California Terrace
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 2829 South California Blvd, Chicago, Illinois 60608
- CMS Provider Number
- 145625
- Inspections on file
- 61
- Latest survey
- March 28, 2026
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at California Terrace during CMS and state inspections, most recent first.
A facility failed to maintain an effective roach control program and sanitary waste management, as evidenced by staff reports of frequent roach sightings, a resident’s report of daily roaches in his room and on his bed and wheelchair, and direct observation of multiple roaches in that resident’s room. Housekeeping and maintenance leaders acknowledged that roach sightings are often reported but admitted they do not review pest sighting logs on the units and sometimes do not request as-needed pest control visits after sightings. The dumpster area was found with open, overflowing containers and scattered food waste, in direct conflict with facility policies requiring sealed trash bags, closed and clean dumpsters, and environmental conditions that prevent insect harborage.
The facility failed to maintain a clean, safe, and homelike environment as required by its housekeeping policy, affecting all residents. Multiple residents, including individuals with moderate cognitive impairment and others with intact cognition and significant medical conditions, reported dirty rooms, overflowing trash, and filthy dining chairs. Surveyors observed dirty bathroom floors, brownish stains on walls and floors, dried food and spills on floors and tables, stained and caked-on food in chair crevices, dust and old food on heating units, and black or brown dust on ceilings and vents across several floors. Broken tables and seats were left in resident-accessible dining areas, and shower and privacy curtains were missing in some areas. Housekeeping and supervisory staff acknowledged that floors were not being mopped daily, chairs were not being cleaned, day rooms were not consistently cleaned after meals, trash was not always emptied daily, and that staffing and workload sometimes prevented daily room cleaning, contrary to the written housekeeping guidelines.
A resident with schizoaffective disorder, bipolar type, muscle wasting, and rheumatoid arthritis, and moderate cognitive impairment was found with clothing in a closet that was not folded and included stained pants and shirts, making it unclear which items were clean or dirty. An LPN reported that CNAs are responsible for separating clean and dirty clothes after laundry but that this was not done, and both the LPN and a CNA acknowledged that mixing clean and dirty clothes is not acceptable and can leave the resident in smelly, uncomfortable clothing. This situation conflicted with the facility's Resident Rights policy requiring a safe, clean, comfortable, homelike environment and care that promotes dignity and quality of life.
A resident with epilepsy, unsteadiness, and muscle wasting was pushed and knocked down by another cognitively intact resident with serious mental illness and documented behavior problems, after a verbal altercation involving a third resident escalated despite staff presence and attempted separation. The injured resident sustained a scalp hematoma requiring hospital evaluation. Interviews showed that while a CNA attempted to intervene, the push occurred as staff turned away, and the Administrator later characterized the event as an accident. The Social Service Director acknowledged not reviewing PASRR Level I/II documents for the involved residents, contrary to facility policy requiring PASRR review to identify behavioral needs and guide care planning, contributing to the failure to prevent resident‑to‑resident physical abuse.
The facility failed to maintain an adequate supply of clean linen, including towels and washcloths, resulting in two residents not receiving timely hygiene care and showers. One resident with severe cognitive impairment and extensive medical comorbidities required incontinence care after a BM but remained in bed waiting to be changed while a CNA reported having no towels or washcloths and resorted to using pieces of a cut-up sheet. Another cognitively intact resident reported that when he wanted to shower in the morning, towels were sometimes unavailable. Surveyors observed empty linen rooms and carts on upper floors, staff confirming delayed or missing linen deliveries, and very limited stock in the central linen room, while laundry logs documented minimal or no towels delivered to certain floors, demonstrating a systemic linen shortage affecting resident cleanliness and comfort.
The facility failed to prevent and control a roach infestation, resulting in live roaches being found in resident rooms and beds. Multiple residents with intact cognitive status, as well as family members and staff, reported or observed roaches in mattresses, personal items, and throughout living areas. Maintenance logs and staff interviews confirmed the ongoing presence of pests despite regular extermination efforts, and the facility did not effectively implement its pest control policy.
Several residents with significant mobility and self-care deficits experienced prolonged delays in staff response to call lights, with some waiting up to an hour or more for assistance. Additionally, multiple residents reported that broken furnishings, such as bedside tables and bathroom grab bars, were not repaired for weeks or months, despite maintenance policies and care plan interventions requiring prompt attention. Staff interviews and record reviews confirmed that maintenance issues were not consistently reported or addressed in a timely manner.
Surveyors found persistent stains, debris, and unaddressed maintenance issues throughout the facility, including dirty dining rooms with leftover food and trash, stained and damaged ceiling panels, and chipped paint. Multiple residents reported slow maintenance response and inadequate housekeeping, while staff interviews confirmed lapses in daily cleaning and environmental checks, resulting in unsanitary and unhomelike conditions.
A resident with left-sided weakness and a history of falls was repeatedly observed without a required wheelchair leg strap, despite care plan directives. The resident and others encountered hazards due to multiple cracks and uneven surfaces on the patio ramp, causing mobility devices to get stuck and nearly resulting in a fall. Staff were aware of the missing leg strap and the ramp hazard, but neither issue was addressed, contrary to facility policy.
Two cognitively intact residents engaged in a verbal and physical altercation after a dispute over TV and radio volume, resulting in one resident being struck on the head with a dumbbell and sustaining a laceration that required staples. Staff responded after being alerted by another resident, and documentation confirmed the incident as physical abuse. Staff were aware of abuse prevention protocols and had received relevant in-service training.
A resident with multiple medical and psychiatric diagnoses was subjected to verbal and emotional abuse by another resident, who became aggressive and attempted to strike him during an altercation over personal belongings. Staff and LPNs confirmed the incident, which was not prevented despite facility policies on abuse prevention and resident safety.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents. The environment did not meet required safety standards, resulting in insufficient oversight.
The facility failed to ensure timely responses to nurse call systems, affecting seven residents. Observations showed that calls were often ignored or delayed, with one resident found in need of care and another having to use a personal phone for assistance. Staff were unaware of calls due to a covered call system screen, despite a policy requiring prompt responses.
The facility failed to maintain a functional call light system, affecting residents on the third and fourth floors. Observations revealed unplugged or malfunctioning call light phones, leading to delayed staff responses. Residents reported long wait times for assistance, with one experiencing a medical emergency. Staff acknowledged the risks of a non-functional system, and maintenance issues were noted.
A resident with severe cognitive impairment was physically abused by another resident in the dining room, resulting in a laceration and hospitalization. The aggressive resident, who was mildly cognitively impaired, was difficult to redirect and verbally aggressive. The facility failed to prevent the altercation, leading to a deficiency in care standards.
The facility failed to ensure cleanliness in the third and fourth floor shower rooms, affecting residents' use of these areas. Surveyors found feces and a soiled diaper on the floors, and residents reported similar observations. Housekeeping and nursing staff had unclear responsibilities for cleaning, leading to unsanitary conditions. The facility's policies require maintaining a clean and safe environment, which was not met.
The facility failed to post accurate and timely daily nursing staffing information, affecting all 230 residents. The staffing information was not posted on time on one day and was posted with an incorrect year and missing census on another. The Staffing Coordinator admitted to these oversights, while the DON and Administrator confirmed the requirement for accurate postings at the start of each shift.
The facility failed to ensure cleanliness in the residents' common shower room on the second floor, affecting 66 residents. A surveyor observed debris and dirt, including plastic bottles and towels, on the floor. The Nurse Manager and Housekeeping staff acknowledged the unsanitary conditions and the infection control concern. The DON confirmed the expectation for cleaning between uses to prevent infection spread.
The facility failed to maintain a pest-free environment, with cockroaches observed in resident rooms on the 2nd floor. Multiple residents reported frequent sightings of roaches, and the nurse manager confirmed the issue. Facility inspection reports highlighted cleanliness problems and food left around, attracting pests. The administrator had no comment on pest control measures.
A resident with a history of cellulitis and an amputated leg developed maggots in a foot wound due to inadequate wound care. Despite hospital recommendations for daily betadine and gauze dressing, the facility's records show inconsistent treatment. The resident reported a painful ingrown toenail, but the Nurse Supervisor did not assess the foot, and the Wound Care Nurse refused a bandage change. The Nurse Practitioner confirmed maggots in the wound, attributing it to moisture attracting flies.
A facility failed to implement and supervise a care plan for a resident with self-harm and suicidal behaviors, resulting in multiple incidents of self-injury. The resident accessed dangerous objects like a shaving blade and a spoon to cut himself and punched a glass-framed picture, requiring hospitalization. The care plan was not updated, and no interventions were in place to prevent further harm, despite the resident's known history and triggers related to smoking restrictions.
A resident with schizophrenia and bipolar disorder exhibited aggressive behavior, leading to altercations with two other residents. Despite staff intervention, the situation escalated, resulting in physical harm to one resident. The facility's failure to provide adequate supervision and address the risk of abuse in care plans contributed to these incidents.
The facility failed to report two incidents involving a resident and other residents, where physical and verbal altercations occurred. Despite staff presence, including the Administrator and Assistant Director of Nursing, these incidents were not reported to the State Agency as required by the facility's policy. The Director of Nursing, working remotely, was not informed, highlighting a breakdown in communication and policy adherence.
The facility failed to maintain food safety standards, including daily temperature checks for coolers and freezers, proper storage of scoops, and use of beard guards by dietary staff. Additionally, expired test strips were used for sanitizing utensils, potentially compromising food safety. These deficiencies were acknowledged by staff and highlighted by the consultant dietary manager.
