Central Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 2450 North Central Avenue, Chicago, Illinois 60639
- CMS Provider Number
- 145648
- Inspections on file
- 33
- Latest survey
- January 2, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Central Nursing Home during CMS and state inspections, most recent first.
A deficiency was identified when multiple residents and staff reported ongoing shortages of clean towels and linens, leading to the use of makeshift items such as sheets, pillowcases, and diapers for personal care. Staff described receiving far fewer towels than needed, with some resorting to cutting up old towels or purchasing their own wipes. Residents with significant care needs were unable to maintain personal hygiene due to the lack of supplies, and stained or damaged linens were observed in use because laundry staff could not replace them with new items.
Two residents were involved in a physical altercation, resulting in one sustaining a facial abrasion. The incident occurred as one resident was leaving the dining room and was struck by another, who was a new admission with no prior behavioral issues. Staff provided first aid, notified appropriate parties, and documented the event, but the facility failed to prevent the assault.
Two residents were involved in a physical altercation resulting in injury, which was reported internally and to law enforcement, but the required notification to the State Agency was not completed due to miscommunication between the Administrator and DON. Facility records and State Agency confirmation showed no evidence of the mandated report being submitted, despite facility policy requiring prompt reporting of abuse incidents.
A resident alleged verbal and mental abuse by two staff members, but the facility did not follow its policy to immediately suspend the accused staff during the investigation. The Administrator allowed the staff to continue working, citing staffing needs and the resident's absence, despite the policy requiring suspension to protect residents. The DON confirmed the policy was not followed.
Two residents did not receive prescribed medications as ordered, including missed doses of eye drops for glaucoma and intravenous antibiotics for cellulitis. MAR reviews and staff interviews confirmed the omissions, with staff unable to explain the missed administrations. Facility policy requires medications to be given and documented as ordered.
A resident's belongings were improperly packed during discharge, with clothing and a bottle of chocolate syrup placed together, resulting in the syrup leaking onto the clothes. The items were given to a family member on a dirty cart, and the family refused to accept them due to the contamination. Staff interviews confirmed that food should not have been packed with clothing and that the facility's policy on respectful handling of personal property was not followed.
Staff failed to prevent both verbal abuse by a former LSW toward a resident and multiple incidents of physical abuse between residents, including hitting, scratching with a comb, and slapping a cup that caused injury. These events occurred despite the facility's abuse prevention policy and were confirmed by staff and resident interviews.
A resident with severe cognitive impairment and a history of stroke experienced an unwitnessed fall. Staff performed immediate assessment and notified the physician and family, but did not review or communicate the resident's use of antiplatelet medication as required by facility protocol. The physician later indicated that knowledge of the medication would have prompted further diagnostic action. The facility failed to fully implement its fall protocol, including medication review and comprehensive assessment.
A resident experienced a lack of dignity during incontinence care when a CNA used a bed sheet instead of towels due to a shortage. The facility's administrator acknowledged previous concerns about towel availability, which could lead to skin breakdown and affect residents' dignity. The resident, who is cognitively intact, has a care plan that does not document the use of bed sheets for care.
A resident with multiple health conditions, including eczema, did not receive timely nail trimming and care, leading to long fingernails with debris. Despite being cognitively intact and requiring assistance for personal hygiene, the resident's request for nail trimming was not fulfilled. The facility lacked a specific grooming policy, relying on a general ADL policy, which was not adequately followed, resulting in a deficiency in nail care.
The facility failed to implement adequate fall prevention interventions and supervision for two high fall risk residents. One resident, with multiple diagnoses including Parkinson's and Alzheimer's, was left unsupervised, leading to a fall. Another resident, with a history of falling, was found with improperly placed fall mats and inadequate supervision. The facility's policy required quarterly fall risk assessments and appropriate interventions, but these were not consistently performed, contributing to the deficiencies observed.
A resident with dementia and other cognitive impairments eloped from a facility due to inadequate supervision and security measures. Despite known elopement risks, the resident exited through a fire door, triggering an alarm that staff failed to respond to effectively. The resident was later found deceased, highlighting severe lapses in the facility's monitoring and safety protocols.
The facility failed to follow proper sanitation and food handling practices, risking food contamination. A cook used a blender pitcher and spatula still wet with sanitizer to puree pasta, despite a kitchen aide acknowledging the need for drying to prevent contamination. The facility's policy requires sanitizing but lacks guidance on drying before reuse.
The facility failed to maintain infection control standards, as a resident's urinary catheter bag was found on the floor, risking contamination. Additionally, linens were improperly handled, touching the floor during folding, and an air blower in the linen room was dusty. The facility's infection prevention policies were outdated and lacked annual review documentation.
