Chicago Ridge Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago Ridge, Illinois.
- Location
- 10602 Southwest Highway, Chicago Ridge, Illinois 60415
- CMS Provider Number
- 145639
- Inspections on file
- 58
- Latest survey
- February 6, 2026
- Citations (last 12 mo.)
- 12 (1 serious)
Citation history
Health deficiencies cited at Chicago Ridge Snf during CMS and state inspections, most recent first.
A resident with schizoaffective disorder and other comorbidities had Seroquel doses progressively increased without documented informed consent from the resident or his guardian and without behavior documentation or evidence of non-pharmacological interventions, despite facility policy requiring these steps. The resident reported concern about receiving higher doses than expected and stated he had not consented and was refusing the medication. Behavior monitoring sheets over several months showed no behaviors, while the guardian reported concerns about the resident’s worrying and frequent calls to police and believed the dose remained at 100 mg. The ADON, psychiatrist, psych NP, and an LPN all acknowledged either the absence of documented behaviors or the requirement for informed consent and behavior documentation, which were not met.
A resident with a contracted left hand and wrist was repeatedly observed sitting in a wheelchair with the hand clenched in a fist and no device in place to prevent further contracture, despite a care plan stating the resident would perform AROM to all extremities. The resident reported that staff had not encouraged arm or hand exercises. The restorative nurse stated they were unaware of the contracture and had not assessed the resident’s restorative needs, and the therapy manager reported that therapy had not been informed of the condition until the surveyor’s inquiry. On assessment, the resident experienced pain when attempting to open the hand, and the therapy manager indicated the resident would benefit from a resting hand splint, contrary to facility policies and the restorative nurse job description requiring timely restorative evaluation, coordination with therapy, and management of splints.
The facility did not follow its own Community Access Determination policy requiring Social Services to complete community survival skills assessments upon admission and quarterly for all residents, and when outside passes are requested. Record review showed that several residents had not received a community skills assessment for many months beyond the required frequency. During interview, Social Services staff described a practice of completing these assessments quarterly, annually, and with outside pass requests, while a separate internal document listed them as admission, significant change, and annual assessments, which conflicted with the written policy. The DON and ADON later clarified that this internal document was not a formal policy, yet the documented assessment schedule still did not match the policy requirements, resulting in missed assessments for multiple residents.
A resident reported that her personal cell phone went missing from her room and stated she informed the Social Service Director, an RN, and CNAs, but did not receive follow-up or a written response. The resident documented the report and later noted that a phone was found in a medication storage room, while staff interviews confirmed that the concern had been reported but not pursued. The grievance binder contained no written grievance about the missing phone, and a grievance form produced by the facility lacked the preparer’s name and only suggested another resident might have taken the phone. Review of belongings inventories showed the resident’s phone and other personal items were not listed, and the inventories were not signed by the resident, despite facility policies requiring complete documentation and resident signatures for belongings and written, timely handling of grievances.
The facility failed to implement its abuse prevention policy when a resident with psychosis, schizophrenia, and bipolar disorder, who had been frequently refusing ordered psychotropic medications, entered another resident’s room, became upset about spoiled milk, and physically assaulted her by hitting her head with a milk carton, pushing her onto the bed, and violently shaking her until another resident intervened and staff arrived. Multiple residents provided consistent statements that the aggressor was on top of and hitting the victim, who reported pain to her arm and behind her ear. Despite repeated medication refusals and a recent hospitalization for aggressive behavior, there was no documentation that the physician or psychiatrist was notified with each refusal, and NP notes indicated no nursing concerns. The facility’s abuse investigation did not include staff interviews and concluded there was no credible evidence of abuse, contrary to the resident witness accounts.
A resident with severe mental illness, documented poor impulse control, and a history of physically abusive behavior was not adequately supervised, despite care plans calling for daily monitoring and psychotropic medication management. The resident, who was known to be noncompliant with medications and exhibited delusions, disorganized thought processes, and auditory hallucinations, was able to enter another resident’s room, become agitated over a milk carton he believed was spoiled, and verbally and physically assault the resident by striking her with the carton, pushing her onto the bed, and violently shaking and hitting her until other residents and staff intervened.
The facility failed to prevent illicit drugs from being brought in, distributed, and used by residents, resulting in two residents testing positive for fentanyl and opiates and experiencing medical emergencies, including one requiring Narcan. Multiple residents and staff reported ongoing drug distribution within the facility, and drug paraphernalia was found in resident rooms and ceilings. The facility lacked an effective plan to identify how drugs were entering, did not consistently enforce its contraband policy, and staff were unclear about when to administer Narcan.
