Carlton At The Lake, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 725 West Montrose Avenue, Chicago, Illinois 60613
- CMS Provider Number
- 145679
- Inspections on file
- 32
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Carlton At The Lake, The during CMS and state inspections, most recent first.
Surveyors found that multiple nurses on several floors did not complete their morning medication passes within the facility’s required one-hour before/after window, resulting in numerous medications showing as late on the eMAR. RNs and LPNs reported starting medication administration early in their shifts but still had outstanding medications several hours later, and some acknowledged giving medications without promptly documenting them. Audit reports confirmed that multiple residents across several floors received medications late, and facility policy requires that medications be administered on time and signed on the MAR immediately after administration.
A resident with intact cognition but significant left-sided weakness and multiple care needs was observed seated in a mechanical chair while the call light was placed on the bed out of reach. The resident reported being unable to reach the call light due to weakness from a prior stroke and stated they sometimes had to shout for help or rely on a cell phone because the call light was not always accessible. A CNA and an RN both acknowledged that the resident could not reach the call light as placed and that call lights should be within residents’ reach so they can obtain assistance, and the DON confirmed that facility policy requires call lights to be placed within reach of residents able to use them at all times.
A resident with intact cognition and multiple medical conditions reported that the facility’s showers were dirty and contained soiled incontinence briefs. Surveyors later observed strong, pervasive feces and urine odors in shower rooms on multiple floors, with one shower room’s odor so strong it could not be entered and a yellowish-brown substance resembling mixed feces and urine smeared on a shower entry wall. The Environmental Services Director acknowledged the odors and substance, and the Assistant Administrator confirmed that showers are expected to be clean and odor-free, despite a policy requiring regular cleaning and disinfection of public and high-touch areas.
A resident with type 2 DM, severe cognitive impairment, and multiple comorbidities did not receive care in accordance with physician orders and facility policy. An A1c lab ordered with instructions to re-attempt using a different technician after an initial refusal was only documented as refused once, with no record of a subsequent attempt. Blood glucose monitoring parameters for when to notify the provider were not documented, and an RN reported not knowing these parameters and being unable to locate documented blood glucose values. Blood glucose checks were recorded with times that did not match the ordered administration times, despite policy requiring that all treatments and the MAR accurately reflect physician orders.
A resident with multiple medical conditions and intact cognition repeatedly did not receive requested scrambled eggs at breakfast or expected double portions, despite dietary notes documenting these preferences. CNAs and LPNs reported that the resident’s meals were often incorrect and required frequent calls to the kitchen for corrections. Review of records showed only a regular diet order without double portions and no documented Food Preference Interview, indicating that the resident’s stated dietary preferences were not consistently incorporated into formal diet orders.
A resident with psychiatric disorders reported ongoing threats, theft, and intimidation by their roommate, including threats of physical harm and taking of a debit card. Despite these allegations being communicated to several staff members, the incident was not reported to the abuse coordinator or administration as required by facility policy, resulting in a failure to follow mandated abuse reporting procedures.
A resident with multiple psychiatric and neurological diagnoses reported a sexual assault to the ADON after returning from a community pass. Although the facility's policy required reporting abuse allegations to the state agency within two hours, the Administrator delayed notification until the next day due to conflicting accounts and lack of initial disclosure to hospital staff. The delay in reporting exceeded the facility's stated policy and regulatory requirements.
A resident with multiple psychiatric and neurological diagnoses was allowed to leave the facility on a supervised community pass but did not return as scheduled. Staff did not contact police after the required grace period, failed to complete an elopement risk assessment upon admission, and delayed initiating a care plan for community pass privileges, all in violation of facility policy.
Two residents experienced ongoing bed bug infestations after being relocated due to an initial finding of bed bugs in their shared room. Despite treatment by a pest control company and laundering of belongings, bed bugs were observed again during a survey, and there was no documentation of follow-up inspections or checks of the new rooms as required by facility policy.
A resident with a history of hypotension and mobility issues experienced a fall resulting in injuries after the facility failed to incorporate the resident's medical diagnosis and medication regimen into the fall prevention care plan. The care plan did not address the need for Midodrine when blood pressure was low, and fall risk assessments were not consistently performed or used to guide interventions. Staff interviews revealed confusion over responsibilities and a lack of coordination in updating care plans and assessments.