A registered nurse failed to document medication administration immediately after administering medications to 19 residents, as required by the facility's policy. The nurse took the MAR away from the medication cart to sign off on the medications after the fact, which is against professional standards. The DON confirmed that undocumented medication administration is considered not given, potentially leading to errors.
The facility failed to ensure controlled substances were counted and documented at shift changes for two shifts, potentially affecting 45 residents. On two occasions, the required narcotic drug count was not performed or documented, with missing signatures on the Shift Change Accountability Record. The DON stated that the facility's policy requires off-going and oncoming nurses to count narcotics together, and failure to do so raises concerns about potential drug diversion.
The facility failed to secure medications and remove expired stock, as observed by surveyors. An LPN left a medication cart unlocked, risking resident access and potential medication errors. Additionally, an RN found expired Vitamin B6 in a cart, admitting expired medications were not checked or discarded as required by policy.
The facility failed to refer two residents with serious mental disorders for Level II PASRR screenings. One resident, diagnosed with paranoid schizophrenia and major depressive disorder, lacked documentation for a Level II screening despite an initial Level I screening. The administrator acknowledged the oversight but was unsure why the referral was not made. Another resident with schizoaffective disorder and schizophrenia was also not referred for a Level II screening, as their name was not added to the PASRR Census Report until the survey day, contrary to facility policy.
Two residents in the facility were found with overgrown and unkempt toenails, despite expressing a desire for care. One resident had toenails overgrown to 1/2 inch past the tip of her great toes, while another had thick, curled toenails with black discoloration. Both residents were cognitively intact and had care plans that included toenail care by a podiatrist. However, the facility failed to ensure these residents were assessed and received the necessary care, as per their policy that requires a podiatrist to perform toenail care.
A resident with severe cognitive impairment was found chewing on a piece of his incontinence wear, which posed a choking hazard. A CNA offered a chocolate bar to persuade the resident to remove the item, unaware of the resident's dietary restrictions. The incident was not reported to the nurse immediately, contrary to facility policy.
The facility failed to document the immunization status for two residents regarding influenza and pneumococcal vaccinations. There were no records of immunizations in the electronic record, and the Infection Preventionist/Registered Nurse acknowledged the oversight. Additionally, the facility's immunization policy was outdated and had not been reviewed or updated annually.
A staff member failed to follow standard precautions and proper hand hygiene during incontinence care for two residents. The staff did not use necessary cleansing materials and touched surfaces with soiled gloves, violating the facility's policies on perineal care and hand hygiene. The residents involved had complex medical histories, including incontinence, and the Director of Nursing confirmed the expectations for proper procedures to prevent infection.
The facility failed to provide timely incontinence care for two residents who required assistance with toileting. One resident was left unchanged for approximately five hours, and another reported waiting 5-6 hours for care. Both residents were found with heavily soiled incontinence briefs, despite the facility's policy requiring care every two hours.
The facility failed to ensure call light accessibility for several residents, leading to extended wait times for assistance. Residents reported call lights being left out of reach, and observations confirmed this issue. A CNA was found inattentive, using a cell phone while a resident's call light was on the floor. The facility's policy requires call lights to be within reach, but this was not consistently followed.
Failure to Provide Adequate Clean Towels and Linens for Resident Care
Penalty
Summary
The facility failed to provide an adequate supply of clean towels and linens in good condition for resident care, as evidenced by multiple observations, interviews, and record reviews. Residents reported having to purchase their own towels due to shortages, and staff confirmed that there were not enough towels and linens available to meet the needs of all residents. On several occasions, staff resorted to using sheets, pillowcases, or even diapers to clean residents when towels and washcloths were unavailable. The laundry staff acknowledged delivering significantly fewer towels than required, and described cutting up bath towels to create makeshift washcloths, which were observed to be tattered, frayed, and stained. Clean linens and blankets were also observed to have persistent stains, including feces, pus, and blood, which could not be removed despite laundering. Residents affected by this deficiency included individuals with significant care needs, such as those who were always incontinent of urine and bowel, required maximal assistance for hygiene, and had multiple comorbidities including morbid obesity, diabetes, contractures, and mobility limitations. These residents were dependent on staff for all aspects of personal care, including bathing, toileting, and hygiene. The lack of adequate linens and towels directly impacted their ability to maintain personal cleanliness and dignity, as they were sometimes unable to wash their faces or be properly cleaned after incontinence episodes. Staff interviews revealed that the shortage of towels and linens was a recurrent and well-known problem, with CNAs frequently having to search other units or purchase their own wipes to provide care. Laundry staff reported being unable to discard stained or damaged linens due to insufficient supply, and did not have access to new linens stored in a locked supply closet. Nursing and administrative staff were aware of the issue, with some indicating that they had provided instructions for reporting shortages, but the problem persisted due to lack of communication and inadequate replenishment of supplies.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent a resident-to-resident physical assault involving two residents, resulting in one resident sustaining a skin abrasion. One cognitively intact resident reported being struck on the left side of her face by another resident as she was leaving the dining room. She experienced bleeding from a small abrasion and sought assistance from staff, who provided first aid. The resident declined hospital treatment, reporting only a minor scratch and no ongoing pain. Staff observed a small scar on her face with no signs of infection during the survey. Interviews with staff revealed that the incident was reported promptly, and the involved resident was described as calm and non-provocative. The resident who committed the assault was a new admission with no prior signs of agitation or aggression. Staff and police were notified, and the resident responsible for the assault was sent for psychiatric evaluation. Documentation confirmed the physical altercation and the resulting injury, and the facility's abuse policy was referenced, which states that residents have the right to be free from abuse.
