Bria Of Westmont
Inspection history, citations, penalties and survey trends for this long-term care facility in Westmont, Illinois.
- Location
- 6501 South Cass, Westmont, Illinois 60559
- CMS Provider Number
- 145405
- Inspections on file
- 64
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Bria Of Westmont during CMS and state inspections, most recent first.
Surveyors found that significant medications were not administered as ordered for multiple residents when an LPN began the morning med pass several hours late, resulting in insulin, cardiac drugs, anticoagulants, inhalers, antibiotics, anticonvulsants, psychotropics, and pain/anxiety medications ordered for the morning being given around midday or later. Residents with conditions including DM, COPD, CHF, atrial fibrillation, end-stage renal disease, seizures, and anxiety reported receiving their "morning" medications in the afternoon, and medication administration audits confirmed that 9:00 AM doses were routinely documented as given between late morning and late afternoon, contrary to physician orders and facility policy requiring timely administration.
A dependent, cognitively intact resident with MS and paraplegia fell from a shower chair after reporting she was not seated properly, landing on her weaker leg. Nursing staff obtained an X‑ray that showed a right distal femur fracture, and multiple staff observed significant knee swelling, absence of usual leg spasms, and increased pain with manipulation over the following days. The overnight LPN documented the fracture result and relayed it to the DON and oncoming nurse but did not notify the physician, and no one contacted the physician about the X‑ray findings until several days later. Only then did the DON obtain an order to send the resident to the ED, where hospital staff confirmed a comminuted, displaced distal femur fracture with lipohemarthrosis and a subacute fibular fracture. This sequence reflects a failure to follow facility policy requiring prompt physician notification for accidents, significant changes in condition, and X‑ray results showing a fracture, resulting in delayed emergency and surgical care.
A resident with MS, paraplegia, and significant mobility impairments, fully dependent on staff for care, was positioned in a shower chair by two CNAs and reported not being seated properly from the start of the shower. While staff had the resident leaning forward to apply lotion and fasten a bra, the resident slipped out of the shower chair and fell, landing on the right leg. The resident later exhibited marked right knee swelling and absence of her usual leg spasms, and imaging revealed an impacted distal femur fracture and a proximal fibular fracture. The fall occurred despite the resident’s known high fall risk and dependence for positioning, and the care plan intervention to ensure centered seating and assisted leaning was documented only later during the surveyor’s investigation.
The facility failed to maintain an effective pest control program, as evidenced by months of pest control logs documenting roach activity, fruit flies in kitchen and dish room areas, and mouse droppings in the kitchen, along with inspection notes citing the need for improved cleaning and repair of broken tiles and missing grout. Multiple CNAs reported roaches in shower rooms, an employee washroom, and at a nurses’ station, and gnats in dining and resident care areas, describing one shower room as consistently “nasty” and infested. Several residents reported frequent gnats in their rooms, used gnat traps, avoided keeping fresh fruit, and stated they would only bathe in an alternate spa shower room because their usual shower room was full of bugs and unclean. A surveyor directly observed gnats in a resident room and about 30 gnats in a B wing shower room on two separate entries, while the Maintenance Director acknowledged ongoing gnat and roach issues in various locations but stated he was unaware of the gnats in the B wing shower room due to lack of staff reports.
A resident with quadriplegia, prior CVA, cervical spine injury, and multiple comorbidities, who was dependent for most care and required assistance with bed mobility, did not have a functioning bed to meet his needs. His care plan called for two-person assist with bed mobility and use of bilateral half rails, and he reported that his bed had not worked for about a month and a half despite previously telling staff. A CNA stated that many beds were broken and that this resident’s bed was always broken, preventing him from raising the head of the bed to eat, which he did in his room. Surveyors observed him lying flat in bed, and the Maintenance Director, who was unaware of the problem, found the power cord pulled out under the bed with the clip missing. Review of maintenance logs showed no work requests for this bed during the period reviewed, while the DON stated she expected staff to report broken beds and acknowledged the importance of functioning equipment.
Two residents who were always incontinent of bowel and bladder and fully dependent on staff for toileting hygiene and bed mobility reported that their incontinence briefs were routinely changed only at bedtime and then not again until early morning, despite care plans and facility policy requiring care after each incontinent episode. One resident stated she was still wearing the same soiled brief applied in the early morning hours, and another reported her brief had not been changed since early morning and was currently soiled. The DON stated that staff are expected to reposition and change incontinent briefs at least every two hours, but the residents’ accounts and surveyor observations showed this was not occurring as planned.
Multiple cognitively intact, dependent residents with conditions such as hemiplegia, paraplegia, dementia, severe back pain, incontinence, and pressure ulcers did not receive timely assistance with ADLs and toileting. Family members reported long delays in call light response, residents being left soiled with urine or feces, and staff placing briefs on a continent resident who could request a urinal. One resident stated she was not checked or changed for many hours despite needing hygiene before wound care, and another reported incomplete cleaning after a large bowel movement when a CNA said the overnight shift does not provide wash-ups. A family member described repeatedly finding a resident soiled, having to supply briefs and wipes, and submitting unresolved concerns about call light response and toileting. These accounts conflicted with staff statements that residents are to be rounded on at least every two hours, call lights answered promptly by any staff, and soiled conditions addressed immediately on all shifts.
Several dependent residents with complex medical needs experienced significant delays in receiving assistance with transfers, toileting, and dressing. Residents were left in soiled incontinence briefs for hours, call lights were ignored or turned off without care being provided, and staff were often unaware of their assignments or failed to respond to requests for help. Interviews and documentation confirmed ongoing issues with staff availability and delayed response to resident needs.
The facility did not consistently provide coffee to residents during meals as required by the approved menu, with several residents and staff reporting frequent shortages and missed servings. Staff described running out of coffee, especially later in the week, and sometimes needing to purchase more from a store. Residents reported difficulty obtaining coffee or not receiving it at all during meals.
Multiple residents and staff reported that the coffee served during meals was unpalatable, with descriptions ranging from 'brown water' to 'sludge.' Instant coffee was used in place of the usual product, resulting in coffee that was either too weak or too thick, and both residents and staff found it undrinkable.
A newly admitted resident with hypertensive heart disease and heart failure did not receive all prescribed medications on schedule due to the unavailability of Entresto and Carvedilol. Although most medications were delivered, Entresto was not available and was administered late, and Carvedilol was marked as unavailable for a scheduled dose. Staff interviews and record review showed that required procedures for obtaining and administering missing medications were not followed.
A resident with dementia, limited mobility, and a history of falls was not provided with required fall prevention devices such as floor mats, a non-slip wheelchair device, and a specialized cushion, despite these being listed in her care plan and communication sheets. Staff confirmed the resident had recently fallen from her wheelchair and that interventions were not in place during observation, even though she required constant supervision and redirection due to unsafe movements.
A facility with 175 residents failed to employ a qualified full-time social worker, as required for facilities with over 120 beds. The social services department was understaffed, with only one unlicensed individual covering the role. The facility had been without a Social Services Director since May 2024, and another social worker was terminated in October 2024. The facility engaged two LCSWs as consultants, but they were not present full-time, impacting the delivery of essential social services.
A resident with multiple health issues, including incontinence, experienced delays and inadequate incontinence care at the facility. Despite being dependent on staff for toileting hygiene, the resident reported long waits for assistance and had to clean herself due to incomplete care by a CNA. The facility's policies on call light response and incontinence care were not followed, as observed during a survey.
A facility failed to timely coordinate with an outside agency to complete guardianship paperwork for a resident with severe mental illness. Despite multiple requests from the APS case manager, the facility delayed providing an updated physician's report necessary for the guardianship process. This delay left the resident without a legal guardian to make critical care decisions. The facility's lack of documentation and communication contributed to the delay, as emails from the APS case manager went unnoticed in the Administrator's spam folder.
The facility failed to provide timely incontinent care to two residents, one with intact cognition and another with severe cognitive impairment. The first resident reported being left in soiled briefs for hours on two occasions, while the second was found with a urine-soaked brief. Both residents' care plans required prompt incontinent care, which was not provided, as confirmed by staff interviews and observations.
A resident with multiple serious health conditions did not receive significant medications as ordered, including insulin and heart medications. The EMAR showed missed doses on specific dates, and the DON confirmed the lack of documentation by nurses. The facility's policy requires documentation and notification of any deviations, which was not followed.