The facility failed to maintain an effective pest control program, as dumpsters were observed overflowing with trash and lids left open, allowing potential pest entry. Additionally, a gap between the loading dock doors was noted, further compromising pest control efforts. Staff acknowledged these issues, which contradict the facility's policies on sanitation and pest prevention.
A resident with cognitive impairments and chronic respiratory issues was found with a portable oxygen tank improperly stored on the floor, contrary to facility policy. Staff acknowledged the risk of combustion from the free-standing tank, which should have been secured in a holder or designated area.
The facility failed to properly label, date, and contain oxygen equipment for several residents requiring respiratory care. Observations showed outdated and improperly stored nebulizer masks and humidifier bottles, contrary to facility policy requiring weekly changes. Staff acknowledged the oversight and the importance of proper equipment maintenance for infection control.
The facility failed to accurately account for controlled substances and did not dispose of expired medications, affecting four residents. Discrepancies in drug counts and expired insulin were found during a survey. LPNs admitted to not following procedures for narcotic accountability and medication storage, leading to these deficiencies.
A facility failed to implement Enhanced Barrier Precautions (EBP) for residents with conditions requiring such measures, and a CNA did not follow proper glove and washcloth changing protocols during ADL care. The Infection Preventionist and nursing staff showed inconsistent understanding of EBP requirements, and there were no EBP orders in residents' records, risking infection spread.
The facility failed to maintain cleanliness in the fourth floor resident pantry, affecting 65 residents. Observations revealed substances on the microwave, overflowing garbage, and dried substances on walls and floors. Staff interviews confirmed that housekeeping is responsible for cleaning, but the schedule was not followed, resulting in unsanitary conditions.
The facility failed to provide a homelike environment due to insufficient linens and towels, leading to residents using dirty pillowcases and sheets. Privacy and cleanliness were compromised as some residents lacked privacy curtains, and several rooms were missing window curtains, affecting residents' comfort and privacy.
A resident with severe cognitive impairment and multiple diagnoses was found with dirty fingernails, indicating a failure in providing adequate nail care. The resident expressed a desire for nail cleaning, and staff acknowledged that nail care should be part of daily activities and showers. Facility policies require maintaining residents' nails short, smooth, and clean.
The facility failed to monitor personal refrigerator temperatures for two residents, leading to a deficiency in food safety. Despite policies requiring daily checks, inconsistencies were found in the monitoring process, with staff providing conflicting information about responsibilities. This oversight affected a cognitively intact resident and another with cognitive impairments, potentially exposing them to spoiled or expired food.
A resident's call device was found non-functional, affecting their ability to request assistance. The issue was confirmed by the Social Service Director, and another resident noted the device had been broken for months. The affected resident's care plan emphasized the need for a working call light due to fall risks.
A facility failed to assess a resident's ability to self-administer medication, resulting in medication being left in the resident's room. The resident, with diagnoses of type 2 diabetes and hypertension, was found with split potassium pills and could not recall which nurse provided them. The facility's policy requires assessment and physician approval for self-administration, which was not documented for this resident.
A facility failed to provide timely incontinence care to a resident, as a CNA prioritized other tasks over immediate care. The delay resulted in the resident having several dried stools on their skin, indicating prolonged exposure to soiled conditions. The DON confirmed that such delays could affect residents' skin and self-esteem.
The facility failed to maintain a functioning call light system for two residents, one with a broken call light and another quadriplegic resident without a specialized call light. Staff relied on intermittent fixes and hourly monitoring instead of providing accessible call light options.
The facility failed to provide residents with needed supplies for ADLs, such as linens, affecting all 252 residents. Multiple residents and staff reported a significant shortage of linens, with observations confirming nearly empty linen carts. Budget cuts and improper handling of dirty linens contributed to the issue.
The facility failed to ensure food items were covered, labeled, and dated, and did not enforce the use of beard restraints among dietary staff, potentially leading to foodborne illnesses. Multiple dietary staff members with beards were observed not wearing beard restraints, and various food items were found uncovered, unlabeled, and undated in the reach-in cooler and walk-in freezer.
The facility failed to properly dispose of garbage, resulting in overflowing dumpsters with open lids and trash scattered around. Gaps in the delivery and kitchen doors were also observed, potentially allowing rodents to enter. The Dietary Manager acknowledged these issues, which were in violation of the facility's policies on safe food handling and pest control.
The facility failed to ensure that four residents received adequate nail care, resulting in long fingernails with a brownish-gray substance underneath. Despite policies and job descriptions emphasizing the importance of personal hygiene, staff interviews revealed that nail care was insufficiently provided.
The facility failed to ensure resident safety by not removing disposable razors from rooms and not providing adequate supervision for medications. Four residents were found with razors, and two residents had medications left at their bedside without orders to self-administer. Staff confirmed these items should not have been left in the rooms.
The facility failed to ensure that two licensed personnel conducted a physical inventory of controlled substances at each change of shift, affecting eight residents on the 4th Floor Team 1 and Team 2 medication carts. Specific shifts in March 2024 had blank spaces on the controlled substances check forms, indicating non-compliance with the facility's protocols.
A resident with multiple diagnoses, including diabetes and schizophrenia, was observed eating lunch from a tray placed on their bed due to the unavailability of a bedside table. The facility's Administrator and DON acknowledged this practice was unacceptable and contrary to the facility's policies on dignity and respect.
The facility failed to provide clean linen for two residents, one of whom had stained sheets and reported being told there were no clean sheets available. Staff confirmed linen shortages, and the Director of Nursing stated that linen should be changed daily, but this standard was not met.
The facility failed to report new skin alterations and set the low air loss mattress correctly for a resident. A CNA did not report a new skin opening on a resident's coccyx, and the mattress was set for a higher weight than the resident's actual weight. The Wound Care Nurse was unaware of the wound, leading to a delay in appropriate treatment.
A facility failed to properly disconnect and flush a resident's feeding tube after feeding. The LPN did not follow the required procedure, leaving the feeding tube attached with formula present. The resident had a diagnosis of dysphagia and CVA, requiring total assistance with eating and tube feeding. The facility's policy lacked procedures for continuous feeding, contributing to the oversight.
The facility failed to properly log refrigerator temperatures for two residents' personal refrigerators and did not provide a thermometer in one resident's refrigerator. Staff interviews revealed inconsistencies in temperature checks and documentation, despite the facility's policy requiring daily monitoring. One resident was cognitively intact, while the other had moderately impaired cognition. This failure has the potential to affect all 71 residents in the sample.
The facility failed to follow its abuse prevention policy and manage a resident with a history of aggression, leading to a physical altercation that caused significant injuries to another resident. Despite documented aggressive behaviors, the facility did not adequately monitor or separate the aggressor, resulting in ongoing safety concerns.
The facility failed to ensure that call lights were accessible for two residents, leading to deficiencies in accommodating their needs and preferences. Both residents, who had limited mobility and required assistance, were found with call lights on the floor and out of reach, contrary to their care plans and the facility's call light policy.
Failure to Maintain Effective Roach Control and Sanitary Waste Management
Penalty
Summary
The facility failed to maintain an effective pest control program to eliminate roaches, affecting one of three residents reviewed and potentially all 247 residents. A housekeeping aide reported seeing roaches during routine cleaning, most recently about one week prior on the fourth floor, and stated she uses roach spray in resident rooms when she sees many roaches and reports sightings continuously to the Administrator. Another housekeeping aide reported last seeing roaches about two months earlier in resident rooms and stated that after he reports sightings to the Administrator, the pest control company typically comes the following week. During observation of a resident in his room, the resident reported seeing roaches daily, especially at night, and stated he could not eat food in his room without roaches crawling into it and that roaches were on his bed and chair at night and felt as if they were biting him. At that time, the surveyor observed multiple roaches crawling under and on the resident’s motorized wheelchair and on the wall near the bathroom. When this was brought to the housekeeping aide’s attention, he acknowledged they were roaches and commented that they appeared because there was “company,” indicating awareness of an ongoing roach presence in the environment. The Housekeeping Director stated that staff and residents frequently report roach sightings to him and the Maintenance Supervisor, that pest control visits occur bimonthly and as needed, and that there is a pest control sighting book on each unit. However, he admitted that he and the Maintenance Supervisor do not check these books and that only the pest control company reviews them during bimonthly visits, meaning there could be unaddressed sightings. He also acknowledged seeing a roach in the pantry one week earlier and killing it without contacting pest control for an as-needed visit. The Maintenance Supervisor confirmed that staff and residents report sightings to him and the Housekeeping Director, denied knowledge of the pest control books, and reported seeing a roach in a shower room about a month earlier without notifying pest control until their next scheduled visit. Additionally, inspection of the dumpster area revealed open and overflowing dumpsters with trash and old food scattered from the ramp to the dumpster, contrary to the facility’s policies requiring sealed trash bags, closed and clean dumpsters, and grounds free of debris, as well as the pest control policy assigning responsibility for coordinating pest control and maintaining conditions that prevent insect harborage.