Failure to Timely Report Resident-to-Resident Abuse to State Agency
Penalty
Summary
The facility failed to report an incident of resident-to-resident physical abuse to the State Agency as required. On the day of the incident, one resident was struck in the face by another resident while entering the dining room, resulting in a bleeding abrasion on the left side of the face. The injured resident, who was cognitively intact, reported the incident to staff, and the LPN on duty observed the injury and notified the Assistant Director of Nursing, the police, both residents' physicians, and family members. The resident who committed the act was sent to the hospital for psychiatric evaluation. Despite internal notifications and documentation of the incident, there was confusion among facility leadership regarding who was responsible for submitting the required report to the State Agency. The Administrator believed the DON was responsible, while the DON stated she was not able to submit the report due to being offsite and without computer access, and that the Administrator had agreed to handle it. Both parties referenced their usual practices for reporting but could not provide evidence that the report was submitted for this specific incident. Review of facility records and confirmation from the State Agency indicated that no report was received for the incident. The facility's own policy requires that all allegations of abuse involving injury be reported to the State Agency within two hours, with a final report submitted within five business days. For this incident, the initial and final reports provided by the facility were undated, untimed, and lacked any evidence of submission. The absence of confirmation documentation and the statements from both the Administrator and DON confirmed that the required reporting did not occur for this event.
Failure to Follow Abuse Investigation and Suspension Policy
Penalty
Summary
The facility failed to follow its policy regarding the investigation and prevention of further abuse following allegations made by a resident. Specifically, a resident reported that a CNA was verbally abusive and that a Restorative Aide engaged in mental abuse. The resident could not recall the exact date or time of the incidents, and there were no witnesses. Upon being informed of the allegations, the Administrator acknowledged that there were no prior reports against the staff members in question but stated she would follow up. The facility's policy requires immediate suspension of any staff accused of abuse pending investigation to protect residents from potential harm. However, the Administrator did not suspend the accused staff, citing the need to maintain staffing levels during the holidays and the resident's absence from the facility. The Administrator conducted interviews with the accused staff and completed the investigation quickly, allowing the staff to continue working without suspension. The Director of Nursing confirmed that the facility's policy is to immediately suspend any staff accused of abuse, whether they are on duty or scheduled to work, until the investigation is complete. Documentation reviewed included the facility's abuse policy, investigation and reporting documents, and in-service attendance records. The failure to suspend the accused staff during the investigation was not in accordance with the facility's established policy and procedures.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to administer medications as prescribed by physicians for two residents. One resident, with diagnoses including glaucoma, anxiety disorder, and major depressive disorder, did not receive all required doses of her prescribed eye drops (brimonidine tartrate) on two occasions, as confirmed by both her statements and a review of the Medication Administration Record (MAR). The MAR was not signed for these doses, and the nurse responsible could not provide an explanation for the missed documentation or administration. Another resident, with complex medical conditions including cellulitis, MRSA infection, and an open wound, did not receive his prescribed intravenous antibiotic (daptomycin) on three separate occasions. The MAR confirmed these missed doses, and the Assistant Director of Nursing acknowledged that the antibiotic should not have been missed to ensure proper treatment of the infection. The nurse practitioner indicated that insurance issues delayed approval for the medication, leading to a change in antibiotic therapy after several missed doses. Facility policy and job descriptions require medications to be administered as ordered and documented accordingly.
Resident Belongings Mishandled During Discharge
Penalty
Summary
A resident's personal belongings were not treated with respect during the discharge process. When the resident was transferred to another facility, a family member arrived to collect the resident's items and found that all belongings had been placed together in a single bag on a dirty cart. The family member observed that chocolate syrup had leaked onto the resident's clothes, contaminating them. Staff interviews confirmed that food items, specifically a bottle of chocolate syrup, were packed together with clothing, resulting in the spillage. The staff involved were unclear about who specifically packed the belongings, but it was acknowledged that the facility's policy prohibits packing food with clothing and requires respectful handling of resident property. The Director of Nursing (DON) and an LPN both stated that the facility was not informed in advance that the family would be picking up the belongings, and the process for packing and storing items was not properly followed. The family member refused to accept the contaminated belongings and requested a refund, which led to further communication attempts with the facility's administration. The facility's policy, dated March 2025, specifies that resident belongings must be treated with respect, regardless of their perceived value, a standard that was not met in this instance.