A resident with a history of hypotension and mobility issues was not given physician-ordered Midodrine when their systolic blood pressure fell below the prescribed threshold. The medication was not documented as administered on the MAR, and the DON confirmed it was not given. This omission led to the resident experiencing low blood pressure and a fall, resulting in lacerations.
A resident with multiple health conditions, including diabetes mellitus, did not receive prescribed Lantus insulin for ten days due to a delay in following a physician's order. The resident's cognitive impairment and high fasting blood sugars necessitated the medication, but the order was not entered until several days after the clinic visit. The facility's policy requires timely execution of physician orders, which was not followed in this instance.
A facility failed to document medication administration for a resident with multiple health conditions, including diabetes and impaired cognition. The resident's MAR lacked a nurse's signature for a scheduled dose of Trulicity, indicating the medication may not have been administered. The ADON confirmed that missing initials suggest non-administration, and the facility's policy requires documentation after medication is given.
The facility failed to revise care plans with preventive interventions for two residents, resulting in injuries of unknown origin. A resident with dementia sustained a hand fracture, believed to be from bumping a bedside table, but the care plan lacked preventive measures. Another resident with hemiplegia was found with a leg fracture, suspected from bumping a bed rail, yet the care plan did not include interventions to prevent further harm.
The facility failed to follow procedures for administering and documenting enteral feedings for two residents, leading to discrepancies in feeding schedules and intake monitoring. One resident's feeding bottle was found full despite orders for continuous infusion, and another's bottle was not replaced as per schedule. The LPN admitted to not clearing the pump, and the facility did not document enteral intake, contributing to the deficiencies.
The facility failed to remove and discard expired medications in one of two medication carts reviewed. A surveyor found an opened bottle of Docusate Sodium 100mg with an expiration date of December 2022 in the Team 1 medication cart. The RN responsible for the cart admitted that expired medications should not be stored and should be discarded. This oversight has the potential to affect 20 residents whose medications are stored in the Team 1 medication cart on the second floor.
The facility failed to convey funds to a resident's family after the resident's death. The Business Office Manager was unaware of the facility's policies, leading to delays and miscommunication. The Administrator acknowledged that the funds should go to the individual overseeing the resident's estate, as per the facility's policy.
A facility failed to provide timely incontinence care for a dependent resident who reported being left in soiled briefs for extended periods. Despite the care plan and facility policies requiring checks every two hours, the resident was found soiled and had not been changed since the start of the CNA's shift.
Untimely Medication Administration and Delayed eMAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to administer prescribed medications in a timely manner according to physician orders and to document administration promptly on the electronic medication administration record (eMAR). On the date of survey, multiple nurses on different floors reported starting their shifts around 7:00–7:30 AM and beginning medication passes between 7:30–8:00 AM, yet by approximately 10:11–10:39 AM several had not completed their medication passes. When the surveyor reviewed the eMARs with these nurses, multiple residents’ medication entries appeared in red, which the nurses stated indicated that the medications were late. Some nurses also stated that they had administered certain medications but had not yet documented them on the eMAR. One nurse assigned to the third floor stated she had completed her medication pass and acknowledged that medications not given on time are considered medication errors and that all medications should be given on time according to physician orders. The Director of Nursing stated that the facility’s time frame for medication administration is one hour before and one hour after the scheduled time. Facility medication administration audit reports for the same date documented that multiple residents on the second, third, fourth, and fifth floors received their medications late. The facility census documented 34 residents on the second floor, 57 on the fourth floor, and 54 on the fifth floor, indicating that the issue had the potential to affect 145 residents. Facility policy titled “Medication Pass,” dated 07/02/2025, states in part that after medication is administered to each resident, staff must sign the MAR to indicate it was given. The observations, staff interviews, and audit reports collectively show that medications were not consistently administered within the prescribed time frame and were not consistently documented immediately after administration, resulting in untimely medication administration for multiple residents.