Failure to Maintain Clean, Safe, and Homelike Environment Throughout Facility
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment in accordance with its housekeeping policy, affecting all 244 residents. Multiple residents with varying cognitive and physical conditions reported and were observed living in unclean conditions. One resident with intact cognition and a history of diabetes, frostbite, gangrene, and partial toe amputation refused to sit on dining room chairs, describing them as “nasty and filthy” and stating he had never seen them cleaned. Another resident reported that floors were usually swept but not mopped, garbage was not taken out daily, and that overflowing trash in the room made him feel bad; his bathroom and toilet floors were observed to be dirty with brownish material on the toilet bowl and floor, and his garbage can was overflowing. Surveyors observed widespread environmental uncleanliness and disrepair throughout the facility’s common areas and resident rooms. On multiple floors, dining rooms and day rooms had dried food particles on floors and tables, chairs with brownish stains and caked-on food in crevices, spills on floors, dust and old food particles on heating units, and black or brown dust on ceilings and vents. Broken tables and seats were present in resident-accessible dining areas, including two broken tables on one floor and broken seats in another dining room. On one unit, there were no shower curtains on the large end of the shower room separating two showers, and in one resident’s room, large brownish stains were observed on the walls and floors, with food particles around the baseboards and no privacy curtains present. Facility staff interviews corroborated the observations of inadequate cleaning and environmental maintenance. A housekeeper stated that floors on one floor were not clean, with used paper towels, food particles, and cups on the floor, and that dining room seats were very dirty with brownish stains and caked-on food and dirt; she reported she had not cleaned chairs since starting work and had not seen anyone else clean them, and that floors that were supposed to be mopped daily had not been mopped. The housekeeping supervisor reported having ten full-time housekeepers and two floor technicians and stated that day rooms and parlors were supposed to be cleaned after every meal, that seats with urine and food grease stains should be cleaned daily, that garbage cans were supposed to be emptied every day, that shower curtains should always be present for privacy, and that broken furniture should not be left in resident areas. Another housekeeping staff member stated she was assigned 30 rooms per day and sometimes could not clean all of them, even though rooms were supposed to be cleaned daily. The facility’s housekeeping policy required daily trash removal, cleaning of surfaces when dust or soiling was visible, and adherence to daily cleaning assignments to maintain a clean and orderly environment, which was not followed as evidenced by the observed conditions.
Failure to Maintain Clean and Organized Clothing for a Resident
Penalty
Summary
The facility failed to honor a resident's rights to dignity and a clean, homelike environment by not managing the resident's clothing in a clean and organized manner. The resident had diagnoses including schizoaffective disorder, bipolar type, muscle wasting and atrophy at multiple sites, and rheumatoid arthritis, and an MDS BIMS score of 9/15 indicating moderate cognitive impairment. During an observation, the resident was lying in bed, was teary eyed, and difficult to understand. When the first-floor supervisor LPN opened the resident's closet, the resident's clothes were found not folded, with whitish pants showing a large brownish stain in the crotch area and other pants and shirts observed with stains. The LPN stated it was difficult to know which clothes were clean or dirty. The LPN explained that CNAs are responsible for maintaining resident clothing after it is returned from laundry and are supposed to store clean clothes separately from dirty clothes, and that it is not acceptable to mix clean and dirty clothes because staff or residents would not know which items are clean. The LPN also stated that if the resident wears dirty clothes, he can smell and that the resident needs supervision choosing which clothes to wear, although he dresses himself. A CNA similarly stated that it is not acceptable to mix the resident's clean and dirty clothes because everything will smell and the resident will not be comfortable wearing smelly clothes, which can make him feel horrible. The facility's Resident Rights policy dated 11/18 documents that the facility must be safe, clean, comfortable, and homelike, and that the facility must treat residents with dignity and respect and care for them in a manner that promotes their quality of life.
Failure to Prevent Resident-to-Resident Physical Abuse and Inadequate PASRR Utilization
Penalty
Summary
The deficiency involves the facility’s failure to prevent and protect a resident from resident‑to‑resident physical abuse. On the date of the incident, one resident (R9), who had a PASRR Level II indicating serious mental illness and a care plan noting risk for potential abuse due to behavior problems, poor impulse control, and poor boundaries, became involved in a verbal interaction with another resident (R13). A third resident (R8) exited his room and became involved in the exchange. According to the facility’s reported incident document, R8 became disrespectful in his choice of words and stepped in front of R9 as R9 turned to go back to his room. Staff were present and attempted to separate the two residents, but R9 reached around staff and pushed R8, causing R8 to stumble and fall. R8’s medical history included generalized epilepsy with status epilepticus, unsteadiness on feet, muscle wasting and atrophy at multiple sites, and other lack of coordination, placing him at higher risk for injury from a fall. Following the push, R8 was sent to the hospital, where records documented a small left posterior parietal scalp hematoma with scalp swelling. R9’s behavior note documented that he admitted shoving R8 after R8 threatened him. During a later interview, R9 stated that R8 “went crazy and touched” him, threatened to beat and kill him, and that he pushed R8 in response. Another resident (R13) recalled arguing with R9 and that R8 became involved, and reported that R9 later told him he had pushed R8, though R13 did not witness the actual push. Staff interviews revealed gaps in the facility’s processes related to abuse prevention and PASRR follow‑up. A CNA (V6) described that, when witnessing residents arguing or being triggered, he would separate them, notify the nurse and supervisors, redirect them, move them to a different location, and monitor them. The Administrator (V1), who witnessed the event, stated that she saw staff (a CNA) go over and separate the residents, and then saw R9 push R8 as the CNA turned away, characterizing the incident as an accident and stating she did not think it could have been prevented. The Social Service Director (V16), responsible for PASRR Level II follow‑up, stated he had not reviewed the PASRR Level I or II documents for either R8 or R9, despite the facility’s PASRR policy requiring review of PASRR documents to determine problems, needs, and issues to be addressed in care planning. The facility’s Abuse and Retaliation Prevention policy defined physical abuse as the infliction of injury on a resident by non‑accidental means requiring medical attention, including controlling behavior through corporal punishment, underscoring that the push and resulting injury met the facility’s own definition of physical abuse.
Failure to Maintain Adequate Linen Supply for Resident Hygiene and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not ensuring adequate clean linen, including towels and washcloths, for residents on the 3rd and 4th floors. One resident, a [AGE]-year-old with hemiplegia, cerebrovascular disease affecting the left dominant side, aphasia, cerebral infarction, type 2 diabetes with retinopathy, constipation, hypertension, GERD, hyperlipidemia, unspecified dementia, psychotic disturbance, mood disturbance, and anxiety, had a Brief Interview for Mental Status score indicating severe cognitive impairment and care plan goals to remain clean, dry, and odor free with appropriate cleansing and peri-care after each incontinent episode. On one survey day, a CNA reported that this resident needed incontinence care after a bowel movement but there were no towels or washcloths available, and the CNA was observed holding pieces of a cut-up sheet, stating she would have to use this to clean residents and that she had not been able to change residents all day due to lack of linen. The resident was observed lying in bed waiting to be changed while the CNA apologized and explained the absence of linen and towels. Another resident, a [AGE]-year-old with bipolar disorder, schizoaffective disorder, asthma, cocaine dependence with cocaine-induced mood disorder, and hypertension, was cognitively intact per a recent Brief Interview for Mental Status. This resident reported that sometimes when he wanted to shower in the morning, there were no towels available on the floor. During the survey, a CNA on the 4th floor showed the clean linen room, which had no fresh linen, including towels, and stated that linen had not been delivered yet for her 7:00 a.m. to 3:00 p.m. shift and that residents complain when they want to shower and there are no towels. Laundry staff confirmed that the 4th floor had not yet received its linen delivery and that deliveries to other floors had occurred earlier in the morning, with the 4th floor typically receiving linen around 10:00 a.m. Multiple staff interviews and observations documented ongoing linen shortages affecting both floors. On one day, the 3rd floor linen room had no towels, washcloths, or linens to make beds, and linen carts were empty, with CNAs stating they had not received linen/towels yet and were using a small amount left from the previous shift, causing some residents to wait for care until linen arrived. The housekeeping/laundry supervisor acknowledged that the 3rd floor linen cart should have been delivered earlier, that linen supplies were low at the end of the month while awaiting a new order, and that complaints about needing linen, towels, and washcloths were common. The facility’s extra linen room was observed to contain only limited remaining stock, and laundry logs showed minimal or no towels delivered to certain floors on specific dates, supporting the finding that the facility failed to maintain adequate linen supplies necessary to honor residents’ rights to a safe, clean, comfortable, and homelike environment.
Failure to Prevent and Control Roach Infestation in Resident Rooms
Penalty
Summary
The facility failed to prevent and control a live roach infestation in resident rooms, resulting in roaches being observed in beds and throughout resident living areas. Multiple residents, all with cognitive capacity as indicated by their BIMS scores, reported or were observed to have roaches in their rooms, on their mattresses, and in personal spaces such as wheelchairs. Family members and staff confirmed the presence of roaches, with one family member describing roaches running throughout a resident's mattress and emerging from clean sheets. Staff, including CNAs and housekeeping, reported that roaches were prevalent on multiple floors and were especially noticeable when food was present or beds were moved for cleaning. Maintenance logs documented repeated reports of roaches and bed bugs in resident rooms over several months. Interviews with facility leadership, including the administrator, DON, and housekeeping director, confirmed awareness of the ongoing roach problem. Staff stated that they were instructed to report pest sightings on maintenance logs, but the issue persisted despite regular extermination efforts. The facility's pest control policy, which requires prevention and control of insects, was not effectively implemented, as evidenced by continued reports and direct observations of live roaches in resident areas. The administrator attributed the infestation in part to resident behaviors and external factors but acknowledged the ongoing problem.