Failure to Prevent Verbal and Physical Abuse by Staff and Residents
Penalty
Summary
The facility failed to prevent both verbal and physical abuse involving staff and residents. In one incident, a former Licensed Social Worker (LSW) engaged in a verbal altercation with a resident in the dining room, during which both parties exchanged profanities. Multiple staff members and the resident involved confirmed that the staff member used inappropriate language and engaged in argumentative behavior, which was considered verbal abuse. The altercation was witnessed and reported by staff, and the resident expressed feeling abused by the staff member's actions. Additionally, the facility did not prevent physical abuse between residents in several instances. In one case, a resident was struck on the head by another resident without provocation, as observed by a CNA. In another incident, a resident was scratched on the face with a comb by another resident following an argument about a prosthetic sleeve, resulting in superficial injuries. The aggressor in this case had expressed unfounded fears about disease transmission, and the victim reported feeling unsafe due to the return of the aggressor to the facility. A further incident involved a resident slapping a cup out of another resident's hand, causing the cup to hit the resident in the lip during a verbal confrontation. The facility's abuse prevention policy states that residents have the right to be free from all forms of abuse, including physical and verbal abuse, and that protection must be provided from abuse by anyone, including staff and other residents. Despite this policy, the facility did not effectively prevent these incidents of abuse.
Failure to Follow Fall Protocol and Medication Review After Unwitnessed Fall
Penalty
Summary
The facility failed to follow its fall clinical protocol for one resident who experienced an unwitnessed fall. According to staff interviews and record review, the resident was found sitting on the floor next to his bed early in the morning. Immediate assessment was performed, including checking vital signs, and the resident was assisted back to bed. The resident was severely cognitively impaired, with a history of cerebrovascular accident resulting in right hemiparesis, and was at high risk for falls as documented in his care plan. Despite the facility's protocol requiring assessment and documentation of all current medications, especially those associated with increased risk of bleeding, there was no evidence that the resident's use of antiplatelet medication was considered or communicated to the physician at the time of the fall. The primary physician later stated that, had he been informed of the resident's antiplatelet use and the unwitnessed nature of the fall, he would have ordered a CT scan due to the risk of internal bleeding, even though the resident's vital signs were stable. The protocol also required a thorough head-to-toe assessment and monitoring for signs of injury, which was not fully documented in the records reviewed. Staff interviews revealed inconsistent understanding and application of the fall protocol, particularly regarding the need to review medications and communicate relevant information to the physician. The facility's failure to follow its own clinical protocol for falls, including comprehensive assessment and communication, resulted in a deficiency related to providing appropriate treatment and care according to orders, resident preferences, and goals.
Deficiency in Resident Dignity During Incontinence Care
Penalty
Summary
The facility failed to ensure the dignity of a resident during incontinence care. On January 15, 2025, a Certified Nursing Assistant (CNA) was observed providing care to a resident (R2) without the use of proper towels, instead using a bed/flat sheet to wipe the resident's bottom. The resident confirmed that the facility often runs out of towels, leading to the use of pillowcases and bed sheets for incontinence care. This practice was observed when the CNA had to leave the room to retrieve a linen cart, only to find no towels available, thus resorting to using a bed sheet. The facility's administrator acknowledged a previous concern regarding the availability of linen towels and mentioned that the issue might be due to staff mistakenly discarding them. The administrator stated that the lack of towels could lead to skin breakdown and affect the residents' dignity, as they have the right to an environment similar to their home. The resident involved, R2, is a cognitively intact individual with a BIMS score of 15/15 and has medical conditions including osteoarthritis, morbid obesity, and incontinence. The resident's care plan did not document the use of bed sheets for incontinence care, highlighting a gap in ensuring the resident's dignity and proper care.