Failure to Keep Call Light Within Reach of Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow its call light policy by not ensuring a cognitively intact resident with left-sided weakness could access the call light. The resident had diagnoses including hemiplegia and hemiparesis following cerebrovascular disease affecting the left non-dominant side, major depressive disorder, and dysphagia following cerebral infarction. An MDS dated February 16, 2026 documented a BIMS score of 15/15, indicating intact cognition, and Section GG showed the resident required varying levels of assistance with eating, oral hygiene, personal hygiene, toileting, dressing, footwear, and bathing. On observation at 12:26 PM, the resident was seated in a mechanical chair on the right side of the bed, while the call light was placed on the bed out of the resident’s reach. The resident stated they could not reach the call light due to left-sided weakness from a stroke, demonstrated an inability to reach it with the left hand, and reported needing to shout for help and keeping a cell phone nearby because the call light was sometimes placed too far away. At 12:49 PM, a CNA and the surveyor again observed the call light on the bed out of the resident’s reach. The CNA confirmed the resident had left-sided weakness and could not stretch far enough to reach the call light where it was placed, and stated the call light needed to be closer so the resident could call staff when help was needed, otherwise the resident’s needs would not be met and the resident could fall or choke. At 1:00 PM, an RN stated that call lights should be within residents’ reach so they can access staff for help and that if not accessible, a resident might fall out of bed trying to get help or be in an emergency and unable to reach staff. At 3:45 PM, the DON stated call lights should be placed close enough for residents to reach to call for assistance and that if the call light is far from a resident, the resident will not be able to call for assistance. The facility’s call light policy dated June 30, 2025 documented that call lights must be placed within reach of residents who are able to use them at all times, which was not followed in this case.
Failure to Maintain Clean and Odor-Free Shower Rooms
Penalty
Summary
The facility failed to maintain clean, odor-free shower rooms, resulting in a deficient environment for residents. One cognitively intact resident with multiple medical conditions, including hemiplegia, major depressive disorder, dysphagia, severe protein-calorie malnutrition, and hypertension, reported that the showers were dirty and contained soiled incontinence briefs, particularly on the floor where the resident previously lived. The resident’s BIMS score of 15 indicated little to no cognitive impairment, supporting the reliability of the report about the condition of the showers. On the day of surveyor observations, multiple shower rooms on several floors had strong, pervasive feces and urine odors. On the 4th floor, both shower rooms had such strong odors that one shower room in the East wing could not be entered by the surveyor. Similar strong odors were present in the 2nd floor shower rooms. On the 5th floor, in addition to strong feces and urine odors, there was a yellowish-brown substance approximately 7 by 10 inches smeared on the entry wall of a shower, appearing like mixed feces and urine. The Environmental Services Director acknowledged the substance and agreed the odors were unpleasantly strong and unacceptable. The Assistant Administrator stated that showers are expected to look and smell clean and free of debris, and the facility’s Public Areas Daily Cleaning Workflow policy states that public areas and high-touch areas are to be regularly cleaned, disinfected, and well-maintained to promote a hygienic environment.
Failure to Follow Physician Orders for Diabetic Monitoring and A1c Lab
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and its own policy regarding diabetes management and lab monitoring for one resident. The resident had multiple diagnoses including type 2 diabetes mellitus with hyperglycemia, metabolic encephalopathy, bipolar disorder, schizoaffective disorder, chronic embolism and thrombosis of the femoral vein, and difficulty in walking, and was documented as having severe cognitive impairment with a BIMS score of 3/15. A physician order dated 2/19/2026 directed that an A1c lab be completed on 2/20/2026, with instructions that if the resident refused, a different technician should attempt the draw in the morning. Progress notes show the resident refused the A1c at 1:02 AM on 2/20/2026, but there is no documentation that the A1c was offered again by a different technician as ordered. The DON stated that if it is not documented, it is not done. The facility also failed to document blood glucose monitoring parameters for when to notify the physician, despite the DON stating that the physician gives such parameters and that nurses should carry out orders as written. The RN caring for the resident reported that the resident is diabetic and that blood sugars are taken two times a shift, but she could not locate the blood glucose levels she documented and did not know the parameters for when to notify the physician. Blood glucose records from 2/20/2026 to 2/27/2026 show levels ranging from 122 mg/dL to 230 mg/dL, and on 2/28/2026, blood glucose checks ordered for 8:00 AM and 11:00 AM were documented as taken at 2:03 PM, which did not align with the physician’s ordered times. These actions and omissions conflict with the facility’s policy requiring that all treatments and plans of care be in accordance with physician orders and that orders in the POS be accurately reflected in the MAR.