Delayed Call Light Response and Untimely Furnishing Repairs
Penalty
Summary
Surveyors identified that the facility failed to answer call lights in a timely manner for four residents and did not accommodate timely repairs for furnishings for three residents, as observed through interviews, record reviews, and direct observation. One resident, who is cognitively intact but has quadriplegia and requires substantial assistance with daily activities, reported that staff often took up to an hour to respond to call lights, sometimes turning off the light and leaving without providing assistance. During the survey, the resident's call light was activated and not answered for 46 minutes, despite visible indicators at the nurses' station and in the hallway. Other residents also reported similar delays, with one stating that staff response could take up to an hour and a half, and another noting that staff would turn off the call light and not return for hours. In addition to delayed call light responses, the facility failed to address maintenance issues in a timely manner. One resident had a broken bedside table with peeling plastic that had not been fixed since July, while another had a missing wheel on a bedside table that had been broken for two to three weeks. A third resident reported a missing grab bar in the bathroom, which had not been repaired for months. Maintenance staff stated they rely on nursing staff to report broken items, but no work orders were found for these issues, and the maintenance supervisor was unaware of the problems. Facility policies require prompt response to call lights and timely reporting and repair of maintenance issues. Care plans for the affected residents included interventions for staff to respond promptly to requests for assistance and to ensure the use of appropriate assistive devices. Despite these documented expectations, staff failed to meet the required standards, resulting in prolonged wait times for assistance and unresolved maintenance concerns that impacted residents' ability to safely and independently perform daily activities.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for multiple residents, as evidenced by persistent stains, debris, and unaddressed maintenance issues across several floors. Observations revealed brown and dark tan splatter stains on central walls, stained and bubbled ceiling panels in resident rooms, and chipped paint and peeling floor trimming. Dining rooms on multiple floors were found with food particles, debris, dirty trays from previous meals, and other items such as paper towels, plastic bags, and bath towels left on the floor during meal times, even as residents were present and eating. Residents reported that maintenance was slow to address repairs and that housekeeping did not adequately clean, particularly with sweeping. Staff interviews confirmed that maintenance relies on staff to report environmental issues and does not conduct daily checks in resident rooms. The Maintenance Supervisor was unaware of the stained and bubbled ceiling panels in several rooms, despite the potential for ceiling panels to fall if leaks were present. Housekeeping staff were expected to clean dining rooms after each meal and maintain cleanliness in hallways and resident rooms daily, but these tasks were not consistently performed as observed during the survey. Facility policies required daily cleaning assignments, prompt removal of trash, and regular environmental tours or safety audits to identify and address concerns such as watermarks, peeling paint, and damaged wall coverings. However, visual quality control and adherence to these guidelines were lacking, resulting in unsanitary and unhomelike conditions that affected multiple residents throughout the facility.
Failure to Maintain Safe Environment and Follow Care Plan for Fall Risk Residents
Penalty
Summary
The facility failed to follow a resident's plan of care and did not recognize or address accident hazards in the patio area. One resident with significant musculoskeletal impairments, including left hemiplegia, muscle weakness, and a history of repeated falls, was dependent on staff for wheelchair mobility and required a leg strap to prevent the left leg from falling off the wheelchair footrest. Despite care plan interventions specifying the use of a leg strap, the resident was observed multiple times without the strap, and both nursing and aide staff were unaware of its whereabouts. The resident reported previous incidents of the left leg falling out of the footrest, particularly when traversing the ramp in the patio area, which was described as uneven and cracked. Observations and interviews revealed that the patio ramp had multiple cracks and uneven surfaces, with height differences of up to 0.75 inches, causing difficulties for several residents using wheelchairs and rollators. Multiple residents, all identified as fall risks, experienced their mobility devices getting caught on the cracks, and one resident nearly tipped over as a result. Staff and residents reported that the ramp had been a known hazard for an extended period, with loose pieces of cement present. The facility's own policies required regular environmental safety audits and removal of hazards, but these were not effectively implemented, resulting in ongoing risks to residents' safety.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to prevent a resident-to-resident physical assault involving two cognitively intact residents. One resident was watching television and listening to the radio when he got up to assist his roommate with a lunch tray and accidentally fell on him. This led to a verbal altercation over the volume of the TV/radio, during which both residents exchanged profanities. The situation escalated when one resident attempted to hit the other with a food tray, prompting the roommate, who was bed bound, to strike the first resident on the back/side of the head with a dumbbell. Staff were alerted to the commotion by another resident and responded immediately, finding one resident bleeding from a head injury. The injured resident was transported to the hospital by paramedics and received two staples for a laceration to the head before returning to the facility the same day. Documentation reviewed included hospital emergency department records, witness statements, and assessments for aggressive behaviors. The incident was reported as an assault, and the dumbbell used in the altercation was confiscated. Staff interviews confirmed knowledge that hitting constitutes resident-to-resident physical abuse, and records indicated that in-service training on abuse prevention had been conducted prior to the incident.
Failure to Protect Resident from Verbal and Emotional Abuse
Penalty
Summary
A deficiency occurred when a resident (R5) was not protected from verbal and emotional abuse by another resident (R1). R1, who has diagnoses including Chronic Obstructive Pulmonary Disease, Primary Insomnia, Major Depressive Disorder, and Paranoid Schizophrenia, became verbally aggressive towards R5, who also has multiple diagnoses such as Chronic Obstructive Pulmonary Disease, Undifferentiated Schizophrenia, Type 2 Diabetes Mellitus, Anxiety Disorder, and Hypertension. The incident took place in the dining room, where R1 was observed yelling at R5, accusing him of taking his cigarettes. Multiple staff members, including LPNs and a CNA, confirmed that R1 was shouting, screaming, and moving aggressively towards R5, and at one point attempted to strike him. Staff were made aware of the situation and intervened to redirect R1. Despite the facility's policies on resident safety, supervision, and abuse prevention, the incident demonstrates a failure to prevent verbal and emotional abuse. The facility's own staff, including the Assistant Director of Nursing and the Administrator, acknowledged that no form of abuse should occur within the facility. Documentation and interviews confirm that the altercation was not prevented or adequately managed to protect R5 from abuse, as required by facility policy and regulatory standards.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to prevent potential incidents. No additional details regarding the specific hazards, the individuals involved, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Respond to Nurse Call Systems
Penalty
Summary
The facility failed to ensure reasonable accommodations for residents' needs by not providing accessible and timely responses to nurse call systems for seven residents out of a sample of twenty. Observations and interviews revealed that residents experienced significant delays in receiving assistance after activating their nurse call systems. In one instance, a resident was found with a strong urine odor and stated that the nurse call was not answered promptly, resulting in a delay in receiving necessary care. Another resident activated the nurse call during an interview, and despite the call light being visible, it went unanswered for ten minutes as the nurses at the station were unaware due to the call system screen being covered by a sheet of paper. Further interviews with residents indicated a pattern of neglect, with reports of calls being ignored or turned off by staff. One resident mentioned having to use a personal cell phone to contact the front desk for assistance. The facility's policy requires that all call lights be answered promptly by any staff within their scope of practice, yet this was not adhered to, as evidenced by the staff's lack of awareness and response to activated calls. The administrator was unaware of the issue with the covered call system screen and the staff's failure to respond to calls, despite the facility having a policy in place to ensure timely responses to residents' needs.
Call Light System Malfunction and Monitoring Failure
Penalty
Summary
The facility failed to ensure that the call light system was functional and adequately monitored, affecting the residents on the third and fourth floors. During observations, it was noted that a resident's call light was illuminated without an audible alert at the nurse's station, and the call light system phone was found unplugged. This issue was observed on both the third and fourth floors, where the call light phones were either unplugged or not functioning properly, leading to a lack of awareness among staff about residents' needs. Interviews with staff revealed that the call light system was supposed to alert them with an audible sound and display the resident's room number when activated. However, due to the phones being unplugged or malfunctioning, these alerts were not being received. Staff members acknowledged the potential risks of a non-functional call light system, including delayed responses to emergencies. Maintenance issues were reported, such as a broken cord that frequently disconnected the phone, and a call light that continuously illuminated without being pressed. Residents reported significant delays in response times, with one resident waiting 45 minutes for assistance while experiencing a medical emergency, and another often waiting up to two hours. The facility's policy emphasized the importance of responding to call lights promptly, yet the system's failures and the staff's lack of awareness of these issues contributed to the deficiency. The resident council meeting minutes also documented complaints about delayed responses to call lights, indicating ongoing concerns about the system's reliability.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to prevent and protect a resident from resident-to-resident physical abuse, affecting one resident out of three reviewed for abuse. On the day of the incident, a resident with severe cognitive impairment was involved in an altercation with another resident who was mildly cognitively impaired. The altercation occurred in the dining room, where the aggressive resident struck the other resident in the face, resulting in a laceration near the eyebrow. The aggressive resident was reported to have been verbally aggressive and difficult to redirect by staff. The incident was witnessed by another resident and staff members, who reported that the aggressive resident punched the other resident hard enough to cause a loud impact. The staff responded by separating the residents and assessing their conditions. The injured resident was found to have a laceration and was sent to the hospital for further evaluation, where additional medical issues were identified, including signs of multiple infarctions and possible stroke. The aggressive resident was also sent to the hospital for psychiatric evaluation due to their behavior. The facility's administrator was informed of the incident and initiated a report to the state agency. The facility's policy on abuse prevention emphasizes the residents' right to be free from abuse, neglect, and mistreatment. Despite this policy, the facility's failure to prevent the altercation and protect the resident from harm constitutes a deficiency in their care standards.