Deficiency in Resident Nail Care
Penalty
Summary
The facility failed to provide timely nail trimming and care for a resident, identified as R1, who was part of a sample of three residents reviewed for activities of daily living (ADL) care. R1's admission record includes diagnoses such as moderate intellectual disabilities, acute kidney failure, major depressive disorder, hypertensive heart disease without failure, anxiety disorder, schizoaffective disorder, and scabies. Despite being cognitively intact with a BIMS score of 15, R1 required partial/moderate assistance for showering and supervision or touching assistance for personal hygiene. Observations on 9/30/24 revealed R1 struggling to open a milk carton due to long fingernails with debris underneath, indicating a lack of proper nail care. On 9/30/24, a registered nurse and a licensed practical nurse assisted R1 with drinking from the milk carton but did not address the long fingernails. R1 expressed a desire to have the nails trimmed, acknowledging that staff had previously offered to cut them. However, the nails remained untrimmed and unchanged by 10/1/24. A certified nursing assistant confirmed that R1 had requested nail trimming but noted that the clippers were kept with the nurse. The facility's wound care nurse and director of nursing acknowledged the importance of keeping R1's nails short to prevent skin tears, especially given R1's ongoing treatment for intrinsic eczema and tinea. The facility lacked a specific policy for grooming and nail care, relying instead on a general ADL policy. The policy stated that residents should receive routine daily care to promote hygiene and comfort, with ADL care provided throughout the day. Despite this, R1's care plan, which included interventions for skin integrity and self-care deficits, was not adequately followed, resulting in the observed deficiency in nail care. The facility's job descriptions for CNAs and RNs emphasized the importance of adhering to professional standards and providing comprehensive ADL care, which was not met in this instance.
Inadequate Fall Prevention and Supervision for High-Risk Residents
Penalty
Summary
The facility failed to implement adequate fall prevention interventions and supervision for two high fall risk residents, R2 and R3. R2, who has multiple diagnoses including Parkinson's disease, Alzheimer's disease, and dementia, was identified as a high fall risk due to impaired cognitive skills and mobility issues. Despite this, R2 was left unsupervised at the nurse's station, leading to a fall incident. The staff, including CNAs and nurses, were inconsistent in their understanding and communication of R2's fall risk status, and R2 was observed wearing non-skid proof socks, contrary to the care plan's intervention for appropriate footwear. R3, also a high fall risk resident with a history of falling and multiple medical conditions, was found in a room with fall mats improperly placed away from the bed. R3's cognitive skills were severely impaired, and the resident was observed leaning over the bed without adequate supervision. The staff's responses indicated a lack of awareness of R3's fall risk status, and the fall prevention interventions were not consistently implemented, as evidenced by the improper placement of fall mats. The facility's policy required quarterly fall risk assessments and appropriate interventions for high-risk residents, but these were not consistently performed. R2's fall risk assessment was overdue, and there was a lack of communication among staff regarding the residents' fall risk status and necessary precautions. The facility's failure to adhere to its fall prevention program and ensure proper supervision and interventions contributed to the deficiencies observed in the care of R2 and R3.
Failure to Prevent Resident Elopement Leads to Tragic Outcome
Penalty
Summary
The facility failed to properly monitor and supervise a resident with a known risk of elopement, resulting in the resident leaving the facility without permission. The resident, who had a history of dementia, bipolar disorder, and PTSD, was cognitively impaired and required supervision to ensure safety. Despite these needs, the resident managed to exit the facility through a fire exit door, triggering an alarm that staff failed to respond to effectively. The resident was later found deceased in an abandoned building, highlighting the severe consequences of the facility's oversight. Interviews and observations revealed that the facility had inadequate security measures in place, such as malfunctioning alarms and easily accessible elevator codes, which residents could use to leave the building unsupervised. Staff members, including the receptionist and nursing staff, were aware of the resident's elopement risk but did not take appropriate actions to prevent the resident from leaving. The facility's elopement risk assessments and care plans were not effectively implemented, and there was a lack of documentation and communication regarding the resident's attempts to leave the facility. The facility's failure to maintain a secure environment and provide adequate supervision for residents at risk of elopement was further compounded by staff's inability to promptly locate the resident after the alarm was triggered. The facility's policies on missing residents and elopement risk were not adequately followed, leading to a tragic outcome. The lack of proper training and awareness among staff members contributed to the facility's inability to prevent the resident's elopement and subsequent death.
Removal Plan
- R1 is no longer at the facility.
- Resident head count of the whole facility was completed by the DON/clinical managers. There was no concern identified.
- Headcount is done during shift change as part of the nurse-to-nurse shift reporting and when the staff identifies that a resident is missing.
- Facility wide audit was done to identify residents that are high risk for elopement by the DON, unit manager, Administrator and Social Services.
- Any resident who is identified with wandering behavior/elopement risk will have care plans developed. This will be completed by the IDT.
- The elopement binders have been updated and all elopement binders in all floors. The elopement binder is updated when a new resident is added to the binder. A resident is added to the binder when the resident is identified with exit seeking-behavior/risk for elopement.
- The Maintenance Director or designee will check all exit doors. Initially done and daily.
- The DON or designee will provide education and competency test to the staff including agency staff. The education items include but not limited to: Code 99, Use of the elopement binders, Exit-seeking behaviors and interventions, Elopement risk and wandering and interventions, Policy on missing resident, Responding to alarms, Resident safety and supervision. The training was completed. Any staff who are not available, on vacation or leave of absence will have training completed at the start of their shift upon return to work.