A resident with multiple health conditions, including COVID-19, did not have vital signs taken as ordered by their physician on multiple occasions. Despite orders for vital signs every 12 hours and later every 4 hours, the facility failed to comply. Interviews with staff confirmed the expectation to follow physician orders, yet the Director of Nursing admitted there was no excuse for the oversight.
A resident who tested positive for COVID-19 did not have the required transmission-based precautions implemented. Despite orders for contact and droplet isolation, there were no signs or PPE outside the resident's room. Staff were unaware of the resident's COVID-19 status, leading to potential exposure. The facility's policy on transmission-based precautions was not followed.
The facility failed to administer wound care treatments as ordered for two residents, leading to a deficiency in nursing care. One resident with a left breast wound did not receive prescribed treatments on multiple occasions, while another resident with diabetic foot ulcers refused treatment several times, and the facility lacked documentation of treatment administration. The wound care nurses were responsible for care during weekdays, but the TARs showed multiple days without documentation, violating the facility's guidelines for weekly review.
A facility failed to administer pressure ulcer treatments as ordered for a resident with a sacral pressure ulcer. The resident, with severe cognitive impairment, did not receive prescribed wound care on multiple occasions in August and September. The wound care nurse confirmed the lack of documentation, indicating treatments were not done. The responsibility for wound care falls on floor nurses when the wound care nurse is unavailable.
The facility failed to assist several residents with personal hygiene, specifically shaving, despite their inability to perform this task due to medical conditions such as cognitive impairments, hemiplegia, and weakness. Residents expressed the need for staff assistance, which was not provided, resulting in long, unkempt facial hair. Care plans indicated the need for assistance with ADLs, but the facility did not fulfill these requirements.
The facility failed to provide correct portion sizes for mechanical soft and pureed diets, affecting seven residents. The dietary staff used incorrect scoop sizes, resulting in insufficient protein portions. The Food Service Manager's justification contradicted the menu spreadsheet, and the Registered Dietitian confirmed the need to follow specified scoop sizes to meet protein requirements.
The facility failed to serve pureed consistency vegetables to residents on pureed diets. During meal preparation, the Assistant Food Service Manager did not achieve the required smooth consistency for the pureed zucchini, leaving hard rinds that needed to be chewed. Both the manager and the Dietary District Manager acknowledged the deficiency. The Registered Dietitian confirmed that the pureed consistency should be smooth, and the facility's diet order sheet indicated that the affected residents were on pureed diets.
The facility failed to follow its policy of offering the pneumococcal vaccine to residents, as shown by the lack of documentation for five residents with various medical conditions. The facility's records did not indicate that these residents were offered or refused the vaccine, which is required by the facility's policy and CDC guidelines. The Director of Nursing acknowledged the oversight, but the records did not reflect the necessary actions.
The facility failed to align physician orders for life-sustaining treatment with residents' POLST forms, resulting in discrepancies in the EMRs of two residents. One resident's POLST indicated DNR, but the EMR showed Full Code, and another resident's POLST was not updated in the EMR. The Director of Nursing confirmed the errors, which were contrary to the facility's policy on advanced directives.
A facility failed to refer a resident with a new diagnosis of schizophrenia for a Level II PASARR. Initially, the resident's records showed no psychiatric disorders, but later assessments revealed multiple mental health diagnoses. Despite this significant change, the required rescreening was not conducted, as confirmed by facility staff.
The facility failed to hold interdisciplinary care plan conferences at required intervals for three residents, as per policy. One resident, admitted with multiple diagnoses, had not received therapy and awaited discharge without a documented care plan meeting. Another resident had a care plan invitation but no subsequent meetings, exceeding the 90-day interval. A third resident experienced a five-month gap between care plan conferences. The care plans for all three residents were not updated or revised since their initial target dates.
A facility failed to follow treatment recommendations for a resident with hemiplegia who required a hand splint to prevent contractures. Despite physician orders and a care plan specifying the use of a splint, the resident was observed without it on multiple occasions. Staff were unaware of the splint's location, and the responsible CNAs were on vacation, leading to a lapse in care.
Two residents experienced inadequate pain management due to the facility's failure to assess and administer pain medication as ordered. One resident did not receive prescribed oxycodone, while another had not received acetaminophen for knee pain since February, despite reporting significant discomfort. The facility's pain management policy was not followed, leading to these deficiencies.
A facility failed to document a resident's death according to policy. The resident, with multiple health issues, died in the facility. The last EMR entry noted a medication follow-up and need to contact hospice, but lacked further assessment, notifications, time of death, body disposition, or discharge note. The DON confirmed the policy requires such documentation.
A facility failed to train staff on LVAD care before a resident's admission, leading to inadequate management of the device. The resident's MAP was often outside the recommended range, and LVAD dressing changes and weight monitoring were inconsistently documented. Staff training occurred only after the resident's admission, and the facility lacked a specific LVAD care policy.
A resident with no cognitive impairment was injured when a sink fell on her in the bathroom. The sink had been reported as loose by another resident, but no action was taken. The Maintenance Director was unaware of the issue, as maintenance requests were not properly documented. The facility's preventative maintenance plan requires regular inspections, but the loose sink was not addressed, leading to the incident.
The facility failed to maintain an updated list of residents at high risk for elopement and did not adequately train staff on the elopement policy. Inconsistent lists with conflicting information were found, and some staff were unaware of the elopement code or which residents were at risk. The facility's policy requires regular reviews and updates, but these were not effectively implemented, leading to the deficiency.
A resident receiving hospice care was improperly suctioned by an RN without a physician's order, leading to discomfort. The RN used a suction method that caused the resident to gag, contrary to hospice guidelines. The facility's policy requiring physician orders and proper assessment was not followed.
A resident requiring a two-person assist for incontinence care slid out of bed and sustained a forehead laceration requiring sutures when a CNA attempted to provide care alone, despite the care plan's instructions. The incident was confirmed through observations, interviews, and record reviews.
A resident requiring hemodialysis for ESRD experienced delays in transport to dialysis, resulting in shortened treatment times. The issue was attributed to staffing shortages, which delayed the resident's transfer using a mechanical lift. The resident's care plan indicates a need for timely dialysis, but late arrivals led to incomplete treatments, as confirmed by the dialysis nurse and technician.
A resident experienced increased pain and decreased activities of daily living after a fall, but the facility failed to notify the physician of the change in condition in a timely manner, resulting in a delayed diagnosis of a right hip fracture.
A resident reported that his phone screen was shattered after being taken to the washroom by a CNA. Despite informing Social Services and leaving a voicemail for the Administrator, no follow-up occurred. The facility's grievance policy, which requires addressing grievances within 72 hours, was not followed.
A facility failed to correctly transcribe and reconcile a resident's hospital discharge medication orders upon readmission, leading to the resident being prescribed and administered the wrong medication regimen. This resulted in the resident experiencing a change in condition that required transfer to the hospital emergency room and subsequent hospital admission.
Widespread Late Administration of Significant Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that significant medications were administered as ordered, within the accepted one-hour window before or after the scheduled time, for seven residents reviewed for medication administration. On one day, an LPN (V18) reported arriving after 10:00 AM due to scheduling confusion and did not begin administering scheduled morning medications until after 11:00 AM, completing the pass around 2:45 PM. Multiple residents complained of receiving their morning medications in the afternoon, and the Director of Nursing and Administrator both acknowledged that medications were not administered on time, contrary to physician orders and facility policy requiring medications to be given at the proper time. For one resident with diabetes mellitus, asthma, heart disease, and cardiomyopathy, electronic records showed ordered Humalog insulin three times daily, sliding scale insulin with meals, insulin glargine every 12 hours, Advair HFA twice daily, and furosemide twice daily. The medication administration audit showed that scheduled morning insulin doses, sliding scale insulin, Advair, and furosemide ordered for early morning times were instead administered between mid-afternoon times. Another resident with aortic valve insufficiency, hypertensive disease, bursitis, facial cellulitis, and anxiety disorder had gabapentin, Xanax, and amoxicillin-clavulanate ordered for 9:00 AM, but the audit showed these were administered between early afternoon times. A resident with hallucinations, anxiety, and dementia, with orders for haloperidol and divalproex three times daily and memantine twice daily, had 9:00 AM medications administered after 11:00 AM. Additional residents experienced similar delays. One resident with chronic pulmonary disease, end-stage renal failure on dialysis, and venous thrombosis/embolism had carvedilol, Advair inhaler, and apixaban ordered for 9:00 AM but administered in the late afternoon. Another resident with seizures, atrial fibrillation, hypotension, and chronic pain, ordered apixaban every 12 hours, levetiracetam twice daily, and Lyrica twice daily at 9:00 AM, received these medications early in the afternoon. A resident with heart failure, fibromyalgia, pulmonary embolism, and anxiety disorder, ordered alprazolam twice daily, gabapentin three times daily, losartan for hypertensive heart disease with heart failure, and apixaban twice daily at 9:00 AM, received them between mid- and late afternoon. A resident with chronic kidney disease and COPD, ordered fluticasone HFA every 12 hours/twice daily at 9:00 AM, received the medication in the early afternoon. These findings, based on resident interviews, EMR review, and medication administration audits, show that ordered morning medications were consistently administered several hours late for all seven residents.