Failure to Maintain Cleanliness in Shower Rooms
Penalty
Summary
The facility failed to maintain cleanliness and sanitation in the third and fourth floor shower rooms, potentially affecting all 33 residents on the third floor and 60 residents on the fourth floor. During a survey, a brown colored substance, identified as feces, was observed on the floor of the fourth-floor east side shower room. Additionally, a blue soiled diaper was found on the floor of the third-floor east side shower room. Interviews with residents revealed that feces were occasionally observed on the shower room floors, leading to at least one resident avoiding the use of the shower facilities. Housekeeping staff and nursing personnel provided conflicting accounts of responsibility for cleaning the shower rooms. The fourth-floor housekeeper indicated that either the floor tech or housekeeper could clean the shower rooms, while the third-floor RN stated that housekeeping staff were mainly responsible. The Housekeeping Director confirmed that shower rooms should be cleaned two to three times a day and as needed, and it was unacceptable for feces and soiled diapers to be present. The facility's policy and job descriptions emphasize maintaining a clean, safe, and comfortable environment, which was not upheld in this instance.
Failure to Post Accurate Daily Nursing Staffing Information
Penalty
Summary
The facility failed to post the daily nursing staffing information accurately and in a timely manner, affecting all 230 residents. On the morning of January 6th, the surveyor observed that the daily nursing staffing information was not posted upon entrance to the facility. It was later posted near the receptionist area, but not at the required time. On the following day, the staffing information was posted with an incorrect year and lacked the resident census. The Staffing Coordinator, responsible for posting the information, admitted to missing the census and posting the information late. The Director of Nursing and the Administrator both confirmed that the daily staffing should be posted at the beginning of the shift, around 7 a.m., and should be complete and accurate. The facility's job descriptions for the Staffing Coordinator, Director of Nursing, and Administrator outline their responsibilities in ensuring appropriate staffing levels and accurate postings. However, the failure to adhere to these responsibilities resulted in incomplete and inaccurate staffing information being posted, which is a deficiency in meeting the regulatory requirements for nursing facilities.
Failure to Maintain Cleanliness in Shower Room
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the residents' common shower room on the second floor, which has the potential to affect all 66 residents residing there. During an investigation, a surveyor observed debris and dirt on the floor of the shower room, including plastic bottles, gloves, paper, plastic bags, clothes, and towels. The Nurse Manager acknowledged the unkempt condition of the shower room and identified it as an infection control concern. The Housekeeping staff stated that the shower room should be disinfected after each use for sanitary purposes. The Director of Nursing confirmed that the expectation is for the shower room to be cleaned between uses to prevent the spread of infection. The facility's housekeeping guidelines emphasize maintaining a safe and sanitary environment for residents, staff, and visitors.
Cockroach Infestation in Resident Rooms
Penalty
Summary
The facility failed to ensure that residents' rooms were free of cockroaches, affecting all 66 residents on the 2nd floor. During an investigation, a surveyor observed a cockroach crawling near a resident's bed, and multiple residents reported seeing roaches frequently in their rooms. The nurse manager acknowledged the roach problem, and the facility administrator had no comment regarding pest control measures. Facility service inspection reports from October 2024 documented issues with cleanliness and food being left around, which attracted pests. These reports also noted the presence of roaches in residents' rooms, the 2nd floor nurses' station, and the front lobby. The facility's pest control policy aims to prevent or control insects and rodents from spreading disease, but the reports indicate that these measures were not effectively implemented.
Inadequate Wound Care Leads to Maggot Infestation
Penalty
Summary
The facility failed to provide appropriate wound care for a resident, leading to the development of maggots in a foot wound. The resident, who is cognitively intact and has a history of cellulitis, spinal stenosis, and an amputated left leg, reported a painful ingrown toenail to the Nurse Supervisor, who did not assess the foot. The resident also requested a bandage change from the Wound Care Nurse, which was refused. The resident expressed distress over the presence of maggots in the wound prior to a leg amputation. The Nurse Practitioner confirmed seeing maggots in the wound and noted that moisture could attract flies, leading to maggot infestation. The facility's records indicate inconsistent wound care treatment. Hospital records recommended daily betadine and gauze dressing, but the facility's Medication Administration Records show limited administration of these treatments. The Wound Care Nurse and Nurse Practitioner documented the presence of infection and necrosis in the resident's toe, with hospital records noting a necrotic toe and possible osteomyelitis. Despite these issues, the facility's wound care policy aimed to promote healing, but the lack of adherence to recommended wound care practices contributed to the deficiency.
Failure to Implement Care Plan for Resident with Self-Harm Behaviors
Penalty
Summary
The facility failed to follow its care plan policy to develop, implement, and supervise a newly admitted resident with self-injurious and suicidal behavioral concerns. This resulted in multiple incidents where the resident gained access to dangerous objects and harmed himself. The resident, who has a history of self-harm and various psychiatric diagnoses, was able to access a shaving blade and a spoon, which he used to cut his arm. Additionally, the resident punched a glass-framed picture, causing an injury that required hospitalization and sutures. The resident's care plan was not updated to address these incidents, and no interventions were put in place to prevent further self-harm. Despite the resident's known history of self-harm and suicidal ideations, the facility did not conduct adequate risk assessments or implement necessary safety measures. The care plan lacked specific interventions to manage the resident's behavior, and staff failed to provide the necessary supervision to prevent access to harmful objects. Interviews with staff revealed that the resident's behavior was often triggered by the inability to smoke, leading to agitation and self-harm. Staff members expressed concerns about the appropriateness of the facility for the resident, given his behavioral issues and the lack of effective interventions. The facility's environment, including the presence of glass-framed pictures, posed additional risks for the resident, which were not adequately addressed in the care plan.
Failure to Prevent Resident Abuse and Ensure Adequate Supervision
Penalty
Summary
The facility failed to protect residents from verbal and physical abuse by another resident, leading to multiple altercations involving residents with cognitive impairments and aggressive behaviors. Resident 1, diagnosed with schizophrenia and bipolar disorder, exhibited aggressive and noncompliant behaviors, including verbal threats and physical aggression towards other residents. Despite being sent for a psychiatric evaluation, Resident 1 returned to the facility and continued to display aggressive behavior, resulting in altercations with Residents 11 and 12. Resident 12, who also has a history of cognitive impairment and confrontational behavior, engaged in a verbal altercation with Resident 1, which escalated to a near-physical confrontation. Staff intervened to separate the residents, but the situation was not adequately de-escalated, leading to further incidents. Resident 11, who has a history of aggressive behavior, was involved in a physical struggle with Resident 1 over a cane, which required staff intervention to prevent harm. The facility's failure to provide adequate supervision and intervention allowed Resident 1 to strike Resident 2 in the face, causing physical harm. Despite the presence of staff, the incidents were not effectively managed, and the care plans for the involved residents did not adequately address the risk of abuse. The facility's policies on supervision and abuse prevention were not effectively implemented, contributing to the occurrence of these incidents.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to adhere to its policy of reporting allegations of abuse to the administrator and the State Agency, as evidenced by two incidents involving a resident, R1, which were not reported. The first incident involved R1 and another resident, R11, who were seen tussling over a cane, resulting in R11 striking R1 twice in the face. Despite the presence of several staff members, including the Administrator, Assistant Director of Nursing, and CNAs, the incident was not reported to the State Agency. The second incident involved a verbal altercation between R1 and another resident, R12, which escalated to a physical confrontation invitation outside the facility. Again, this incident was not reported to the State Agency, and the facility's records showed no reportables for these incidents. Interviews with staff revealed that the Director of Nursing was working remotely and was not informed of the incidents, while the Assistant Director of Nursing was onsite and in charge. The facility's policy mandates that any suspicion or allegation of abuse must be reported immediately to the administrator and documented, with a thorough investigation to follow. However, the Administrator and Director of Nursing confirmed that no reports were made for the incidents involving R1, R11, and R12, indicating a failure in communication and adherence to the facility's abuse prevention policy.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to several food safety and sanitation protocols, which could potentially affect all residents. During an inspection, it was observed that the walk-in cooler and freezer temperature logs had missing entries, indicating that temperatures were not checked daily. This lapse was acknowledged by a dietary aide, who confirmed the absence of temperature records for an entire day. Additionally, a scoop used for dry food was found improperly stored on the lid of a bin, which could lead to cross-contamination. The dietary aide admitted that the scoop should have been stored in a designated area to prevent such risks. Further observations revealed that dietary staff were not wearing appropriate beard guards, which is necessary to prevent hair from contaminating food. One dietary aide admitted to removing the beard guard, while another incorrectly believed it was unnecessary in the dish machine area. Moreover, the facility was using expired test strips to check the concentration of sanitizing chemicals, which could compromise the effectiveness of utensil sanitation. The dietary aide was unaware of the expiration and could not locate new test strips. The consultant dietary manager confirmed the importance of these protocols, emphasizing the need for daily temperature checks, proper storage of scoops, use of beard guards, and unexpired test strips to ensure food safety.