Failure to Consistently Honor Resident Dietary Preferences and Portions
Penalty
Summary
The facility failed to consistently honor a resident’s documented dietary preferences and needs, specifically regarding double portions and scrambled eggs at breakfast. The resident had diagnoses including hemiplegia and hemiparesis following cerebral infarction, muscle wasting and atrophy, dysphagia (oropharyngeal phase), benign prostatic hyperplasia, hypertension, and depression, and was documented as cognitively intact with a BIMS score of 14. The resident reported ongoing complaints about receiving the wrong food orders. The dietician stated that on one occasion the resident did not receive scrambled eggs with breakfast because the meal ticket had not been updated after the resident requested scrambled eggs every breakfast the previous day. The dietician also noted that the scrambled eggs were a preference and that the resident was to receive double portions with meals. Multiple CNAs and LPNs reported that the resident’s food orders were frequently incorrect, including not receiving scrambled eggs with breakfast and not receiving double portions as expected, requiring calls to the kitchen for corrections. One CNA reported that the resident complained that morning about not getting double the portion of eggs. Nursing staff confirmed that the resident was prescribed double portion meals and often complained about not receiving them, and one LPN stated that most of the time the resident’s meals were wrong. Review of the resident’s diet order showed only a regular diet with no specification for double portions, and although the dietician’s notes documented the preference for scrambled eggs at breakfast, there was no corresponding diet order for double portions or documentation of the required Food Preference Interview in the electronic medical record.
Failure to Report Alleged Abuse and Threats Between Roommates
Penalty
Summary
The facility failed to follow its 'Abuse and Neglect' policy by not reporting an allegation of abuse involving a resident with schizophrenia, delusional disorders, major depressive disorder, and anxiety disorder. This resident alleged that their roommate, who also had significant psychiatric diagnoses and behavioral issues, had threatened to hit them, requested money, and took their debit card. The resident reported these threats and theft to staff, stating that the threats had persisted for several days. Despite these allegations, the staff did not report the incident to the abuse coordinator or the appropriate authorities as required by facility policy. Multiple staff members were aware of the situation, with some reporting the behavior to other staff but not escalating it to the designated abuse coordinator or administrator. Interviews revealed confusion and lack of communication among staff regarding the reporting process. The nurse who was informed of the threats relayed the information to the social worker, who in turn did not report it to the abuse coordinator. The social worker and restorative nurse both stated they were not made aware of any abuse allegations, and the director of nursing and assistant administrator confirmed they were not informed until the surveyor brought it to their attention. The facility's policy clearly states that all allegations or suspicions of abuse must be reported immediately to the administrator or their designee, which did not occur in this case.
Failure to Timely Report Alleged Sexual Abuse to State Agency
Penalty
Summary
The facility failed to follow its abuse policy and procedure by not reporting an allegation of sexual abuse to the State Agency within the required two-hour timeframe. A resident with diagnoses including major depressive disorder, epilepsy, bipolar disorder, anxiety disorder, and dissociative and conversion disorder, who was cognitively intact, reported being sexually assaulted while out on pass with a family member. The resident communicated the assault to the Assistant Director of Nursing via text message, who then informed the Administrator. Despite the facility's policy requiring immediate reporting of abuse allegations to the Illinois Department of Public Health (IDPH) within two hours, the Administrator delayed the report until the following day, citing conflicting stories and lack of disclosure to hospital staff upon the resident's return. The initial report to IDPH was made more than 20 hours after the resident returned to the facility and disclosed the assault. Documentation shows that the resident described the assault, underwent a nursing assessment, and a police report was eventually filed. The facility's own policy clearly states that all allegations of abuse must be reported to IDPH immediately, not exceeding two hours after the initial allegation is received, but this protocol was not followed in this case.