Failure to Notify Physician of Fracture and Delay in Emergency Care After Fall
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a physician of X‑ray results showing a fracture and to ensure timely emergency care for a resident after a fall. The resident had multiple sclerosis, paraplegia, muscle wasting, gait abnormalities, and was dependent on staff for most care, but had no cognitive impairment. She reported that during showering staff positioned her leaning forward in a shower chair, she felt she was not seated properly, and despite voicing concerns she slipped and was assisted to the floor, landing on her weaker leg. A nurse’s note documented that after the fall the resident was found on the shower room floor, reported right knee pain rated 3/10, and an X‑ray of the right knee was ordered and called in to a mobile X‑ray company. Later that evening, nursing documentation showed that the mobile X‑ray company was contacted again and that the technician arrived before midnight to perform X‑rays of the right knee, right shoulder, and right humerus, with results pending and endorsed to the oncoming shift. On the overnight shift, an LPN documented that the X‑ray results showed a right knee impacted supracondylar fracture of the distal femur and that this information was relayed to the DON, with a note that the DON would have to compare the current diagnosis with the existing one and that this was endorsed to the morning nurse. The LPN stated she did not notify the physician of the fracture, believing the day nurse would do so, and also stated she did not visualize the resident’s leg during her shift. CNA interviews indicated that by the overnight and subsequent shifts the resident’s leg was very swollen, lacked its usual spasms, and appeared twice the size by the second night, with the resident reporting pain and requesting Tylenol. Over the weekend following the fall, another LPN reported that the resident stayed in bed, that she monitored and managed the resident’s pain, and that she observed swelling of the right knee and documented that the resident reported increased pain with manipulation. A CNA assigned the day after the fall described the resident as emotionally down, concerned about her leg, and reported that the knee was swollen and painful to touch. Despite these findings and the documented X‑ray result of a distal femur fracture, the medical record showed no evidence that the resident’s physician was notified of the X‑ray results until several days later, when the DON documented a change of condition noting the fracture and obtained an order to send the resident to the emergency department. The resident was then transported to the hospital, where records confirmed an acute comminuted and displaced distal femur fracture with large lipohemarthrosis and a subacute proximal fibular diaphysis fracture, and the physician stated he would have expected to be notified of the fracture when the X‑ray results were first available and would have advised hospital transfer at that time. The facility’s own policies required physician notification for accidents/incidents and significant changes in condition, and for falls to be reviewed with care plans evaluated and modified as needed, but the physician was not notified of the fracture result until days after it was known to facility staff. The DON acknowledged being notified of the fall on the day it occurred and being aware that X‑rays were ordered, but stated that Monday was the first time she spoke with the physician about the fracture. She indicated that the nurse’s note about comparing diagnoses was a misunderstanding related to reportability and that she would have expected the nurse to notify the physician of the X‑ray results. Staff interviews confirmed that the usual expectation was to notify the physician when X‑ray results showed a fracture and to report such events to administration. Despite this, the fracture result was not communicated to the physician until several days after the X‑ray, during which time the resident remained in the facility with a swollen, painful leg and continued transfers and care without physician-directed fracture management or timely emergency evaluation.
Failure to Ensure Safe Positioning and Supervision During Shower Resulting in Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe shower environment and adequate supervision for a dependent resident, resulting in a fall from a shower chair and significant injury. The resident had multiple sclerosis, paraplegia, peripheral vascular disease, muscle wasting, gait and mobility abnormalities, and was dependent on staff for most care. She reported that during a shower, two CNAs were present and that from the start she felt she was not positioned properly in the shower chair, with her buttocks not fully in the seat opening. She stated she told staff this more than once, but they either did not hear her or ignored her. At the time of the fall, staff had her leaning forward so they could apply lotion to her back, and she described herself as leaning further forward than a normal sitting position. According to the resident, while she was leaning forward, she began to slip from the shower chair and ultimately fell, landing on her weaker right leg. She reported that one CNA commented she was slipping, but the resident still slid out of the chair and “went down hard enough” to break her leg. A CNA interview later confirmed that the resident slipped out of the shower chair while the CNA was leaning her forward to fasten her bra in the back. The CNA stated she did not hear the resident say anything during the shower. The nurse who responded to the shower room found the resident on the floor in a supine position with the shower chair to her left. At that time, the resident reported right knee soreness, rated 3/10, but no redness, bumps, bruising, or obvious deformity were documented. Subsequent documentation and interviews showed that the resident’s right knee became markedly swollen and that her usual right leg spasms were absent, as observed by a CNA on the overnight shift. The CNA reported the resident told her she had fallen from the shower chair and that she had not been fully seated in the chair. The CNA noted the leg was very swollen and questioned whether it might be broken. Imaging later revealed an impacted supracondylar fracture of the distal femur and a subacute proximal fibular diaphysis fracture. The facility’s fall investigation concluded the incident was unavoidable and described the resident as leaning forward to dry herself when she slid from the shower chair, with staff attempting to lower her to the floor. The resident’s care plan identified her as at risk for falls related to generalized weakness, immobility, MS, paraplegia, PVD, obesity, and osteoarthritis, and included an intervention for staff to ensure she was sitting centered and to assist with leaning forward, but this intervention was documented as created while the surveyor was in the facility investigating the fall.
Ongoing Pest Infestation in Resident Care, Kitchen, and Staff Areas
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective pest control program to support a sanitary environment, as evidenced by ongoing issues with roaches, gnats/fruit flies, and mouse droppings documented over several months. Pest control logs from October 2025 through January 2026 showed repeated findings of roach activity reported by the Maintenance Director and multiple inspections noting 15–30 fruit flies in the main kitchen, dish room, and throughout kitchen areas. One inspection documented that all visible fruit flies were eliminated during that visit but emphasized that cleaning and repair of broken tiles and missing grout were crucial to fully address the problem. The facility’s own pest sighting log also recorded roaches in a resident room on two dates in December and mouse droppings in the kitchen in late December. Staff interviews further demonstrated that pests were present in resident care and staff areas beyond the kitchen. Multiple CNAs reported roaches in second-floor shower rooms, the employee washroom, and at the second-floor nurses’ station, as well as gnats in the dining room, around a water container, and on certain wings. One CNA stated that gnats were “terrible” on specific wings and that staff kept their belongings in bags because they did not want to take bugs home. Another CNA described the B wing shower room as “nasty” with “always some type of bug,” and reported seeing roaches at the nurses’ station when working on the second floor. Resident interviews and direct surveyor observations confirmed that pests were present in resident rooms and bathing areas and were an ongoing issue. One resident reported that gnats were “always an issue,” kept gnat traps in the room, and avoided keeping fresh fruit there due to the gnats. Another resident on B wing stated that gnats were occasionally seen in the room and had reported this to housekeeping. The surveyor observed gnats flying in a resident room and approximately 30 gnats in the B wing shower room on two separate entries, with gnats on the walls, in the air, and on the shower curtains. Two residents reported they would only shower in the spa shower room on another unit because the B wing shower room was “nasty and full of bugs” and said they would refuse showers if not taken to the spa shower room. The Maintenance Director acknowledged problems with gnats and prior roach issues, and stated that roaches had been reported in the nurses’ station, clean utility room, and shower room on the second floor, while also indicating he was unaware of the gnats in the B wing shower room because staff had not informed him.