Pest Control Deficiency Due to Improper Dumpster Management
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by several observations and interviews. On October 6, 2024, during an initial tour of the dumpster area, it was noted that each of the two large dumpsters had one open lid. A dietary aide confirmed that the lids should not be open to prevent animals from accessing the dumpsters. Additionally, a gap was observed between the two doors leading to the loading dock, which was acknowledged by the assistant maintenance staff. The gap in the doors and the open dumpster lids were identified as potential entry points for pests such as mice and cockroaches. On October 7, 2024, further observations revealed that the dumpsters were overflowing with trash and the lids remained open. The assistant maintenance staff indicated that housekeeping or other staff responsible for disposing of trash were expected to close the dumpster lids to prevent animal access. The facility's policies on food and nutrition services sanitation and pest control emphasize the importance of securely covering dumpsters and ensuring that all building openings are tight-fitting to prevent pest entry. These failures in adhering to the facility's policies have the potential to affect all residents by allowing pests to enter the facility.
Improper Storage of Oxygen Tank Poses Hazard
Penalty
Summary
The facility failed to ensure a safe environment free from hazards for a resident, identified as R189, who was observed with a portable oxygen tank on the floor in their room. R189, who has chronic obstructive pulmonary disease and acute respiratory failure with hypoxia, requires continuous oxygen therapy. The resident's cognitive impairments, indicated by a BIMS score of 7, further necessitate careful supervision and adherence to safety protocols. Despite these needs, the oxygen tank was not stored in a holder, posing a potential risk of falling and causing a hazardous situation. The Director of Nursing and a Registered Nurse acknowledged the improper storage of the oxygen tank, emphasizing the potential dangers of a free-standing tank, including the risk of combustion. The facility's policy on oxygen administration and storage clearly states that oxygen cylinders must be stored in designated areas and not left free-standing in residents' rooms. This oversight in following established safety guidelines and regulations for oxygen storage could potentially affect all 64 residents on the third-floor unit.
Failure to Properly Label, Date, and Contain Oxygen Equipment
Penalty
Summary
The facility failed to properly label, date, and contain oxygen equipment, affecting four residents who required respiratory care. Observations revealed that a resident with asthma, heart disease, and epilepsy had a nebulizer mask dated from August and a humidifier bottle from June, both not properly contained. Despite the resident's cognitive intactness, the equipment was not changed as per facility policy, which mandates weekly changes. A registered nurse confirmed the oversight and acknowledged the need for equipment to be covered to prevent dust and bacteria accumulation. Another resident with COPD, heart failure, and cerebrovascular disease was observed with an undated humidifier bottle attached to an oxygen concentrator. The resident's cognitive impairment was noted, and the facility's Director of Nursing stated that the humidifier bottle should be changed weekly and dated, contrary to a nurse's claim of monthly changes. The lack of proper dating and changing of the equipment was highlighted as a potential infection risk. A third resident with COPD and acute respiratory failure was found with an oxygen nebulizer mask dated from June and not contained. The resident, who was cognitively intact, used the oxygen when experiencing breathing difficulties. A licensed practical nurse acknowledged the outdated equipment and the importance of changing and containing it for sanitation purposes. The facility's policy requires weekly changes and proper storage of oxygen equipment to maintain infection control, which was not adhered to in these cases.
Controlled Substance and Medication Storage Deficiencies
Penalty
Summary
The facility failed to maintain an accurate account of controlled substances and did not dispose of expired medications, affecting four residents. During a survey, discrepancies were found in the controlled drug records for three residents. For one resident, the Lorazepam count was off by one tablet, while another resident's Lacosamide count was also short by one tablet. Similarly, a third resident's Hydromorphone count was incorrect by one tablet. Additionally, a bottle of Lantus Insulin for another resident was found to be expired, yet still stored in the medication cart. Interviews with the facility's LPNs revealed lapses in following the facility's policies for narcotic accountability and medication storage. One LPN admitted to not signing out medications immediately after administration due to being rushed, while another confirmed that expired medications should be returned to the pharmacy or discarded. The facility's policies require narcotics to be signed out when administered and counted by two nurses at shift changes, and expired medications to be removed and destroyed. These procedures were not consistently followed, leading to the deficiencies observed.
Inadequate Infection Control and EBP Implementation
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, specifically Enhanced Barrier Precautions (EBP), for several residents. Four residents, identified as having conditions such as obstructive and reflux uropathy, pressure ulcers, and end-stage renal disease, were not placed on EBP despite having medical conditions that warranted such precautions. During a survey, it was observed that there were no Personal Protective Equipment (PPE) bins or EBP signs near or on the doors of these residents' rooms, indicating a lack of adherence to the facility's policy on EBP. Additionally, a Certified Nursing Assistant (CNA) failed to follow proper glove and washcloth changing protocols during Activities of Daily Living (ADL) care for a resident. The CNA used only one pair of gloves and two washcloths to wash and dry the resident's entire body, which is against the facility's policy that requires changing gloves and washcloths between different body sites to prevent cross-contamination. The Director of Nursing confirmed the expectation for staff to change gloves and use different washcloths for different body parts to avoid spreading bacteria or germs. The Infection Preventionist and other nursing staff demonstrated a lack of understanding of EBP requirements, as evidenced by inconsistent statements regarding the necessity of gowns and gloves during high-contact resident care activities. The facility's policy clearly outlines the need for gowns and gloves during such activities, especially for residents with wounds or indwelling medical devices. The absence of EBP orders in the residents' records further highlights the facility's failure to ensure compliance with infection control protocols, potentially putting all residents at risk of infection spread.
Unsanitary Conditions in Fourth Floor Resident Pantry
Penalty
Summary
The facility failed to maintain cleanliness and sanitation in the fourth floor resident pantry, which has the potential to affect the 65 residents residing on that floor. During an observation on October 6, 2024, the surveyor noted multiple areas of brown, green, and white substances on the microwave, both inside and outside. Additionally, the garbage was overflowing, with trash observed on the floor surrounding the garbage can. The walls and floor of the pantry also had dried brown substances, indicating a lack of regular cleaning and maintenance. Interviews with facility staff revealed that the pantry is used by both residents and employees, and it is the responsibility of the housekeeping department to ensure its cleanliness. The Nursing Supervisor acknowledged the unclean state of the pantry and indicated that housekeeping should address it. The Housekeeping/Laundry Director confirmed that the housekeeping team is responsible for the upkeep of the pantry, which is supposed to be cleaned a few times a day. However, the observed conditions suggest that the cleaning schedule was not adequately followed, leading to the unsanitary state of the pantry.
Inadequate Linens and Privacy Measures in Facility
Penalty
Summary
The facility failed to provide a homelike environment for several residents due to inadequate supply of linens and towels. Residents reported not having enough towels to dry themselves after showers and having to use dirty pillowcases and sheets because clean ones were not available. Observations confirmed that some residents had discolored and dirty pillowcases, and staff acknowledged the shortage of linens. The laundry department's records showed insufficient distribution of linens across the facility's floors, and staff admitted that the supplies were not enough to meet the residents' needs. Additionally, the facility did not maintain privacy and cleanliness standards in residents' rooms. One resident's privacy curtain was stained, and another resident did not have a privacy curtain at all. The housekeeping director was unaware of these issues, despite policies requiring regular room inspections. Staff confirmed that they often had to wait for linens to be available before providing care, further indicating a lack of adequate supplies. Furthermore, several residents' rooms lacked window curtains, affecting their privacy and comfort. Residents expressed dissatisfaction with the lack of curtains, which allowed excessive light into their rooms and compromised their privacy. The maintenance director acknowledged that all rooms should have curtains but was unaware of the missing ones. The facility's administrator also confirmed that rooms should have curtains to ensure residents' privacy and dignity, but could not explain why some rooms were missing them.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to provide adequate nail care for a resident diagnosed with Chronic Obstructive Pulmonary Disease, Vascular Dementia, Major Depressive Disorder, Metabolic Encephalopathy, and Lack of Coordination. The resident, who has a severe cognitive impairment with a Brief Interview of Mental Status score of 03, was observed by a surveyor to have a greyish black substance under the fingernails on both hands. The resident expressed a desire to have his fingernails cleaned. A Licensed Practical Nurse acknowledged that nail care should be performed daily, while the Director of Nursing stated that nursing staff are responsible for providing nail care during activities of daily living and showers, which occur twice a week. A Certified Nursing Assistant confirmed that nail care is provided as needed, especially if the fingernails are dirty or need trimming. The facility's policy and job description for Certified Nursing Assistants include maintaining residents' nails short, smooth, and clean.
Failure to Monitor Personal Refrigerator Temperatures
Penalty
Summary
The facility failed to adequately monitor the temperature logs of personal refrigerators for two residents, leading to a deficiency in ensuring food safety. Resident 98, who is cognitively intact with a BIMS score of 15, and Resident 174, who has some cognitive impairments with a BIMS score of 8, were both affected by this oversight. The surveyor observed that the temperature logs for these residents' personal refrigerators were not consistently checked as required. Resident 174 was unable to confirm how often the refrigerator was checked, and Resident 98 indicated that their refrigerator was checked only once a week, contrary to the facility's policy. The facility's policy mandates that nursing staff monitor personal refrigerators for spoilage, contamination, and safety, with temperatures recorded daily. However, interviews with staff revealed inconsistencies in the monitoring process. A Registered Nurse stated that floor nurses are responsible for checking refrigerator temperatures every shift, while a Licensed Practical Nurse indicated that night shift nurses are responsible for this task. The Director of Nursing confirmed that personal refrigerators should be checked daily to prevent exposure to spoiled or expired food, which could harm residents. Despite these protocols, the temperature logs for the residents' refrigerators were not maintained as required, leading to a potential risk of foodborne illness.