- The DON or designee also reviewed the general orientation to ensure that the following items were included: Code 99, Use of the elopement binders, Exit-seeking behaviors and interventions, Elopement risk and wandering and interventions, Policy on missing resident, Responding to alarms, Resident safety and supervision.
- Ad-Hoc QAPI meeting was completed which were participated by the leadership team which includes the Director of Nursing, ADON, Social services Director, Assistant Administrator, Rehabilitation Manager, and the Activities Director. The Medical Director also participated via telephone. The QAPI team discussed the incident and the corrective actions to prevent similar events.
- Elopement drill was completed by the Administrator. This will also be completed daily, for the seven days, and will be done at different shifts. After seven days, the elopement drills will be done weekly for three months, then monthly thereafter.
- All exit doors in the facility will also be checked by the Maintenance Director to ensure all doors were locked, secure and alarms are functioning. Staff will be stationed at each identified exit until the identified exits have a delayed egress installed. Service has been contacted and scheduled to install egress delays. Door checks will be completed daily, including weekends by the MOD manager or designee. The door checks will be completed by Maintenance Director, or designee. If there is any concern identified, the Administrator and/or the Maintenance Director will be notified immediately. If there is any concern with the door, a staff member will be assigned as door monitor until the door concern is addressed.
- Daily, the DON, clinical managers, and members of the IDT will hold clinical meetings and discuss new or worsening wandering/exit-seeking behaviors. Any new and/or worsening behaviors will be addressed by ensuring that appropriate clinical interventions are implemented to prevent an incident of elopement. The MOD/charge nurse or designee will also conduct weekend clinical meetings to review new or worsening exit-seeking/wandering behaviors and ensure interventions are in place to prevent elopement.
- New admissions will be reviewed by the DON or designee for elopement risk and any resident identified as being at risk will be updated into the facility elopement books.
- The QAPI team will hold a weekly Ad-Hoc QAPI meeting to discuss the elopement prevention program and review interventions to new/worsening wandering/exit-seeking behaviors. The QAPI team will determine if additional corrective actions are necessary based on concerns identified.
- Staff is stationed at each identified exit until the identified exits have a delayed egress installed.
- The identified exits are emergency exits and will have 15 second delayed egress installed.
- Service with outside vendor has been contacted and scheduled to install egress delays.
- All staff on the unit will respond to the codes. Follow up by the nurse-supervisor.
- Codes were changed to door. Residents do not have access to codes.
Improper Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to adhere to proper sanitation and food handling practices, which are essential to prevent foodborne illnesses among residents. During an observation, the head cook was seen pureeing a veal patty and subsequently instructed a kitchen aide to wash the blender pitcher and rubber spatula used in the process. The kitchen aide washed these items in a washer container, then moved them to a rinse container, and finally to a sanitizing compartment. However, the head cook used the blender pitcher and spatula to puree pasta while they were still wet with sanitizer, which could potentially contaminate the food. The kitchen aide acknowledged that the equipment should be completely dry before reuse to avoid contamination. The facility's policy on manual sanitizing in a three-compartment sink requires utensils and equipment to be sanitized by immersion in hot water or a chemical sanitizing solution, but it does not specify the need for drying before reuse.
Infection Control Deficiencies in Catheter Care and Linen Handling
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as evidenced by several observations and interviews. A resident with a urinary catheter was found with the catheter bag lying flat on the floor, contrary to the facility's policy that requires the catheter to maintain a sterile, continuously closed drainage system. This oversight was noted by the Director of Nursing, who acknowledged that the urinary catheter bag should not be in contact with the floor to prevent contamination. The resident had a history of urinary tract infection and was receiving antibiotic therapy, highlighting the importance of adhering to infection control protocols. Additionally, the facility did not ensure that linens were handled in a sanitary manner. A housekeeping staff member was observed folding linens that touched the floor, which is against the facility's policy that requires linens to be folded on a table to prevent contamination. Furthermore, an air blower used in the clean linen room was found to be dusty and unclean, which could potentially compromise the cleanliness of the linens. The facility's infection prevention policies and procedures were outdated and lacked documentation of annual reviews, which is necessary to ensure they are in accordance with current national standards.