Failure to Maintain Functioning Bed Equipment for Dependent Resident
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a dependent resident’s bed was functioning to meet his needs. The resident had multiple significant diagnoses, including cerebral infarction, Type 2 DM, quadriplegia, protein-calorie malnutrition, polyneuropathy, fusion of spine, cerebral atherosclerosis, and cervical disc disorder with myelopathy. His facility assessment showed no cognitive impairment and dependence on staff for most care. His care plan documented a self-care deficit in bed mobility related to his conditions, requiring a two-person assist with bed mobility and use of bilateral half rails to promote bed mobility, and noted he required assistance with daily care needs with monitoring for changes and adjustment of assistance as needed. A CNA reported that most beds were broken in some way and specifically stated that this resident’s bed was “always broke” and that he could not raise the head of the bed when he wanted to eat. During observation, the resident was found lying in bed with the head of the bed flat while watching television. He stated that his bed had not been working for a long time, that he had informed staff, and that although maintenance had previously worked on it, it would only function for a short period before failing again. He reported that he preferred to sit up, could sit up on his own but with difficulty due to his prior stroke, and wanted to use the bed remote to raise the head of the bed, especially for eating, which he always did in his room. He said the bed had not been working for about a month and a half on this occasion. When the Maintenance Director inspected the bed, he stated he had not been aware the bed was not working, found the power cord pulled out of the box under the bed with the clip missing, and noted they had no extra beds but used parts from other beds for repairs. Review of the maintenance binder and prior maintenance logs showed no recorded maintenance requests for this resident’s bed during the relevant period. The DON stated that if staff noted a broken bed, she would expect it to be reported to maintenance and fixed, acknowledged the importance of the resident’s equipment functioning, and described the resident’s abilities and prior attempts to sit up or get up on his own.
Failure to Provide Timely Incontinence and ADL Care for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and assistance with ADLs to residents who were fully dependent on staff for toileting hygiene and bed mobility. One resident, admitted with generalized osteoarthritis, adult failure to thrive, chronic pain syndrome, and a history of venous thrombosis and embolism, had an MDS indicating no cognitive impairment but total dependence on staff for toileting hygiene, lower body dressing, and rolling in bed, and was always incontinent of bowel and bladder. The resident’s care plan called for skin care after each incontinent episode, incontinence care as needed, assistance with ADLs, and monitoring of skin integrity during routine care. During observation, the resident reported that CNAs changed her incontinence brief before bed around 10:30–11:00 PM and did not return until about 5:00 AM for medications and around 6:00 AM for a brief change, stating this occurred nightly, including the previous night. At 11:04 AM on the day of survey, the resident stated she was still wearing the same brief that had been applied around 6:00 AM, that it was soiled, and that she needed to be changed. A second resident, with a history including palliative care, obesity, osteoarthritis, and hypertension, also had an MDS showing no cognitive impairment, total dependence on staff for toileting hygiene, lower body dressing, and rolling in bed, and was always incontinent of bowel and bladder. This resident’s care plan documented a self-care deficit in bed mobility, need for assistance with daily care due to weakness and impaired mobility, and risk for altered skin integrity related to weakness, osteoarthritis, and incontinence, with interventions including skin care and keeping the resident clean and dry after each incontinent episode, assistance with ADLs, and monitoring skin integrity. The resident reported that her incontinence brief was typically changed before sleep around 10:00–10:30 PM and not changed again until about 5:00–6:00 AM, and that this occurred every night. In the afternoon, she stated her brief was currently soiled, she was waiting to be changed, and that it had not been changed since early that morning around 5:30 AM. The DON stated that staff are expected to reposition and change incontinent briefs at least every two hours for all residents to prevent infection and skin breakdown, and the facility’s ADL policy described a program of assistance with elimination and hygiene as required.
Failure to Provide Timely ADL and Incontinence Care and Respond to Call Lights
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and adequate assistance with activities of daily living (ADLs), including toileting and incontinence care, to multiple dependent residents. One resident with hemiplegia, dementia, malnutrition, pelvic fractures, and a sacral pressure ulcer was assessed as cognitively intact but dependent on staff for toileting hygiene, bathing, and dressing, and required substantial/maximal assistance with toileting transfers. Family members reported that CNAs did not check on this resident unless the call light was activated and that call light responses took between forty-five minutes to two hours. They also stated that staff placed briefs on the resident and told them he was incontinent, despite the resident being able to verbalize the need to use the restroom and having requested a urinal, and that attempts to meet with nursing and administrative staff about these concerns were unsuccessful or significantly delayed. Another cognitively intact resident with paraplegia, hemiplegia, neuromuscular bladder dysfunction, bowel and bladder incontinence, and a pressure ulcer was care planned as dependent for ADLs and at high risk for abuse and neglect, with staff expected to provide incontinence care as needed and maintain privacy and dignity. This resident reported not being checked or changed during an evening shift until late in the shift and stated that on a subsequent morning she had not been checked or changed since early morning rounds, despite informing a CNA that she needed to be cleaned before wound care. The resident continued to use the call light while the CNA was in neighboring rooms, and care was not provided until several hours later. The wound nurse confirmed that wound care was delayed until after the CNA staff eventually provided hygiene. A nurse stated that this resident frequently complains and refuses care, but progress notes over a month-long period did not document refusals or behavioral issues. A third cognitively intact resident, totally dependent for toileting due to bowel and bladder incontinence and at high risk for falls, was reported by a family member to often be found soiled with feces and to experience call light response delays of over an hour. The family member stated she had to supply her own briefs and wipes and visited multiple times daily to ensure the resident was fed and changed, and had previously submitted a concern form about call light response and toileting that she felt had not been resolved. A fourth resident with severe back pain, decreased mobility, and decreased ADL function required assistance of one staff member for ADLs and reported having a large bowel movement on the overnight shift but not being fully cleaned. The resident stated that the CNA told him the overnight shift does not provide showers or wash-ups and that he would have to wait for the next shift, and the day nurse later confirmed she had not been informed of the need to clean or shower the resident and had not tended to him. Multiple staff, including CNAs and nursing leadership, stated that residents should be rounded on at least every two hours, call lights should be answered as soon as possible by any available staff, and soiled residents should be addressed immediately, including on overnight shifts, which was inconsistent with the care described by residents and families.
Failure to Provide Timely ADL Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), including transfer, toileting, and dressing, to residents who were dependent on staff. Multiple residents with significant physical and cognitive impairments were observed or reported to have waited extended periods for staff assistance, resulting in prolonged exposure to soiled incontinence briefs, missed transfers, and unmet hygiene needs. For example, one resident with dementia, legal blindness, and incontinence was found in the dining room wearing a soiled gown and sitting in a wheelchair with a wet blanket, emitting a strong odor of urine. Family and staff confirmed that the resident had not been changed for several hours, and the assigned CNA did not return to assist after being notified. Another resident with paraplegia and dependent on a mechanical lift for transfers reported that her call light was on for hours without response, and staff were observed turning off her call light without providing the requested assistance. Staff interviews revealed confusion about resident assignments, especially when CNAs arrived late for their shifts, resulting in residents not receiving timely care. Several staff members, including CNAs and LPNs, were unaware of which residents required coverage or assistance during shift changes, leading to further delays in care. Additional residents with conditions such as chronic pain, hemiplegia, and severe cognitive impairment also reported or were observed experiencing significant delays in receiving incontinence care, transfers, and hygiene assistance. Residents described waiting several hours for help, being left in soiled briefs, and having to seek assistance multiple times without response. Resident council meeting minutes and facility concern forms documented ongoing concerns about staff availability and delayed call light response times, further corroborating the pattern of unmet ADL needs among dependent residents.
Failure to Provide Coffee as Required by Menu
Penalty
Summary
The facility failed to serve coffee as required by the planned and approved menu, which specified that coffee should be provided at every breakfast meal daily. Observations and interviews revealed that coffee was frequently unavailable to residents during meal times. Staff reported that the coffee cart was initially placed in the second-floor dining room, but by the time residents in the dining room were served and received seconds, there was no coffee left for residents served in the hallway. Staff also indicated that when coffee ran out, they could call food service for more, but shortages persisted, especially toward the end of the week when staff sometimes had to purchase coffee from a store. Multiple residents reported not receiving coffee during meals, with some stating that the facility often ran out of coffee or that it was difficult to obtain. One resident noted that sometimes coffee was served, but other times it was not, and another stated she often did not receive coffee or other beverages during meals. During breakfast service, a resident was observed receiving her meal without coffee and stated that coffee was frequently missing. Dietary staff and the administrator confirmed that the facility had run out of coffee for residents at times, despite the administrator having the ability to purchase food items as needed.