Non-Functioning Call Device in Resident's Room
Penalty
Summary
The facility failed to ensure that a resident's call device was functioning, which affected one resident in a sample of 67. On October 6, 2024, a surveyor requested the resident to activate his call device, to which the resident responded that it did not work. The Social Service Director confirmed that the call device was not working, as no light was observed on the call device box or the overhead indicator outside the resident's room. Another resident, who was the roommate, stated that the call light had been broken since they moved into the room four months prior. The resident affected by the non-functioning call device was admitted in early September and had a cognitive status indicating they were cognitively intact, as documented in their Minimum Data Set. The resident's care plan highlighted the risk for falls related to co-morbidities and emphasized the importance of having the call light within reach for assistance. The facility's call light policy and procedure underscored the necessity of a functioning nurse call system to respond to residents' needs in a timely manner.
Failure to Assess Resident's Ability to Self-Administer Medication
Penalty
Summary
The facility failed to ensure that medication was not left inside the room of a resident whose ability to safely self-administer medications had not been assessed. During an observation, two half pills were found in a medication cup by the resident's television stand. The resident was unable to recall which nurse provided the medication or whether it was given during the morning or night shift. The resident mentioned splitting the potassium pill in half due to difficulty swallowing the whole pill. The Assistant Director of Nursing initially refused to describe the medication found in the resident's room but later confirmed they were white pills. The Director of Nursing stated that the facility's policy requires nurses to ensure medications are taken by residents at the bedside. The resident involved had diagnoses including type 2 diabetes mellitus and essential hypertension and was documented as cognitively intact with a BIMS score of 14. The resident's records showed an active order for Potassium Chloride ER 20MEQ to be taken once daily, but there was no order or care plan for self-administration of medication. The facility's policy allows self-administration only when assessed as safe and approved by the attending physician and interdisciplinary care planning team. This oversight in following the policy led to the deficiency noted in the report.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure timely incontinence care for a resident who required assistance. On 05/01/2024, a Certified Nursing Assistant (CNA) was observed prioritizing other tasks over providing immediate care to a resident who had requested to get up from bed. The CNA stated that she had already assisted the resident with a bedpan and needed to take soiled clothes to the laundry first. The CNA then proceeded to clean another resident who had been waiting since around 10:00 AM to be changed, despite pressing the call button earlier in the morning. The delay in care was evident as the resident had several dried stools on their skin, indicating prolonged exposure to soiled conditions. The Director of Nursing (DON) confirmed that residents should typically wait only 5-10 minutes to be changed, depending on the supplies needed. The DON acknowledged that longer wait times could affect residents' skin and self-esteem. Facility documentation also emphasized the importance of responding to residents' requests in a timely and courteous manner. The observed delay in providing incontinence care and the CNA's prioritization of other tasks over immediate resident needs led to the identified deficiency.
Failure to Maintain Accessible Call Light System
Penalty
Summary
The facility failed to maintain a functioning call light system that was accessible to residents, specifically affecting two residents. One resident's call light was observed to be malfunctioning over an extended period, with staff acknowledging the issue but not providing a permanent fix. The resident reported that the call light had been intermittently working for about a week, and maintenance staff confirmed that the cord was sometimes loose. Despite the call light being broken, the resident did not have an immediate need for it, but the potential risk for other residents was noted. Another resident, who was quadriplegic and unable to use a standard call light, was not provided with a specialized call light system. Instead, the facility implemented a monitoring program where staff checked on the resident hourly. However, there was no formal assessment to determine the resident's ability to use the call light, and the facility did not have alternative call light options available. Staff relied on hourly rounds and the resident's ability to call the facility on the telephone for assistance, which was not a sufficient substitute for an accessible call light system.
Facility Fails to Provide Adequate Linen Supplies for Residents
Penalty
Summary
The facility failed to provide residents with needed supplies for Activities of Daily Living (ADLs), such as linens. This deficiency affected all 252 residents residing in the facility. Multiple residents reported not having enough linens, with some stating their beds were not made for weeks due to the lack of pillowcases and other linens. Observations confirmed the shortage, with clean linen carts on various floors found to be nearly empty or containing insufficient supplies. Certified Nursing Assistants (CNAs) and other staff members corroborated the residents' claims, noting that they often had to go to the laundry room in the basement to retrieve linens, which were still insufficient for resident care needs. The Central Supplies Manager admitted that budget cuts after the facility's acquisition by a new company led to a significant reduction in the amount of linen ordered, exacerbating the shortage. Additionally, the Laundry Manager mentioned that dirty linens were not being sent back to the laundry for washing, further contributing to the problem. The Administrator acknowledged the linen shortage and suggested that CNAs might be hoarding clean linens and not sending dirty linens to the laundry. The facility's grievance log documented a family member's complaint about a resident's linen not being changed, highlighting the ongoing issue. The facility's dignity policy emphasizes that each resident should be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality, which was not upheld in this instance. The facility's resident census sheet confirmed that 252 residents were affected by this deficiency.
Failure to Ensure Proper Food Handling and Hygiene Practices
Penalty
Summary
The facility failed to ensure food items were covered, labeled, and dated, and did not enforce the use of beard restraints among dietary staff, which could potentially lead to foodborne illnesses. During an inspection, it was observed that multiple dietary staff members with beards were not wearing beard restraints while handling food. The Dietary Supervisor and several Dietary Aides admitted to not wearing beard restraints and were unaware of the requirement. Additionally, various food items in the reach-in cooler and walk-in freezer were found uncovered, unlabeled, and undated, including desserts, sandwiches, fruit cups, thickened beverages, and boxes of vegetables and shrimp. The Dietary Manager confirmed that all food items should be properly labeled with the date they arrived to ensure the FIFO (first in, first out) method is followed and to prevent the use of expired food. The manager also stated that food items should be covered to prevent contamination. The facility's policies on the storage of refrigerated/frozen foods, labeling of food items, and employee health and personal hygiene were not adhered to, as evidenced by the uncovered and unlabeled food items and the lack of beard restraints among dietary staff. These deficiencies have the potential to affect all residents receiving oral nutrition at the facility.
Improper Garbage Disposal and Pest Control Deficiencies
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, leading to overflowing dumpsters with open lids and trash scattered around the surrounding area. On multiple occasions, surveyors observed the dumpsters overflowing with trash and the lids remaining open, with trash littering the ground around the dumpsters. The Dietary Manager acknowledged the issue, stating that the dumpsters were not closing due to the excess trash and confirmed that there were no recyclables mixed in. Additionally, gaps were observed between the delivery door and door frame, as well as at the bottom of the kitchen doors, which the Dietary Manager admitted could allow small rodents to enter the facility. The facility's policies on safe food handling and pest control were not adhered to, as the dumpsters were not securely covered, and the surrounding area was not kept free of trash and debris. The Pest Control Policy specifically required that outside dumpsters be of sufficient size to allow the lids to be tightly closed, which was not the case. The Dietary Manager acknowledged that the open dumpsters and gaps in the doors could lead to pests entering the facility, potentially spreading disease. These deficiencies have the potential to affect all residents at the facility.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to ensure that four residents (R7, R25, R175, R299) received adequate nail care, which is essential for preserving their dignity and increasing self-esteem. Observations revealed that these residents had long fingernails with a brownish-gray substance underneath. Specifically, R299, who has diagnoses including Amyotrophic Lateral Sclerosis and Adult Failure to Thrive, was observed with uncleaned and untrimmed nails and confirmed wanting his nails cleaned and trimmed. Similar conditions were observed for R7, R25, and R175, all of whom have significant medical conditions and dependencies on staff for personal hygiene and grooming tasks. Interviews with staff, including a Registered Nurse (V15) and a Certified Nursing Assistant (V28), indicated that nail care is provided every two weeks and as needed, but this was evidently not sufficient for these residents. The facility's policy on Activities of Daily Living (ADLs) emphasizes the importance of maintaining personal hygiene to promote independence, self-esteem, and dignity. Job descriptions for both Charge Nurses and Certified Nursing Assistants include responsibilities for ensuring residents are treated with kindness, dignity, and respect, and specifically mention assisting with nail care. Despite these guidelines, the facility did not meet the required standards for these four residents, as evidenced by the observations and staff interviews. The Director of Nursing (V2) acknowledged that nail care is part of overall care but did not provide a satisfactory explanation for the observed deficiencies.
Failure to Ensure Resident Safety and Proper Supervision
Penalty
Summary
The facility failed to ensure the safety of residents by not removing disposable razors from their rooms and not providing adequate supervision for medications. Specifically, four residents were found with disposable razors in their rooms, and two residents had oral medications and eye drops left at their bedside without orders to self-administer. These actions were observed by surveyors and confirmed through interviews with staff members, who acknowledged that these items should not have been left in the residents' rooms without proper supervision or orders to self-administer. One resident with a diagnosis of Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, and other conditions was found with two boxes of eye drops and a disposable razor on their dresser. Another resident with similar diagnoses had a clear cup with various tablets and a capsule on their bedside table. Both residents did not have orders to self-administer these medications. Staff members, including an LPN and a Registered Nurse, confirmed that these items should not have been left in the residents' rooms. Additionally, other residents were found with multiple disposable razors in their rooms. One resident had eight razors on their bedpan/basin and bedside table, while another had six razors on their dresser. Staff members, including a CNA and the Director of Nursing, confirmed that razors should be returned to the nursing staff for proper disposal in a sharps container to prevent potential hazards. The facility's policies on self-administration of medications and handling and disposal of sharps were not followed, leading to these deficiencies.
