this case.
Inadequate Food Portions for Residents
Penalty
Summary
The facility failed to provide food portions that meet the needs and preferences of all 238 residents receiving meals. This deficiency was identified through observations, interviews, and record reviews. Several residents, including those with complex medical histories such as psychosis, bipolar disorder, dementia, schizophrenia, and chronic conditions like diabetes and kidney disease, reported that the food portions were inadequate. A Certified Nursing Assistant also noted that the portions, particularly for pureed meals, seemed insufficient. Residents expressed dissatisfaction with the portion sizes, indicating that they were not allowed to have seconds even when the initial serving was not enough. The deficiency was further supported by documentation from Food Committee and Resident Council meetings, as well as grievances filed between July and August 2024, which highlighted repeated requests for larger portions and more meat for breakfast. The facility's Food Quality and Palatability Policy, reviewed on September 13, 2024, states that food should be prepared and served to meet residents' needs, yet the evidence suggests this policy was not being effectively implemented. The failure to provide adequate food portions was a systemic issue affecting all residents receiving meals at the facility.
Failure to Provide Timely Emergency Care and Monitor Blood Sugar Levels
Penalty
Summary
The facility failed to identify and respond to emergency care needs for two residents, resulting in significant delays in treatment. One resident, a male with a history of cerebral infarction, type II diabetes, and dementia, exhibited symptoms of high blood pressure and mental status changes. Despite these symptoms, there was a two-hour delay before emergency services were called, during which the resident's condition deteriorated, leading to a critical neurological event and subsequent death. The physician was not notified in a timely manner, and the care plan for hypertension was not adequately followed. Another resident, also a male with type II diabetes, chronic kidney disease, and hypertension, experienced symptoms of low blood sugar. The nurse on duty administered sugar and glucagon but failed to provide food or escalate the situation to emergency services promptly. The resident went into cardiac arrest and was later revived by paramedics, but suffered a hypoxic brain injury and eventually passed away under hospice care. The care plan for diabetes management was not effectively implemented, contributing to the resident's decline. Additionally, the facility did not adequately monitor blood sugar levels for two other residents receiving diabetic medications. One resident was found unresponsive with severe hypoglycemia and required emergency treatment, while another had no documented blood sugar checks for two weeks. The lack of proper monitoring and documentation, as well as the absence of a diabetes management plan, further exemplifies the facility's failure to provide appropriate care for residents with diabetes.
Failure to Identify and Respond to Emergency Care Needs
Penalty
Summary
The facility staff failed to identify and respond appropriately to emergency care needs for two residents, R1 and R2, who exhibited significant changes in their physical and mental status. R1, a male resident with a history of cerebral infarction, type II diabetes, and dementia, was found vomiting and confused with abnormal vital signs, including low oxygen saturation. Despite these symptoms, there was a delay in calling 911, and R1 was eventually diagnosed with a large subdural hematoma and expired after being airlifted to a hospital. The physician was not notified of R1's condition prior to hospitalization. R2, another male resident with type II diabetes, chronic kidney disease, and hypertension, experienced symptoms of low blood sugar during a medication pass. The nurse on duty administered sugar and orange pop, but R2's blood sugar continued to drop, necessitating an emergency glucagon injection borrowed from another resident. R2 was later found unresponsive and was revived by paramedics after experiencing cardiac arrest. The physician noted that R2 should have been given food and sent to the emergency room immediately after the low blood sugar was detected. Additionally, the facility staff failed to monitor blood sugar levels for residents R5 and R6, who were on diabetic medications. R5 was found unresponsive with low blood sugar and was treated for hypoglycemia and sepsis. The facility also demonstrated a lack of competency in insulin preparation and administration, as observed with incorrect insulin dosing and improper use of insulin pens. The facility did not ensure the availability of resident-specific diabetes medications for emergencies, leading to the borrowing of medications from other residents.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development of an avoidable pressure ulcer in a resident, identified as R77, who was admitted with conditions including End Stage Renal Disease, anxiety, and schizoaffective disorder. Despite being at risk for pressure ulcer development, the resident was not provided with adequate preventative measures such as a low air loss mattress. The care plan lacked comprehensive interventions to prevent skin breakdown, and the facility did not educate staff on pressure ulcer prevention and treatment. Observations revealed that the resident was lying on a regular mattress and reported pain from a wound on her back, which was not documented in the facility's records. The facility's wound care process was inadequate, as evidenced by the lack of timely identification, assessment, and treatment of the resident's wounds. The Wound Nurse, V5, failed to document or assess the wounds until prompted by the surveyor, and there were no treatment records in the Treatment Administration Record (TAR) for June and July. The Wound Physician, V35, confirmed the presence of a stage 3 sacrum pressure ulcer and a skin tear on the resident's back, which were not previously identified by the facility staff. The Director of Nursing, V2, acknowledged the expectation for nurses to notify physicians and the Power of Attorney when wounds are identified, but this protocol was not followed in R77's case.
Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving two residents. One resident, who was alert and oriented, reported hearing sounds and observed another resident going through his pants pocket. Despite being told to stop, the second resident did not comply, leading the first resident to physically assault him. This altercation resulted in the second resident sustaining a bleeding laceration on his upper lip, which required medical evaluation at a hospital. The incident was documented in the Facility Reported Incident as a case of physical abuse. The facility's policy on abuse clearly prohibits any form of abuse, including physical abuse, which is defined as the infliction of injury on a resident that requires medical attention. Despite this policy, the incident occurred, indicating a failure to ensure a resident-sensitive and secure environment. The involved residents were both alert and oriented, with one having a history of schizophrenia, depression, and weakness, and the other having hypertension, schizophrenia, and chronic kidney disease. The facility's staff, including a social service worker and a registered nurse, acknowledged that the incident constituted physical abuse.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents in 10 out of 12 observed rooms. Observations made on June 8, 2024, with the Maintenance Director revealed various forms of wall damage in multiple resident rooms. Specific issues included wall damage next to the toilet room door in one room, rotted metal door jambs, large holes behind headboards, and damage at the floor-wall junctions in several rooms. The Maintenance Director acknowledged awareness of these issues and mentioned ongoing renovations in resident rooms and common areas. The facility's policy, dated June 2015, outlines guidelines for maintaining cleanliness, hygiene, and proper repair, aiming to create a safe and comfortable environment for residents, staff, and visitors.
Failure to Prevent Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure residents were free from physical abuse, resulting in multiple incidents of resident-on-resident violence. In one instance, a resident with a history of violent behavior struck another resident in the face, causing significant injuries including a displaced right maxillary sinus fracture and a displaced fracture of the right zygomatic arch. The incident occurred in the hallway, where staff witnessed a verbal disagreement escalate into physical violence. The injured resident was sent to the local hospital for further medical evaluation and treatment. In another incident, a resident was hit in the face by another resident while trying to enter the facility from the smoking patio. The aggressor, who was reportedly frustrated by the victim's slow movement, immediately apologized after realizing what had happened. Staff intervened by separating the residents and reporting the incident to the nurse. The aggressor was placed on 1:1 supervision to monitor for further behaviors. A third incident involved a resident being struck in the face by another resident who entered her room unprovoked. The aggressor was subsequently sent to a psychiatric unit for evaluation and has not returned to the facility. The victim was moved to another floor for her safety. The facility's policy on abuse and neglect emphasizes the prohibition of abuse and the establishment of a secure environment for residents, but these incidents indicate a failure to uphold these standards.
Failure to Assess Resident with Stage 4 Pressure Ulcer by Dietician
Penalty
Summary
The facility failed to ensure a resident with a stage 4 pressure ulcer was assessed by a Dietician upon admission. The resident, who had multiple diagnoses including diabetes, mild protein-calorie malnutrition, and end-stage renal disease, was admitted from the hospital. Despite a recommendation for a Dietician consult in the resident's Wound Care Telemedicine Initial Evaluation, no order for a Dietician consult was found in the resident's records. The Dietician admitted to being overloaded and missing the resident, acknowledging the importance of assessing residents with pressure ulcers due to their increased calorie and protein needs. The facility's policy requires the Dietician to complete high-risk notes and nutrition assessments for residents with wounds and those on dialysis, which was not followed in this case.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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