Unpalatable and Poorly Prepared Coffee Served to Residents
Penalty
Summary
The facility failed to provide palatable coffee to residents during meals, as evidenced by multiple resident complaints and direct observations. Several residents described the coffee as tasting and looking like brown water, with one resident showing a cup of translucent, light brown liquid that had been served as coffee. Additional residents reported that the coffee smelled rancid, tasted burnt, or was undrinkable. During breakfast service, an LPN sampled the coffee and described it as unusually dark, thick, and resembling sludge. Another sample poured by a dietary aide was noted to be very light and translucent. These observations were consistent across several days and involved multiple residents. Further investigation revealed that instant coffee, purchased from a store, was used to brew the coffee instead of the usual product. Packages of instant coffee were observed on the kitchen counter next to the brewing machine, and dietary staff confirmed its use for breakfast service. The facility's policy requires food and drink to be prepared and served in a manner that preserves palatability, but the coffee served did not meet these standards, as confirmed by both staff and administrative sampling.
Failure to Ensure Timely Availability and Administration of Medications for New Admission
Penalty
Summary
The facility failed to ensure that medications for a newly admitted resident were available for timely administration. The resident, who was admitted with orders for Carvedilol and Entresto to be given twice daily for hypertensive heart disease with heart failure, did not receive all prescribed medications as scheduled. Although most medications were delivered early in the morning, Entresto was not delivered, and Carvedilol was marked as unavailable for the 5:00 PM dose on the day of admission. The Medication Administration Record (MAR) indicated that the 5:00 PM dose of Entresto was not administered until 10:20 PM, and there was no corresponding note explaining the delay for Entresto, while Carvedilol was documented as unavailable. Interviews with facility staff revealed that if a medication is not available in the emergency medication supply (stat-safe), it should be ordered STAT from the pharmacy, and the prescriber should be contacted if there is a delay. The facility's policy requires that emergency or STAT orders be filled and administered as soon as received or within two hours. However, these procedures were not followed, resulting in delayed administration of critical medications for the resident upon admission.
Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement fall prevention interventions for a resident identified as high risk for falls. The resident, who was confused, non-interviewable, and had a history of falls, was observed without required fall prevention devices such as floor mats, a non-slip device (dycem), and a specialized positioning wheelchair cushion, despite these being listed on her care plan and Caregiver communication sheet. Staff confirmed that the resident had recently slid from her wheelchair and that interventions were posted to inform staff, but these interventions were not in place during observation. The resident's care plan, last revised earlier in the month, included multiple active interventions specifically to address her high fall risk due to limited mobility, general weakness, dementia with behaviors, and a history of falls. Staff interviews revealed that the resident required constant supervision and redirection due to frequent unsafe movements in her wheelchair, and that she had experienced two recent falls in the dining room while under staff supervision. Incident reports indicated that the root causes of these falls were related to poor positioning and unsafe leaning in the wheelchair. Although the facility's policy required evaluation and modification of care plans after each fall, the required interventions were not consistently implemented, as evidenced by the absence of fall prevention devices during the surveyor's observation.
Deficiency in Social Worker Staffing
Penalty
Summary
The facility failed to employ a qualified full-time social worker, which is a requirement for facilities with more than 120 beds. At the time of the survey, the facility had a census of 175 residents. The social services department was understaffed, with only one individual, V6, who was not a Licensed Social Worker, covering the role. V6 had an Associate's Degree in Healthcare Management and Human Resources and experience in long-term care but was not qualified to fulfill the role of a licensed social worker. The facility had been without a Social Services Director since May 2024, and another social worker, V5, had been terminated in October 2024. The Assistant Administrator, V2, was temporarily assisting with social services tasks despite having no prior experience in the field. The facility's Administrator, V1, acknowledged the deficiency and stated that the position for a Social Services Director had been posted online for months without success in finding a qualified candidate. The facility had engaged two Licensed Clinical Social Workers (LCSWs) as consultants, but they were not present in the facility on a full-time basis. The facility's policy emphasized the importance of providing competent social work services, yet the current staffing did not meet the required qualifications or the facility's own standards. The lack of a qualified full-time social worker had the potential to affect all residents in the facility, as social services were responsible for critical tasks such as care plan meetings, MDS assessments, discharge planning, and providing support to residents and families.
Failure to Provide Timely and Thorough Incontinence Care
Penalty
Summary
The facility failed to provide timely and thorough incontinence care for a resident, identified as R3, who was reviewed for incontinence care. R3's medical history included diagnoses such as protein-calorie malnutrition, morbid obesity, dermatitis, vitamin B12 deficiency, anemia, hypertension, adjustment disorder, and abnormal uterine and vaginal bleeding. R3 was cognitively intact, always incontinent of bowel and bladder, and dependent on staff for toileting hygiene. The care plan indicated a risk of skin integrity alteration due to these conditions, and interventions included providing skin care after each incontinent episode. Despite this, R3 reported having to wait several hours for staff to respond to her call light for incontinence care, and during an observation, it took 31 minutes for a CNA to respond and provide care after R3 activated her call light. During the observed care, the CNA did not thoroughly clean R3, as R3 had to request a washcloth to clean herself further, revealing visible stool on the washcloth. The Director of Nursing (DON) stated that call lights should be answered within 5-10 minutes and emphasized the importance of keeping residents clean and dry, especially those with a history of pressure injuries or skin breakdown. The facility's policies on call light response and incontinence care were not adhered to, as the care provided did not ensure R3 was kept dry, comfortable, and free from odor, nor did it prevent skin breakdown as intended.
Failure to Timely Coordinate Guardianship for Resident
Penalty
Summary
The facility failed to coordinate with an outside agency in a timely manner to complete guardianship paperwork for a resident with severe mental illness. The resident, who was admitted to the facility in November 2024, had a history of homelessness and severe mental health issues, including delusional disorders, dementia, and major depressive disorder. The Adult Protective Services (APS) case manager made a referral for state guardianship in December 2024, but the facility did not provide the necessary updated physician's report in a timely manner, despite multiple requests from the APS case manager. The APS case manager repeatedly contacted the facility's staff, including the Business Office Manager and Social Services, to obtain the updated physician's report required for the guardianship process. Despite assurances from the facility's Administrator that the issue would be addressed, the report was not completed and submitted until March 2025, after several unsuccessful attempts and communication failures. The delay in providing the necessary documentation hindered the guardianship process, leaving the resident without a legal guardian to make critical decisions regarding her care and treatment. The facility's failure to document and communicate the APS requests and the status of the physician's report in the resident's medical record contributed to the delay. The Administrator was unaware of the APS requests until contacted by the Ombudsman in January 2025, and emails from the APS case manager went unnoticed in the Administrator's spam folder. The facility's Social Work Department Policy emphasizes timely and competent social work services, but the lack of coordination and communication in this case resulted in a significant delay in securing guardianship for the resident.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care to two residents, R2 and R5, who were dependent on assistance for activities of daily living. R2, a 69-year-old resident with intact cognition, reported being left in soiled briefs for extended periods on two occasions. On January 11, R2 was left sitting in urine and feces from 8:15 AM until 10:45 AM, and on another night, R2 was not changed from 10:30 PM until 4:00 AM despite using the call light. R2's care plan required keeping the resident clean and dry after each incontinent episode, which was not adhered to. R5, a 73-year-old resident with severe cognitive impairment, was found in bed with a urine-soaked brief that had blackish discoloration. The CNA responsible for R5 admitted to not checking on the resident since starting her shift at 7:00 AM, as she was busy passing breakfast trays. R5's care plan also required dependent assistance for toileting and providing incontinent care as needed. The Director of Nursing confirmed that incontinent care should be provided immediately upon request. The facility's guidelines emphasize the importance of keeping residents dry and comfortable to prevent skin breakdown.
Failure to Administer Significant Medications as Ordered
Penalty
Summary
The facility failed to administer significant medications as ordered to a resident with multiple serious health conditions, including type 2 diabetes mellitus, coronary artery disease, and hypertension. The resident, who is cognitively intact, reported that medications were sometimes not given as ordered. A review of the Electronic Medication Administration Record (EMAR) revealed that several medications, including Insulin Glargine, Nebivolol, Nifedipine, and Hydralazine, were not administered on specific dates in October 2024. The Director of Nursing confirmed that the EMAR was not signed by the nurses responsible for administering these medications, indicating a failure to follow the facility's medication administration policy. The Nurse Practitioner highlighted the significance of the missed medications, noting that they are crucial for managing the resident's diabetes, hypertension, and heart rate due to coronary artery disease. The facility's medication administration policy requires that all medications be documented on the Medication Administration Record (MAR) as they are prepared, and any deviations from the prescribed orders must be documented with a reason and, if necessary, the healthcare provider notified. The failure to administer these medications as ordered and the lack of proper documentation represent a significant medication error, potentially impacting the resident's health condition.