A resident receiving hydrocodone-acetaminophen for pain did not have consistent documentation in the MAR at the time of administration, and staff failed to consistently monitor and record the effectiveness of the pain medication. Interviews with the ADON and an LPN confirmed that facility policy for medication administration and documentation was not followed, resulting in incomplete records for controlled substance administration.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Surveyors observed that window drapes in the rooms of several residents were falling from curtain rods or tracks, with some rooms using towels to cover window openings. Maintenance staff acknowledged the issue but did not resolve it during the survey, and a resident reported making repeated requests for assistance with her curtains. The DON confirmed that rooms should be clean and homelike, and the facility's housekeeping policy requires a safe and sanitary environment, which was not met in this instance.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as observed by surveyors during the review of care practices.
One of two elevators was nonfunctional, causing delays for residents, staff, and visitors who rely on elevator access for daily activities and services. Maintenance staff reported ongoing issues with elevator breakdowns and could not specify which elevator was serviced or the cause of repeated failures. The facility's maintenance policy lacked protocols for elevator operation.
A resident with a history of substance abuse and a care plan restricting unsupervised passes was allowed to leave on a supervised community pass without proper verification of the escort's identity. The staff failed to ensure the person taking the resident matched the name on the pass request form, and the resident did not return to the facility.
Two residents with diabetes did not receive timely podiatry care or follow-up visits as ordered, resulting in long, thick, and discolored toenails. Despite requests for podiatry services and physician orders for regular follow-up, there was no documentation of recent podiatrist visits or adherence to the facility's policy for diabetic foot care.
A resident with a history of substance abuse obtained and used illicit drugs within the facility, resulting in an overdose that required Narcan administration and hospital transfer. Despite clear signs of drug use and staff and resident reports of suspicious behaviors, the facility did not investigate how the drugs entered the facility or how the resident accessed them, nor did they follow up with involved parties or document the incident as required by policy.
Two residents with histories of substance abuse did not receive required group programming or consistent behavioral health services, despite facility policies and care plans indicating these supports. One resident was excluded from substance abuse groups due to lack of admission documentation, and another did not receive regular counseling, resulting in illicit drug use and an overdose requiring hospital transfer.
A resident with chronic ischemia and vascular disease did not have physician orders to monitor her right foot for discoloration, pedal pulse, and temperature changes transcribed or implemented. Despite a nurse practitioner's verbal order and the presence of a blister, there was no documentation of monitoring or assessment in the medical record, and staff were unaware of the specific orders. This failure was contrary to facility policy requiring all physician orders to be recorded and followed.
A resident with a fractured ankle was physically assaulted by another resident in the dining room when no staff were present to monitor. Both residents had intact cognition and no care plans addressing abuse risk. Staff interviews and records confirmed that the dining room was often left unsupervised, especially during shift changes, and the assaulted resident required hospital evaluation for facial trauma.
A resident with a history of falls and cognitive impairment developed new right hip pain and became non-ambulatory. Despite therapy and nursing staff being notified, there was no timely or documented pain assessment, and PRN pain medication was not administered or recorded as required. The resident remained in pain for about 24 hours before being hospitalized for a hip fracture and surgery, with facility records and staff interviews confirming a lack of adherence to pain management policy.
A resident with a history of psychiatric disorders and intact cognition refused a scheduled long-acting injectable psychotropic medication. The LPN did not document the refusal or notify the physician, as required by the care plan and facility policy. The psychiatric nurse practitioner was unaware of the missed dose, and the DON confirmed that such refusals should be reported and documented.
A resident was verbally abused by a former Social Service Aide/Smoking Monitor during smoking time when the aide refused to provide a cigarette and used derogatory language. The incident was witnessed by another resident and reported to an LPN, who informed the Administrator and filed a police report. The resident involved was cognitively intact and had multiple diagnoses, including anxiety and depression.
The facility's pest control program failed to effectively manage a cockroach infestation, as evidenced by live cockroaches observed in resident rooms and frequent complaints from residents and staff. Despite scheduled pest control visits and actions taken in response to grievances, the issue persisted, affecting the facility's cleanliness and resident satisfaction.
A resident with a history of falls and multiple risk factors experienced repeated falls due to the facility's failure to implement care plan interventions and appropriate fall prevention measures. Despite requiring substantial staff assistance and having specific interventions outlined, the resident fell during unassisted transfers, and the facility could not provide evidence of required physical therapy evaluations.
A resident with a history of seizures and dementia eloped from a facility unsupervised, despite requiring supervision for community access. The resident was later found intoxicated by police, highlighting deficiencies in the facility's supervision and safety protocols. The facility lacked an authorized pass policy, and the resident exited through a basement back door without staff noticing.
The facility failed to promptly respond to call lights, affecting five residents, including those with significant health issues. Observations showed staff ignoring activated call lights, despite being nearby, leading to residents experiencing discomfort and potential health risks. The Director of Nursing confirmed that all staff should respond to call lights immediately, as per policy.