Failure to Follow Elopement Policy and Timely Care Planning for Community Pass Privileges
Penalty
Summary
The facility failed to follow its policies and procedures to ensure the safety and supervision of a resident who was on a supervised community pass. Specifically, the facility did not contact the police to assist in locating the resident when he did not return at the indicated time, as required by their elopement policy. Staff attempted to reach the resident and his family by phone but did not escalate the situation to law enforcement after the two-hour grace period had elapsed. Multiple staff members were unclear about the policy for contacting the police, and communication was limited to internal notifications and calls to emergency contacts. Additionally, the facility did not complete a risk for elopement assessment for the resident upon admission, as mandated by their own elopement policy. The assessment was only completed several days after admission, leaving a gap in identifying and addressing potential elopement risks. The resident had a history of major depressive disorder, epilepsy, bipolar disorder, anxiety disorder, and dissociative and conversion disorder, and was considered cognitively intact but required supervision with activities of daily living. Furthermore, the facility did not initiate a person-centered care plan to address the resident's community pass privilege in a timely manner. Although a physician's order for outside pass privileges was obtained, the corresponding care plan was not started until several days later, beyond the expected timeframe. This delay in care planning meant that the interdisciplinary team did not have timely guidance to address the resident's needs and potential risks associated with community outings.
Failure to Maintain Effective Pest Control Program for Bed Bugs
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of bed bugs in the rooms of two residents. Approximately three weeks prior to the survey, bed bugs were found in the room shared by these residents, prompting their temporary relocation. One resident reported the discovery of bed bugs, while the other was unaware of the reason for the move. During the survey, a bed bug was observed crawling on one resident's bed, and multiple dried blood spots were noted on the bed sheets. Upon further inspection, multiple bed bugs were found under the mattress. The maintenance staff confirmed the presence of bed bugs and acknowledged that the pest control company had previously treated the room with chemicals, and that belongings were bagged and laundered. However, there was no documentation of follow-up inspections or confirmation that the new rooms to which the residents were moved were inspected for bed bugs. Record review showed that the facility's pest control service had documented the initial bed bug finding and treatment, but there was no evidence of subsequent inspections or monitoring to ensure eradication. The facility's own policies require inspection of the affected room, adjacent rooms, and the new room to which residents are relocated, as well as the use of non-chemical control measures when practical. These steps were not documented as completed. The lack of follow-up and failure to inspect new rooms upon relocation contributed to the ongoing presence of bed bugs, affecting the residents involved and potentially the entire facility population.
Failure to Address Hypotension and Medication Needs in Fall Prevention
Penalty
Summary
The facility failed to ensure that a resident's medical diagnosis and medication regimen were incorporated into preventive interventions to avoid falls and accidents. Specifically, the care plan and fall interventions did not address the resident's diagnosis of hypotension or the prescribed medication, Midodrine, which was to be administered when the resident's systolic blood pressure dropped below 95 mm/Hg. Documentation showed that there were days when the resident's blood pressure was below this threshold, but the medication was not administered as ordered. The care plan prior to the fall only included teaching on positioning and instructions for assistance, with no reference to the resident's hypotension or related interventions. The resident, who had a history of hypotension, abnormal gait, lack of coordination, and muscle wasting, experienced a fall resulting in a forehead laceration requiring sutures and a laceration to the left arm. At the time of the fall, the resident's blood pressure was recorded at 85/63 mm/Hg, which was significantly lower than their baseline. The fall occurred when the resident attempted to pick something up from the floor after getting up from bed. Staff interviews revealed that the fall care plan and assessments did not consistently consider the resident's medical conditions or medication regimen, and there was confusion among staff regarding responsibility for fall assessments and care plan updates. Further, the facility's policy required fall risk assessments upon admission, readmission, quarterly, significant change, and annually, with interventions to be reevaluated and revised as necessary. However, the Falls Coordinator stated that quarterly assessments were not performed and that interventions were only added after a fall occurred. There was also a lack of communication and coordination between the restorative nurses and the Falls Coordinator regarding fall assessments and care planning. The failure to address the resident's hypotensive state and medication needs in the care plan and to utilize fall assessments contributed to the resident's fall and subsequent injuries.