Failure to Obtain Vital Signs as Ordered
Penalty
Summary
The facility failed to obtain vital signs as ordered by a physician for a resident diagnosed with multiple sclerosis, COVID-19, peripheral vascular disease, and paraplegia. The physician's orders required vital signs to be taken every shift, every 12 hours, and later every 4 hours due to an active COVID-19 infection. However, the resident's medication administration record showed that vital signs were not taken on several occasions as ordered, specifically on 10/4/24, 10/8/24, 10/12/24, 10/15/24, and 10/18/24. Interviews with facility staff, including a Licensed Practical Nurse and the Director of Nursing, confirmed that vital signs should be obtained as per the physician's orders. The Director of Nursing acknowledged that there was no reason or excuse for the failure to obtain the vital signs as ordered. The facility's policy on physician's orders, revised in August 2024, mandates that physician orders are to be followed as written, highlighting a clear deviation from the established protocol.
Failure to Implement COVID-19 Isolation Precautions
Penalty
Summary
The facility failed to implement transmission-based precautions for a resident (R2) who tested positive for COVID-19. Despite R2's care plan and physician's orders indicating the need for contact and droplet isolation, the necessary precautions were not in place. On the day of the survey, there were no signs posted outside R2's room indicating isolation status, nor was there any personal protective equipment (PPE) available outside the room. R2, who has diagnoses including anxiety disorder, hemiplegia, major depressive disorder, and type 2 diabetes, confirmed being informed of their COVID-19 positive status and isolation requirement. Staff members, including an LPN and a CNA, were unaware of R2's COVID-19 status due to the absence of isolation signs and PPE. The Infection Preventionist confirmed that R2 should have been on isolation, and the Assistant Director of Nursing had to manually place the necessary signs and PPE outside R2's room. The LPN mentioned difficulties in locating isolation signs and PPE containers, despite management being notified. The facility's policy on COVID-19 transmission-based precautions was not adhered to, leading to a lapse in infection control measures.
Failure to Administer Wound Care Treatments as Ordered
Penalty
Summary
The facility failed to administer wound care treatments as ordered by the physician for two residents, R1 and R4, leading to a deficiency in nursing care. R1, who has multiple diagnoses including chronic kidney disease, a left breast open wound, and dementia, did not receive the prescribed wound treatment on several occasions in August and September 2024. The treatment was supposed to be applied every day shift, every other day, but the Treatment Administration Record (TAR) showed missed treatments on specific dates. The facility lacked documentation to confirm that the treatments were administered as ordered. R4, who was admitted with multiple diagnoses including chronic osteomyelitis, diabetes with foot ulcer, and heart failure, also did not receive wound care treatments as ordered. R4 refused treatment on several occasions, and the TAR indicated that treatments were not administered on additional dates. The physician had documented the severity of R4's condition, emphasizing the need for surgical intervention and the risks of refusing treatment. Despite this, the facility did not have documentation to show that the wound care treatments were administered as ordered. The wound care nurses, V3 and V8, were responsible for administering wound care during weekdays, with floor nurses taking over on weekends. However, the TARs for both residents showed multiple days without documentation of treatment administration. V3 confirmed the lack of documentation and acknowledged that if it isn't documented, it isn't done. The facility's Skin and Wound Management Guidelines require weekly review of TARs for completeness, which was not adhered to in this case.
Failure to Administer Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to administer pressure ulcer treatments as ordered by the physician for a resident with a sacral pressure ulcer. The resident, who has severe cognitive impairment and is dependent on staff for all activities of daily living, was admitted with multiple diagnoses including a sacral pressure ulcer. The care plan for the resident included specific interventions for the treatment of the sacral wound, but the facility did not document the administration of these treatments as ordered. The treatment administration records (TAR) for August and September 2024 show multiple instances where the resident did not receive the prescribed wound care treatments. The wound care nurse (WCN) confirmed that the TARs had multiple days without documentation of the wound treatments being administered. The WCN stated that if the treatment is not documented, it is considered not done. The facility's wound care nurse is present only on certain days, and when not available, the responsibility falls on the floor nurses. Despite the presence of a wound care nurse practitioner who visits weekly, the facility failed to ensure consistent wound care as ordered, leading to a deficiency in the care provided to the resident.
Failure to Assist Residents with Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with personal hygiene to residents who were unable to perform these tasks themselves. This deficiency was observed in five residents who required assistance with shaving due to various medical conditions. These residents included individuals with cognitive impairments, hemiplegia, hemiparesis, chronic obstructive pulmonary disease, dementia, and other conditions that limited their ability to perform activities of daily living (ADLs) independently. Resident R109, with diagnoses including hemiplegia and visuospatial deficits, was observed with long, unkempt facial hair and expressed a need for staff assistance with shaving. Despite being alert and verbally responsive, R109 was unable to shave himself and had requested help from the staff, which was not provided. Similarly, Resident R115, who was cognitively intact but required assistance due to a self-care deficit, also had long facial hair and had requested staff assistance for shaving, which was not fulfilled. Other residents, such as R453, R39, and R27, also exhibited long, unkempt facial hair and expressed the need for staff assistance with shaving. These residents had various impairments, including cognitive deficits, weakness, and mobility issues, which necessitated assistance with personal hygiene. Despite their requests and the presence of care plans indicating the need for assistance with ADLs, the facility staff did not provide the necessary support, leading to the observed deficiency in care.
Incorrect Portion Sizes for Mechanical Soft and Pureed Diets
Penalty
Summary
The facility failed to provide the correct portion sizes for mechanical soft and pureed cubed beef steak as specified in the menu spreadsheet for the lunch meal. This deficiency affected seven residents who were observed during dining. The meal prepared was cubed steak, carrots, and mashed potatoes, which was originally scheduled for a different day but was switched due to resident preference. The dietary staff used incorrect scoop sizes for serving the mechanical soft and pureed diets, resulting in residents receiving less protein than required. Specifically, a #12 scoop was used for the mechanical soft diet instead of the #6 scoop, and a #8 scoop was used for the pureed diet instead of the #6 scoop, leading to insufficient portion sizes. The facility's scoop size portion control chart indicated that the #6 scoop should provide 5+1/3 ounces, while the #8 and #12 scoops provide 4 ounces and 2+2/3 ounces, respectively. The Food Service Manager justified the use of smaller scoops by stating that only 4 ounces of protein were required, contradicting the menu spreadsheet. The Registered Dietitian later confirmed that the facility should adhere to the scoop sizes specified in the menu to meet daily protein requirements. The diet order report confirmed the dietary needs of the affected residents, highlighting the inconsistency between the planned and actual meal service.
Failure to Provide Pureed Consistency Vegetables
Penalty
Summary
The facility failed to provide pureed consistency vegetables to residents on pureed diets, affecting eight residents in the sample. On September 24, 2024, the facility's menu listed Capri Mix Vegetables as the vegetable option for lunch. During meal preparation, the Assistant Food Service Manager, V10, was observed preparing pureed meals. V10 blended cooked zucchini but did not achieve the required smooth consistency, as the green rinds remained hard and needed to be chewed. Both V10 and the Dietary District Manager, V11, acknowledged that the pureed product did not meet the required consistency, which should be similar to pudding or applesauce. The Registered Dietitian, V5, confirmed that the pureed consistency should be smooth with no lumps, and the facility should have pureed the Capri mix vegetables as per the menu. The facility's diet order sheet indicated that the affected residents were on pureed consistency diets. The recipe for Capri Mix Vegetables required blending until smooth, which was not achieved, leading to the deficiency in providing appropriate food consistency for residents on pureed diets.