Failure to Document Medication Administration Timely
Penalty
Summary
The facility failed to adhere to professional standards of medication administration documentation, affecting 19 residents. On the morning of the survey, a registered nurse (RN), identified as V15, completed a medication pass for the 9:00 AM scheduled medications but did not document the administration immediately as required. The surveyor observed that V15 took the medication administration record (MAR) away from the medication cart to sign off on the medications after the fact, which is against the facility's policy. The facility's policy mandates that medications must be documented immediately after administration to prevent errors. The Director of Nursing (DON), identified as V2, confirmed that if medication administration is not documented, it is considered not given, which could lead to medication errors. The review of the MAR for the first-floor medication cart #2 revealed that V15 did not sign for the medications administered to the 19 residents. The facility's policy, dated December 2022, clearly states that medication must be charted immediately following administration by the person administering the drugs, including the date, time, and dosage.
Failure to Document Controlled Substance Counts
Penalty
Summary
The facility failed to ensure that controlled substances were counted and documented at the beginning and end of each shift for two out of sixteen shifts, potentially affecting 45 residents on the fourth floor. On two occasions, the Shift Change Accountability Record for Controlled Substances was missing signatures, indicating that the required narcotic drug count was not performed or documented. Specifically, on August 6, 2024, a surveyor observed that the LPN responsible for the 4th floor medication cart did not sign the narcotic count sheet for the 7am-3pm shift. Additionally, on August 2, 2024, both the oncoming and off-going shifts for the same time period were missing signatures. The Director of Nursing (DON) stated that it is the facility's policy for off-going and oncoming nurses to count narcotics together to ensure an accurate count. If the oncoming nurse is late, the off-going nurse should count with another nurse or call the supervisor to perform the count. The facility's policy, dated April 11, 2023, requires that change of shift counts be conducted by authorized nursing personnel to reconcile drug availability. The failure to adhere to this policy raises concerns about the potential for drug diversion, which would necessitate an investigation.
Medication Security and Expired Stock Issues
Penalty
Summary
The facility failed to ensure medications were locked and secured while unattended and did not remove and discard expired house stock medication in three of six medication carts reviewed. On August 6, 2024, a surveyor observed a Licensed Practical Nurse (LPN) leaving a medication cart unlocked and unattended on the second floor. The LPN acknowledged that residents could potentially access the medications, leading to possible overdoses or medication errors if residents self-administered another resident's medication. Additionally, on August 7, 2024, a surveyor, accompanied by a Registered Nurse (RN), found an expired house stock medication, Vitamin B6, in a medication cart on the first floor. The Vitamin B6 had an expiration date of July 2024. The RN admitted that she does not check the medication cart for expired medications and confirmed that expired medications should not be stored in the cart and should have been discarded. The facility's policy mandates that medication carts be locked or attended by authorized personnel and that outdated drugs be immediately withdrawn from stock.
Failure to Conduct Level II PASRR Screenings for Residents with Mental Disorders
Penalty
Summary
The facility failed to refer two residents with newly evident or possible serious mental disorders to the appropriate state-designated authority for review. Resident R33, a [AGE] year-old individual, was diagnosed with paranoid schizophrenia, major depressive disorder, and unspecified schizophrenia. Despite having an initial Level I PASRR screening dated 03/04/2014, there was no documentation of a Level II PASRR screening. The facility administrator, V1, acknowledged that the system should trigger a referral for a Level II PASRR screening based on R33's diagnoses but was unsure why it was not completed. V1 also mentioned that all residents with mental health diagnoses, including those admitted long ago like R33, should have a Level II PASRR screening. Similarly, Resident R14, a [AGE] year-old male with diagnoses including schizoaffective disorder, schizophrenia, and major depressive disorder, was admitted to the facility without a Level II PASRR screening. R14 had an initial Level I PASRR screening dated 01/25/2000, but there was no documentation of a Level II screening. The facility's policy, dated 12/2023, outlines the expectation for the appointed screening agency to complete Level II screens for residents with severe mental illness or intellectual disability. However, V1 admitted that R14's name was not added to the PASRR Census Report for referral until the day of the survey, indicating a lapse in the facility's adherence to its policy.
Failure to Provide Adequate Toenail Care for Residents
Penalty
Summary
The facility failed to provide adequate toenail care for two residents, leading to overgrown and unkempt toenails. One resident was observed with toenails overgrown to approximately 1/2 inch past the tip of her great toes and 1/4 inch past the tip of her other toes. This resident expressed a desire to have her toenails cut, stating it had been more than two months since they were last trimmed. Her medical history includes type 2 diabetes mellitus, schizoaffective disorder, major depressive disorder, anxiety disorder, and mild cognitive impairment, with a BIMS score indicating she is cognitively intact. Her care plan included a referral to a podiatrist or foot care nurse for toenail care. Another resident was found with thick, curled, and overgrown toenails, with one toenail measuring approximately 1 inch in length and another with black discoloration. This resident also expressed a desire to have her toenails cut, stating it had been 6-7 months since they were last trimmed. Her medical history includes major depressive disorder, seizures, Parkinson's Disease, suicidal ideation, hypertensive heart disease, and schizophrenia, with a BIMS score indicating she is cognitively intact. Her care plan noted a risk for self-care deficit due to Parkinson's disease. The facility's policy states that toenail care is to be performed by a podiatrist, who visits weekly, but there was a failure in ensuring these residents were assessed and received the necessary care.