Failure to Administer Prescribed Medication for Hypotension Resulting in Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to administer a physician-prescribed medication, Midodrine 10 mg, to a resident with a diagnosis of hypotension and other mobility-related conditions. The resident was prescribed Midodrine to be given when systolic blood pressure dropped below 95 mm/Hg. Review of the resident's blood pressure logs showed multiple instances of systolic blood pressure below this threshold, but the medication administration record (MAR) did not document that Midodrine was given on those occasions. The Director of Nursing confirmed that if the medication was not documented as administered on the MAR, it was not given, and stated that the expectation is to follow the physician's order for as-needed medication. As a result of this failure, the resident experienced an episode of hypotension with a blood pressure reading of 85/63 mm/Hg and subsequently fell, sustaining lacerations to the forehead and left arm. The facility's medication pass policy requires adherence to physician orders and proper documentation on the MAR after medication administration. The failure to administer the prescribed medication as ordered directly contributed to the resident's hypotensive episode and fall.
Failure to Administer Insulin in a Timely Manner
Penalty
Summary
The facility failed to follow a physician's order for a resident in a timely manner, resulting in the resident not receiving prescribed medication for a period of ten days. The resident, who has a severely impaired cognitive status as indicated by a BIMS score of 03, was diagnosed with multiple conditions including diabetes mellitus, vitamin D deficiency, and other metabolic disorders. On 10/22/2024, a clinic record indicated the need to restart Lantus insulin due to high fasting blood sugars. However, the order for Lantus was not entered until 11/01/2024, and the medication was not administered until after this date. The Assistant Director of Nursing (ADON) stated that the nurse responsible for receiving the resident from a hospital or clinic appointment should review any new medication orders before the end of their shift and verify them with the resident's physician or nurse practitioner. The delay of eight to nine days in contacting the physician to verify the medication order was deemed unacceptable. The facility's policy on physician orders requires that they be carried out within a reasonable time, which was not adhered to in this case.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to appropriately document in the Electronic Medication Record (eMAR) for a resident, identified as R3, who was reviewed for improper nursing care. R3's medical history includes multiple diagnoses such as heart failure, type 2 diabetes mellitus with hyperglycemia, and schizoaffective disorder, among others. The resident's Brief Interview for Mental Status (BIMS) score indicated severely impaired cognition. During a review of R3's Medication Administration Record (MAR) and Physician Order Statement (POS), it was found that there was a missing nurse's signature for a scheduled dose of Trulicity, a medication for diabetes, on a specific date in October 2024. The Assistant Director of Nursing (ADON) confirmed that the assigned nurse is responsible for administering medications and documenting them in the MAR. The ADON stated that missing initials on the MAR suggest the medication was not administered, and there are codes available to indicate reasons for non-administration. The facility's policy requires nurses to sign the MAR after administering medication, and the job descriptions for Registered Nurses (RN) and Licensed Practical Nurses (LPN) emphasize the importance of completing medical records in accordance with nursing policies. The failure to document the administration of medication as per the facility's policy led to the identified deficiency.
Failure to Revise Care Plans with Preventive Interventions
Penalty
Summary
The facility failed to revise comprehensive care plans with preventive interventions for two residents, leading to injuries of unknown origin. Resident R3, diagnosed with dementia, sustained a non-displaced fracture of the right-hand proximal third phalanx, believed to be caused by bumping his hand on a bedside table. Despite the incident, R3's care plan only included monitoring and follow-up actions without preventive measures to avoid further injury. The Care Plan Coordinator acknowledged the absence of preventive interventions, such as assisting the resident or repositioning the bedside table, which were not included in R3's care plan. Similarly, Resident R4, who has hemiplegia/hemiparesis affecting the right side and is non-verbal, was found with a tibial fibula fracture on the right leg. The injury was suspected to have occurred when R4 attempted to move his paralyzed leg using his left leg, causing it to bump against the lower side rail of the bed. R4's care plan lacked interventions to prevent further harm, such as padding the lower side rails, despite the presence of padded upper side rails. The facility's care plan policy mandates the development of person-centered plans within seven days of assessment, but the plans for R3 and R4 did not include necessary preventive measures.