Failure to Offer Pneumococcal Vaccine to Residents
Penalty
Summary
The facility failed to adhere to its policy of offering the pneumococcal vaccine to residents, as evidenced by the lack of documentation for five residents. These residents, who were part of a sample of 33, included individuals with various medical conditions such as type 2 diabetes, heart failure, cerebral infarction, and chronic obstructive pulmonary disease. The facility's records did not show that these residents were offered or refused the pneumococcal vaccine, which is a requirement according to the facility's policy and CDC guidelines. For instance, one resident with multiple diagnoses, including type 2 diabetes and heart failure, was admitted to the facility, but there was no documentation to show that the pneumococcal vaccine was offered or refused. Similarly, another resident with cerebral infarction and hypertension also lacked documentation of being offered the vaccine. In another case, a resident who had previously refused the PCV13 vaccine did not have documentation to confirm this refusal or to show that the vaccine was offered annually as per the facility's policy. The facility's policy, reviewed in January 2024, mandates that all residents be screened annually and offered the PPSV23 and/or PCV13 vaccines. However, the facility did not have the necessary documentation to demonstrate compliance with this policy for the residents in question. The Director of Nursing acknowledged that these residents should have been offered the pneumococcal vaccine upon admission, but the records did not reflect this action.
Inconsistencies in POLST and EMR Orders for Life-Sustaining Treatment
Penalty
Summary
The facility failed to ensure that physician orders for life-sustaining treatment were consistent with the residents' POLST forms, which led to discrepancies in the residents' EMRs. For Resident 8, the POLST form dated August 1, 2017, indicated a DNR status, but the EMR contained an order for Full Code dated July 18, 2024. This inconsistency was confirmed by the Social Services staff member, who was unsure about the responsibility for advanced directives following the departure of the Social Services Director. The Director of Nursing acknowledged that the EMR should have reflected the DNR status as per the POLST form. Similarly, for Resident 95, the POLST form signed by the provider on October 4, 2024, indicated a DNR status, but the EMR still showed an order for Full Code from February 7, 2023. The Director of Nursing confirmed that an order for DNR should have been entered into the EMR once the POLST was signed. The facility's policy on advanced directives and DNR orders requires that such orders be entered into the EMR using a specific template, but this was not followed, leading to the deficiencies identified.
Failure to Conduct Level II PASARR for Resident with New Mental Disorder Diagnosis
Penalty
Summary
The facility failed to refer a resident with a new diagnosis of a mental disorder to the appropriate state-designated authority for a Level II PASARR (Preadmission Screening and Resident Review). This deficiency was identified for one of eight residents reviewed for PASARR in a sample of 33. The electronic medical record showed that the resident was admitted to the facility without any psychiatric or mood disorders as per the Minimum Data Set (MDS) dated January 19, 2022. However, a subsequent MDS indicated diagnoses of anxiety disorder, depression, psychotic disorder, and schizophrenia. The OBRA-I Initial Screen dated January 13, 2022, also showed no mental illness at the time of screening. Despite a significant change in the resident's condition, including a new diagnosis of schizophrenia while hospitalized in June 2022, the facility did not conduct a required Level II PASARR screen. Interviews with facility staff confirmed that the resident should have been rescreened following the new diagnosis.
Failure to Hold Timely Care Plan Conferences
Penalty
Summary
The facility failed to document and hold interdisciplinary care plan conferences at required intervals for three residents, as per their policy. Resident R116, who was admitted with multiple diagnoses including seizure disorder and bipolar disorder, had not received any therapy and was awaiting discharge. The resident had been in the facility for three months without a documented care plan meeting, and the facility could not produce an invitation for such a meeting. The care plan for R116 had not been updated or revised since the initial target date. Resident R52, admitted with conditions such as hemiplegia and diabetes, had a care plan invitation dated March 13, 2024, but no subsequent invitations were issued, exceeding the 90-day interval requirement. Similarly, Resident R87, with diagnoses including end-stage renal disease and diabetes, had a five-month gap between care plan conferences, also exceeding the required interval. The care plans for both residents had not been updated or revised since their respective target dates. The facility's policy requires care plan meetings approximately 14 days after admission and every 90 days thereafter, which was not adhered to in these cases.
Failure to Apply Hand Splint for Resident with Hemiplegia
Penalty
Summary
The facility failed to adhere to the treatment recommendations for a resident who required the use of a hand splint to prevent further decrease of range of motion and contractures. The resident, who was admitted with diagnoses including hemiplegia and hemiparesis following a non-traumatic intracerebral hemorrhage, was assessed to need a splint on the right hand. The care plan and physician orders specified that the splint should be applied in the morning and removed in the evening. However, observations on multiple occasions revealed that the resident was not wearing the splint, and staff were unaware of its location. Interviews with staff indicated a lack of awareness and responsibility for ensuring the splint was applied. A CNA was unaware of the splint requirement, and the Assistant Restorative Director acknowledged that the restorative CNAs responsible for applying splints were on vacation, leading to a lapse in care. Despite searching, staff could not locate the splint, which was supposed to be stored in the restorative gym or the resident's room. This failure to follow the prescribed treatment plan was contrary to the facility's policy on the use of adaptive devices to prevent deformities or further contractures.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to properly assess and administer pain medication to two residents, R20 and R82, as ordered by their physicians. R20, who has multiple diagnoses including paraplegia and chronic pain syndrome, reported not receiving her prescribed oxycodone medication on the evening of September 20, 2024. Despite requesting the medication from an agency nurse, R20 was told she had already received it, which was not the case. The medication administration record confirmed that R20 did not receive any pain medication that evening, and she only received oxycodone the following morning after complaining of pain to another nurse. R82, who has a history of chronic knee pain, was also inadequately managed for pain. Despite having an order for acetaminophen to be administered as needed, R82 had not received this medication since February 12, 2024, even though he reported significant knee pain on multiple occasions. The care plan for R82 did not identify his knees as a source of pain, and there was a lack of documentation and assessment regarding his pain management needs. The facility's policy on pain management emphasizes the importance of assessing and managing pain to promote resident comfort and dignity. However, the facility failed to adhere to this policy, resulting in inadequate pain management for both R20 and R82. The Director of Nursing acknowledged the issue and attempted to investigate the situation, but the agency nurse involved could not be reached for further clarification.
Failure to Document Resident's Death
Penalty
Summary
The facility failed to document essential information regarding a resident's death in accordance with its policy. The resident, who was admitted with multiple diagnoses including unspecified dementia, chronic diastolic and systolic congestive heart failure, lymphedema, morbid obesity, and a pressure ulcer of the right heel, died in the facility. The last entry in the resident's electronic medical record was made at 07:01 AM, noting a follow-up for medication and a need to contact hospice about gurgling sounds. However, there was no subsequent clinical assessment, notification to family, hospice, or the physician, nor was there documentation of the time of death, disposition of the body, or a final discharge note. The Director of Nursing confirmed that the facility's policy requires documentation of a resident's assessment, interventions, notifications, postmortem care, and body disposition when a resident is transitioning while on hospice.
Inadequate LVAD Care and Training
Penalty
Summary
The facility failed to ensure that staff were adequately trained to care for a resident with a Left-Ventricular Assist Device (LVAD) prior to the resident's admission. Upon admission, the resident did not have specific orders for the LVAD, and the staff did not implement the necessary LVAD orders once they were received. The resident, who had multiple complex medical conditions including heart failure and the presence of a heart assist device, was admitted without the staff being prepared to manage her LVAD needs. The resident's MAP (Mean Arterial Pressure) was recorded as being above the recommended range of 60-90 mmHg on 28 occasions between July 15 and August 27, yet the VAD coordinator was only notified four times. Additionally, the resident's LVAD dressing changes were inconsistently documented, with only six changes recorded and twelve instances where changes were not documented. The facility also failed to consistently monitor the resident's weight, with only two weights documented during the period in question. Interviews with facility staff revealed that the nurses responsible for the resident's care had not received training on LVAD management until after the resident's admission. The Assistant Director of Nursing and the Director of Nursing were aware of the lack of LVAD orders upon admission and the need for staff training, but the training was not conducted until six days after the resident's arrival. The facility did not have a specific policy for LVAD care, relying instead on protocols from the VAD clinic, which were not adequately followed or documented.
Sink Detachment Incident Due to Maintenance Oversight
Penalty
Summary
The facility failed to ensure a sink was securely attached to the wall, resulting in an incident involving a resident. The resident, who had no cognitive impairment, reported that the sink fell on her while she was attempting to stand up to brush her teeth. She was unable to reach the emergency cord, which delayed assistance from the staff. The sink broke into several pieces upon falling, and the incident was documented by a Licensed Practical Nurse who took a photo of the broken sink. Prior to the incident, another resident had reported the sink being loose to the nursing staff on two occasions, but no action was taken to address the issue. The Maintenance Director stated that he was not informed about the loose sink and emphasized that maintenance requests should be recorded in a maintenance book at the nurses' stations. The facility's preventative maintenance plan requires regular inspections, but it appears that the loose sink was not addressed in a timely manner, leading to the incident.