Failure to Address Resident's Unsafe Behavior
Penalty
Summary
The facility failed to address behaviors that could endanger the health of a resident, identified as R92, who was observed chewing on a piece of his incontinence wear. R92, an individual with severe cognitive impairment and multiple medical diagnoses including unspecified dementia and major depressive disorder, was found by a surveyor to be chewing on a light blue and white item, which was later identified by a CNA as a piece of his incontinence wear. The CNA attempted to persuade R92 to remove the item by offering a chocolate bar, which R92 accepted, and subsequently spat out the inedible item. The CNA was unaware of R92's dietary restrictions and did not report the incident to the nurse immediately. The RN and RN Supervisor acknowledged that R92 should not be eating inedible items due to the risk of choking and gastrointestinal issues. They also noted that the CNA should not have given R92 a chocolate bar due to his dietary restrictions and risk of aspiration. The Director of Nursing confirmed that the CNA should have reported the behavior to the nurse, as R92 is on a mechanically altered diet with thickened liquids due to dysphagia. The facility's policy requires that any incident involving a resident be reported to the charge nurse as soon as practicable, which was not followed in this case.
Failure to Document Immunization Status for Residents
Penalty
Summary
The facility failed to determine, offer, and document the immunization status for two residents, R481 and R157, regarding influenza and pneumococcal vaccinations, as per their policy. Upon review, it was found that there were no records of any immunizations for these residents in the electronic record under the immunization tab. The Infection Preventionist/Registered Nurse, V7, acknowledged that the immunization details should have been recorded in the designated tab, especially since R157 had been admitted more than two months prior. Additionally, the facility's immunization policy, which was last revised in December 2013, was outdated and had not been reviewed or updated annually as required. These oversights have the potential to affect the residents by not minimizing the risk of acquiring, transmitting, or experiencing complications from influenza or pneumococcal pneumonia.
Failure in Hand Hygiene and Incontinence Care
Penalty
Summary
The facility failed to adhere to standard precautions and proper hand hygiene during incontinence care, as observed by a surveyor. A staff member, identified as V4, was seen performing incontinence care on two residents without washing hands or using appropriate cleansing materials. V4 did not bring necessary items such as a washbasin, soap, and water, and instead used a wet towel to clean the residents' perineal areas. This improper technique was observed during care for a resident with a heavily soiled incontinence brief, where V4 touched various surfaces with soiled gloves and failed to wash hands before donning new gloves. The residents involved had significant medical histories, including conditions like osteoarthritis, diabetes, heart failure, and incontinence. The facility's policies on perineal care and hand hygiene were not followed, as V4 did not perform hand hygiene before and after resident care, nor did they properly cleanse the perineal area. The Director of Nursing acknowledged the expectations for staff to follow these procedures to prevent infection and cross-contamination, especially when caring for multiple residents.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for two residents, R1 and R2, who required assistance with toileting. R2, admitted with multiple diagnoses including hemiplegia and diabetes, was observed to have been left unchanged for approximately five hours, despite being always incontinent of bowel and bladder. The CNA assigned to R2 confirmed that she had not yet attended to R2, even though her shift began at 6:30 am, and the last recorded incontinence care was at 5:05 am. Upon inspection, R2's incontinence brief was found heavily soiled with urine. Similarly, R1, who also has a history of multiple medical conditions including osteoarthritis and heart failure, reported being left unchanged for several hours. R1 stated that she often urinates multiple times before being changed and sometimes waits 5-6 hours for care. During an observation, R1's incontinence brief was found soiled with both urine and feces. The CNA confirmed that R1 was last checked around 9 am, which was several hours before the observation. The facility's policy requires incontinence care to be provided at least every two hours, which was not adhered to in these cases.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to adhere to its call light protocol, resulting in several residents not having access to their call lights. Six residents were affected, with some reporting waiting times of over an hour for assistance. Residents expressed concerns about call lights being left out of reach, particularly when they were unable to move independently. One resident mentioned that this issue had persisted for over a month despite informing the administrator. Observations confirmed that call lights were often placed on the floor or nightstand, making them inaccessible to residents who required assistance. During the survey, a certified nurse assistant was observed using a cell phone while a resident's call light was on the floor, indicating a lack of attention to resident needs. The facility's policy requires call lights to be within reach at all times, but this was not consistently followed. The Director of Nursing acknowledged the importance of having call lights accessible to prevent potential harm. However, the facility did not conduct a call light assessment, and staff were not consistently ensuring that call lights were within reach during rounds.
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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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