Failure to Administer and Document Enteral Feedings Properly
Penalty
Summary
The facility failed to adhere to its policy procedures regarding the administration and documentation of enteral feedings, leading to deficiencies in the care of two residents. Resident 1, who has anoxic brain damage, tracheostomy status, gastrostomy status, and is dependent on a ventilator, was observed with discrepancies in the administration of their enteral feeding. Despite orders for Jevity 1.5 to be infused at 60ml/hr and a 250ml water flush every 6 hours, the feeding bottle was found full, and the pump indicated an incorrect infused amount. The Licensed Practical Nurse (LPN) admitted to not clearing the pump, which is necessary for accurate monitoring of intake, and there was a lack of documentation on the resident's enteral intake. Similarly, Resident 4, who also has gastrostomy status and is ventilator-dependent, was found with an enteral feeding bottle that should have been empty based on the prescribed infusion rate. The LPN confirmed that the bottle had been hanging since the morning, indicating a failure to follow the prescribed feeding schedule. The Assistant Director of Nursing acknowledged that the facility does not document enteral intake, despite the policy requiring nurses to follow orders for feeding type, rate, and duration. This lack of documentation and adherence to feeding schedules contributed to the identified deficiencies.
Expired Medications Found in Medication Cart
Penalty
Summary
The facility failed to remove and discard expired medications that had been open in one of two medication carts reviewed for medication labeling and storage. During an observation on the second floor, a surveyor found an opened bottle of Docusate Sodium 100mg with an expiration date of December 2022 in the Team 1 medication cart. The Registered Nurse responsible for the cart admitted that expired medications should not be stored and should be discarded. The nurse also mentioned that the night shift usually checks for expired medications, but he last checked the cart two to three weeks ago. This oversight has the potential to affect 20 residents whose medications are stored in the Team 1 medication cart on the second floor. A resident reported that a female nurse informed her she was receiving expired medications, although the resident could not identify or describe the nurse. The resident's Minimum Data Set indicated she was cognitively intact. Her physician order sheet included an order for Docusate Sodium 100mg to be taken as needed for constipation. The facility's policy on medication storage, labeling, and disposal states that house stock medications should be labeled with the name, strength, instructions, and expiration date, and should be discarded based on the manufacturer's expiration guidelines.
Failure to Convey Resident Funds After Death
Penalty
Summary
The facility failed to convey funds to a resident's family after the resident's death. The family member of the deceased resident (R4) reported that the Business Office Manager (V6) explained the trust funds would be used for funeral expenses and any remaining balance would be sent back to the state. Despite the family providing a small estate affidavit and invoices for the funeral expenses, V6 insisted that the funds should go to the funeral home directly. The family member expressed frustration and confusion over the process, as the Administrator acknowledged that the funds should go to the individual overseeing the resident's estate, according to the facility's policy. The review of R4's trust fund showed a balance of $7980.88. The facility's policy states that upon a resident's death, the facility must convey the resident's funds and a final accounting of those funds within 30 days to the individual or probate jurisdiction administering the resident's estate. The Business Office Manager admitted to not being aware of the facility's policies concerning the trust fund, leading to a delay and miscommunication in handling the deceased resident's funds. This deficiency affected one of three residents reviewed for resident funds in a total sample of five residents.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a dependent resident, identified as R5, who reported that no one had come to her room to change her incontinence briefs on the morning of 04/13/2024. R5 stated that she was currently soiled and often had to remain in soiled briefs for extended periods, indicating this was an ongoing issue. A Certified Nursing Assistant (CNA), identified as V4, confirmed that she had not yet changed R5's incontinence briefs since starting her shift at 7 AM and was observed checking and finding R5's briefs soiled with urine at 9:38 AM. V4 then proceeded to change the briefs. R5's medical records indicate she is cognitively intact with a BIMS score of 14/15 and is always incontinent of bowel and bladder, requiring complete assistance with ADL care. R5's care plan includes specific instructions for incontinence care, such as checking for incontinence at least every two hours and ensuring soiled areas are washed, rinsed, and dried. The facility's policies on incontinence and perineal care, as well as ADL care, also mandate regular checks and appropriate care based on comprehensive assessments and care plans. Despite these guidelines, the facility did not adhere to the required care protocols, resulting in R5 remaining in soiled briefs for an extended period on the day of the observation.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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