Failure to Conduct Controlled Substances Inventory at Shift Changes
Penalty
Summary
The facility failed to ensure that two licensed personnel conducted a physical inventory of controlled substances at each change of shift. This deficiency was observed on the 4th Floor Team 2 and Team 1 medication carts, where controlled substances check forms for specific shifts in March 2024 were left blank. Specifically, the Nurse's Off box was left blank for the 11pm-7am shift on March 3, 2024, and the 3pm-11pm shift on March 4, 2024, for Team 2. Similarly, the Nurse's Initials on box was left blank for the 1st shift on March 8, 2024, and the Nurse's Initials off box was left blank for the 2nd shift on March 12, 2024, for Team 1. These blank spaces indicate that the controlled substances were not reconciled at the end and beginning of the shifts on the specified days, potentially affecting eight residents who were prescribed controlled substances on these medication carts. Interviews with the nursing staff, including an RN and an LPN, confirmed that the shift change accountability record for controlled substances is used by both the outgoing and incoming nurses to verify the count of controlled substances. The Director of Nursing (DON) also stated that the shift change accountability record is expected to be signed by the nurses at the beginning and end of each shift to identify who took hold of the narcotics. The facility's policy on receiving controlled substances and the Charge Nurse job description both emphasize the importance of accurate recordkeeping for controlled substances, yet the observed deficiencies indicate non-compliance with these protocols.
Failure to Provide Accessible Bedside Table for Resident's Meal
Penalty
Summary
The facility failed to ensure a bedside table was accessible for a resident (R449) when being served lunch in their room. The resident, who has diagnoses including diabetes, hypertension, and schizophrenia, was observed by a surveyor sitting in a wheelchair next to their bed. A CNA placed the resident's lunch tray on the bed and left the room. The resident expressed that staff always put meal trays on the bed and that they had no choice but to eat on the bed due to the lack of a table. The resident's BIMS score of 14 indicates they are cognitively intact. The facility's Administrator and Director of Nursing both acknowledged that it is not acceptable for staff to place meal trays on residents' beds and that residents should have bedside tables. The Director of Nursing mentioned that there was an issue with bedside tables being on back order. The facility's policies and job descriptions emphasize the importance of treating residents with dignity and respect, and ensuring their needs and preferences are accommodated, which was not adhered to in this instance.
Failure to Provide Clean Linen for Residents
Penalty
Summary
The facility failed to provide clean linen for two residents, R27 and R175, out of a sample of 71 residents. R27, who has a diagnosis of Chronic Obstructive Pulmonary Disease, Venous Insufficiency, Type 2 Diabetes Mellitus, Blepharitis, and Blepharochalasis, was observed with a brownish stain on the right side of the foot of the fitted sheet and a reddish stain on the left side of the top of the fitted sheet. R27 stated that he had asked for clean sheets a couple of days ago but was told there were none available. Similarly, R175, who has a diagnosis of Hemiplegia and Hemiparesis affecting the left side, Hypertension, Atherosclerosis, Muscle Weakness, and Adjustment Disorder, was also affected by the lack of clean linen. The facility's staff, including a Laundry Aide and Certified Nursing Assistants, confirmed that there was not enough laundry to provide for all residents and that they often had to get linen from other floors due to shortages. The Director of Nursing stated that linen should be changed daily and as needed, but the facility's Linen Handling Policy indicated that clean linens should be applied to each occupied health center bed at least twice each week or as needed. Despite this policy, the facility failed to meet these standards, as evidenced by the stained and unchanged linens observed on R27's bed. The Certified Nursing Assistant's job description also includes the responsibility of changing bed linens, which was not adhered to in this case. This deficiency highlights a significant lapse in maintaining a safe, clean, comfortable, and homelike environment for the residents.
Failure to Report New Skin Alterations and Incorrect Mattress Settings
Penalty
Summary
The facility failed to ensure new skin alterations were reported to the nurse and did not appropriately set the low air loss mattress for a resident. On 03/11/24, a resident was observed lying on a low air loss mattress with incorrect settings. A skin opening on the resident's coccyx area was noted without a dressing. The Certified Nursing Assistant (CNA) did not report the new skin opening to the nurse, as required. The Wound Care Nurse was unaware of the wound and confirmed the mattress settings were incorrect for the resident's weight. The resident's weight was 168.8 lbs, but the mattress was set for a higher weight, which was not appropriate for the resident's condition. The resident had a history of muscle weakness, lack of coordination, and was at risk for skin breakdown. The resident's cognitive status was severely impaired, requiring substantial assistance for mobility. The facility's procedures required daily skin checks and immediate reporting of new or worsening skin conditions to the nurse, which was not followed. The CNA applied barrier cream but did not report the new skin opening, leading to a delay in appropriate wound care and treatment. The facility's documentation and care plan indicated the use of a pressure redistribution mattress, but the incorrect settings and lack of timely reporting contributed to the development of a stage 2 pressure ulcer on the resident's coccyx area.
Failure to Properly Disconnect and Flush Feeding Tube
Penalty
Summary
The facility failed to ensure proper care for a resident with a feeding tube. On 03/11/24, it was observed that the feeding tube of a resident was not disconnected and flushed after the completion of feeding. The feeding bag, dated 3/10, was still attached to the resident's gastrostomy tube, and the feeding formula was present in the tube. The Licensed Practice Nurse (LPN) admitted to stopping the feeding but did not disconnect or flush the tube as required. The Director of Nursing confirmed that the staff is expected to disconnect the feeding tube and flush it with water to maintain patency after each feeding session. The resident in question had a diagnosis of dysphagia and cerebrovascular accident (CVA), requiring total assistance with eating and tube feeding. The resident's care plan included receiving tube feeding and water flushes per physician orders. However, the facility's policy on G-tube feedings did not include procedures for continuous feeding, which contributed to the oversight. The failure to follow proper procedures for tube feeding care was confirmed through observations, interviews, and record reviews.
Failure to Monitor Refrigerator Temperatures
Penalty
Summary
The facility failed to properly log refrigerator temperatures for two residents' personal refrigerators and did not provide a thermometer in one resident's refrigerator. Specifically, the surveyor observed a black refrigerator in one resident's room with missing documentation of temperatures on the temperature log. The refrigerator contained 2 cartons of 2% milk, 3 bottles of water, and 3 plastic bottles of soda. Another resident's refrigerator was found without a thermometer and no temperature log, containing 2 cartons of 2% milk and four plastic bottles of water. Interviews with staff revealed that certified nursing assistants (CNAs) are responsible for checking and documenting the temperatures, but this was not consistently done. The Director of Nursing (DON) confirmed that all refrigerators should have internal thermometers and daily temperature logs to ensure food safety and prevent foodborne illnesses. The facility's policy, revised in 2016, mandates that staff monitor resident rooms and personal refrigerators for food and beverage safety, requiring internal thermometers and daily temperature recordings. Despite this policy, the surveyor found non-compliance in the cases of the two residents. One resident was cognitively intact with a BIMS score of 15, while the other had moderately impaired cognition with a BIMS score of 8. The failure to adhere to the policy has the potential to affect all 71 residents in the sample, posing a risk of foodborne illnesses due to improper food storage.
Failure to Follow Abuse Prevention Policy and Manage Aggressive Resident
Penalty
Summary
The facility failed to follow its abuse prevention policy, implement necessary interventions, and acknowledge the behaviors of a resident (R4) with a history of aggression. R4, diagnosed with bipolar disorder and paranoid schizophrenia, exhibited physical and verbal aggression towards staff and peers on multiple occasions. Despite these documented behaviors, the facility did not take adequate measures to monitor and manage R4's actions, leading to a physical altercation with another resident (R5) that resulted in significant injuries, including a nasal bone fracture and chronic dizziness and headaches for R5. On the night of the incident, R4 approached R5 at the nurse's station, leading to a confrontation where R4 hit R5 in the face, causing R5 to fall and sustain injuries. The facility's staff failed to immediately remove R4 from resident contact and did not adequately address R4's aggressive behavior. Additionally, R4 continued to exhibit erratic and aggressive behavior, including another physical altercation with a different resident (R3), further indicating the facility's failure to ensure the safety of its residents. The facility's administrator acknowledged the requirement to separate the aggressor from the victim and involve psychiatric and medical professionals immediately. However, R4 and R5 continued to reside on the same unit, and staff did not consistently monitor or redirect R4's behavior. The facility's failure to adhere to its abuse prevention policy and adequately manage R4's behavior resulted in ongoing safety concerns for the residents involved.
Failure to Ensure Call Lights Were Accessible
Penalty
Summary
The facility failed to ensure that call lights were accessible for two residents, leading to deficiencies in accommodating their needs and preferences. Resident 1, diagnosed with generalized weakness, reduced mobility, and lack of coordination, was observed seated in a wheelchair with the call light on the floor and out of reach. Despite having an intact cognitive status and a care plan that required frequent monitoring and keeping commonly used items within reach, the resident had to physically go to staff for assistance. The LPN confirmed that the call light should have been within reach but was found on the floor behind the bed. Resident 2, diagnosed with hemiplegia and hemiparesis, required two-person assistance for transfers and was also found with the call light on the floor and out of reach. The resident, who has cataracts and cannot see well, expressed frustration about staff getting irritated when the call light is used frequently. The LPN confirmed that the call light should have been secured to the resident or linens but was not. The facility's call light policy mandates that the call light system should be easily accessible to residents, which was not adhered to in these cases.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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