Inadequate Elopement Risk Management and Staff Training
Penalty
Summary
The facility failed to maintain an updated and universal list of residents identified as high risk for elopement, which is crucial for ensuring their safety and supervision. The Director of Nursing initially reported nine residents as wanderers, but later inconsistencies were found in the number of residents identified as high risk for elopement. Different staff members had access to various lists with conflicting information about which residents were at risk, and some lists included residents who had been discharged. This inconsistency in record-keeping indicates a lack of coordination and communication within the facility. Additionally, the facility did not adequately train its staff on the elopement policy. Interviews with staff members, including a CNA and a housekeeper, revealed that they were unaware of the facility's elopement code or which residents were at risk. A newly hired CNA also reported not receiving any in-service training on elopement. This lack of training and awareness among staff members further exacerbates the risk of elopement incidents, as staff are not equipped with the necessary knowledge to prevent such occurrences. The facility's policy on elopement, which was reviewed in September 2023, outlines procedures for identifying and managing residents at risk for elopement. However, the facility failed to adhere to these procedures, as evidenced by the outdated and inconsistent lists of at-risk residents and the lack of staff training. The policy requires that residents identified as at risk for elopement be reviewed quarterly and that a master list be maintained and updated by social services. The failure to implement these procedures effectively contributed to the deficiency identified in the report.
Improper Suctioning Procedure for Hospice Resident
Penalty
Summary
The facility failed to ensure that a resident receiving hospice services had a physician's order for suctioning, was properly assessed before and after suctioning, and was suctioned in a manner that maintained the resident's comfort. The incident involved a resident who was readmitted to the facility and was under hospice and comfort care. During a visit by the resident's family, a registered nurse used a suction device inappropriately by inserting a thin plastic tube into the resident's throat, causing the resident to gag. The hospice staff indicated that suctioning should only be performed around the mouth and not in a manner that would cause discomfort. The facility's respiratory therapist confirmed that the suctioning method used was incorrect and that the resident did not have a physician's order for suctioning. The hospice administrator also stated that suctioning was not part of the resident's care plan and should not have been performed in such a manner. Additionally, the registered nurse did not document any assessment of the resident's condition before or after the suctioning procedure. The facility's suctioning policy requires verification of a physician's order and proper assessment and documentation, which were not followed in this case.
Failure to Use Two-Person Assist Results in Resident Injury
Penalty
Summary
The facility failed to use a two-person assist to safely turn a resident (R2) who required such assistance during incontinence care. On 4/28/2024, a CNA (V8) was providing care to R2 alone, despite R2's care plan indicating the need for a two-person assist due to her limited mobility and the use of an air mattress, which can be slippery. As a result, R2 slid out of bed and sustained a laceration to her forehead, requiring sutures. The incident was confirmed through observations, interviews, and record reviews, including statements from the CNA, the Nurse Practitioner (V10), and the Director of Nursing (V2), all of whom acknowledged the necessity of a two-person assist for R2's care. R2's care plan, dated 4/23/2024, clearly listed bed mobility and ADL toileting as requiring a two-person assist. Despite this, the CNA attempted to provide care alone, leading to the accident. Following the fall, R2 was sent to the hospital, where she received nine sutures for the laceration on her forehead. The facility's failure to adhere to the care plan's specified interventions directly resulted in the resident's injury, highlighting a significant lapse in ensuring adequate supervision and safety measures for residents requiring specialized care.
Failure to Ensure Timely Transport to Dialysis
Penalty
Summary
The facility failed to ensure a resident was sent to dialysis on time, resulting in the resident's treatments being cut short. The resident, who requires hemodialysis for end-stage renal disease (ESRD), reported that he has been late to his dialysis appointments in the last couple of weeks, causing his treatments to be shortened. The dialysis nurse confirmed that the resident's treatment time is 4 hours and 15 minutes, but on one occasion, the resident only received 3 hours and 55 minutes of treatment due to late arrival. The dialysis technician also noted that the resident's treatments have been cut short by 20-30 minutes on several occasions because of late arrival. The issue was attributed to staffing shortages, which delayed the resident's transfer to dialysis using a mechanical lift. On one specific instance, the certified nursing assistant (CNA) responsible for getting the resident ready for dialysis had to wait for additional staff to assist with the transfer, resulting in the resident being late for his treatment. The resident's care plan, dated 4/26/2024, indicates that he has renal insufficiency related to ESRD and is receiving hemodialysis. The facility's dialysis schedule for 5/13/2024 shows a start time of 5:15 AM for the resident, but the treatment did not start until 5:43 AM. The delay in transport and subsequent late arrival to dialysis has led to the resident not receiving the full prescribed treatment time, which is critical for removing the right amount of toxins and fluid from his body. The facility staff acknowledged the issue and cited short staffing as a contributing factor to the delays in getting the resident to his dialysis appointments on time.
Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility failed to notify the physician of a change in a resident's condition in a timely manner, resulting in a delay in treatment for a resident who experienced increased pain and a decrease in activities of daily living after sustaining a right hip fracture following a fall. The resident initially fell and was diagnosed with a right wrist fracture. Despite multiple complaints of hip pain from the resident during physical therapy sessions and assessments by various staff members, the physician was not promptly informed, leading to a delay in ordering an X-ray and diagnosing the hip fracture. The resident, who had severe cognitive impairment and multiple medical conditions including type 2 diabetes, chronic kidney disease, and Alzheimer's disease, was initially independent with ambulation but became bed-bound and in significant pain after the fall. Physical therapists and nurses documented the resident's pain and inability to perform certain movements, but communication lapses between shifts and failure to follow up on physician notifications contributed to the delay in addressing the resident's hip pain. The facility's policy required the physician to be paged and, if not reached within 30 minutes, to be notified again, with the Medical Director being contacted if there was still no response. However, this protocol was not effectively followed, as evidenced by the resident's prolonged pain and delayed diagnosis of the hip fracture. The resident's condition was only addressed after the nurse practitioner was finally informed and ordered an X-ray, which confirmed the hip fracture.
Failure to Address Resident Grievance Regarding Shattered Phone
Penalty
Summary
The facility failed to file a grievance and follow up on a concern raised by a resident (R3) regarding his shattered phone. R3 reported to a CNA (V12) that his phone screen was shattered after being taken to the washroom. R3 then informed the Social Services staff (V10) and left a voicemail for the Administrator (V1), but received no follow-up. V10 acknowledged being informed about the incident but admitted to not filing a grievance form or notifying the Administrator. V1 only became aware of the issue during the survey and noted that the facility's phone system was unable to receive voicemails, which had been communicated to the residents. R3's medical records indicate he has multiple diagnoses, including hemiplegia, hemiparesis, dysphagia, type 2 diabetes mellitus, anxiety disorder, benign prostatic hyperplasia, and hypertension. His Minimum Data Set (MDS) showed he was cognitively intact but required varying levels of assistance for daily activities. The facility's grievance policy mandates that grievances be addressed within 72 hours, but this protocol was not followed in R3's case, leading to the deficiency noted in the report.
Medication Reconciliation Failure Upon Readmission
Penalty
Summary
The facility failed to correctly transcribe and reconcile a resident's hospital discharge medication orders upon readmission, leading to the resident being prescribed and administered the wrong medication regimen. This included an opioid, antibiotic, and anticoagulant medications, which resulted in the resident experiencing a change in condition that required transfer to the local hospital emergency room and subsequent hospital admission. The resident, who had multiple diagnoses including Alzheimer's disease and bipolar disorder, was readmitted to the facility with severe cognitive impairment and required substantial assistance with activities of daily living (ADLs). The error occurred when a facility nurse processed the resident's admission orders and mistakenly used discharge orders from the hospital that had a different patient's name on the page. This led to the resident receiving medications that were not previously ordered, including Buprenorphine, Apixaban, Cephalexin, Albuterol Sulfate, Cardizem LA, Metoprolol tartate, Venlafaxine HCL ER, and Levothyroxine sodium. The physician and nurse practitioner involved were unaware of the discrepancies and signed off on the incorrect medications, leading to the resident's deteriorating condition. The Director of Nursing became aware of the medication error when the hospital requested clarification of the resident's medication orders. The resident's emergency department note documented that the resident had received completely different medications than originally ordered, resulting in severe lethargy and other symptoms. The resident was admitted to the hospital for further observation and later discharged to a different nursing facility.
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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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