A resident with reduced mobility was left in a chair for 17 hours due to an uncharged mechanical lift. The family member reported the grievance, but the facility failed to document or resolve it promptly, violating their grievance policy.
On Christmas Day, insufficient staffing led to a failure in administering medications to 34 residents on the third floor of an LTC facility. Only one LPN was available, who did not cover the entire floor, resulting in missed medications for residents with various medical conditions. The DON was aware of the staffing issue but did not provide additional support, and the facility lacked a holiday staffing plan.
A facility failed to administer medications to 34 residents on the third floor during the day shift on Christmas Day due to understaffing. An LPN was responsible only for her assigned residents and did not cover the entire floor, while the DON was aware of the staffing issue but did not ensure all residents received their medications. The facility's policy requires supervision of medication administration, but the failure was not communicated to prescribers, highlighting a breakdown in communication and protocol adherence.
The facility failed to administer seizure medications to five residents on Christmas Day due to staffing shortages and communication issues. An LPN only administered medications to a portion of the residents, while the DON was aware of the staffing issue but did not ensure all residents received their medications. This resulted in missed doses for residents with conditions like dementia and seizures.
A resident with severe cognitive impairment was physically abused by his roommate, resulting in a chest contusion. The incident was not witnessed by staff, but the resident reported being punched, leading to a hospital transfer. The facility's failure to prevent this altercation highlights a deficiency in their abuse prevention program.
The facility failed to serve the planned meals to all 211 residents on two occasions. Residents were served white bread instead of garlic Texas toast for lunch and cream of wheat and scrambled eggs without cheese instead of oatmeal and scrambled eggs with cheese for breakfast. Additionally, there was a shortage of cold cereal and toast, leading to some residents not receiving their requested meals.
The facility failed to provide adequate dining supplies during a lunch meal service, affecting 75 residents. Initially, 45 residents received meals on plastic plates, but the staff ran out, serving the remaining 30 on Styrofoam plates. Additionally, 10 residents received coffee in Styrofoam cups without handles, and 25 residents were not given napkins. The dining room staff did not notify the kitchen to replenish supplies, despite sufficient stock being available.
A facility failed to initiate a timely falls care plan for a resident with a history of falling and generalized weakness. Despite the resident's ability to communicate needs, fall precautions were not implemented immediately upon admission. The resident was observed with injuries from a fall, and the call light cord was repeatedly out of reach. The restorative nurse did not investigate the fall or document necessary interventions in the care plan, which was initiated days later and backdated.
A resident with a history of falls was not accurately assessed for fall risk upon admission, and necessary fall prevention interventions were not implemented. The resident's call light was out of reach, and visible injuries indicated a fall. The Restorative Nurse did not investigate the fall or update the care plan, and the Director of Rehabilitation failed to prioritize the resident for skilled therapy. The facility's fall risk and post-fall assessment policy was not followed, resulting in a deficiency.
The facility failed to maintain a clean and homelike environment, with pervasive urine odors and unclean conditions affecting several residents. Staffing shortages and insufficient cleaning supplies contributed to the issue, as only one housekeeper was available for the third floor. Residents reported unclean rooms and soiled linens, while the facility's owner was unaware of the supply and staffing problems.
The facility did not follow its policy for serving food under sanitary conditions, affecting 66 residents on the 2nd floor. Meal trays were observed uncovered, with gnats present, despite available clean lids. CNAs reported lids were often unavailable or unnoticed, risking contamination. The DON confirmed the need for covered trays to prevent contamination and maintain temperature, as per the facility's policy.
A resident with limited speech due to medical conditions was not provided with a communication board, despite documentation indicating it was needed. Staff, including an LPN and CNA, struggled to understand the resident, and the DON noted that social services should supply the boards. The Social Services Worker used a board but did not leave it with the resident, leading to unmet communication needs.
Two residents with mental health diagnoses were involved in an altercation over a water bottle, during which one resident claimed to have been physically assaulted. Despite staff witnessing aggressive behavior, the facility did not identify or investigate the incident as abuse, contrary to its policy. The lack of communication and awareness among staff contributed to this oversight.
The facility failed to implement effective COVID-19 precautions and infection surveillance, affecting multiple residents. Discrepancies in resident tracking, lack of proper signage and PPE, and inadequate monitoring of vital signs were observed. Visitors were not consistently informed of the outbreak or provided with masks, and infection control policies were not adequately followed.
The facility did not follow its policy to notify a resident's responsible party about the resident's hospitalizations. A survey revealed that the family member of a resident was not informed of two hospitalizations, and the Director of Nursing confirmed this oversight. The facility's policy requires notifying the resident, their physician/NP, and the responsible party of any change in condition, with documentation in the resident's medical record.
The facility failed to maintain effective pest control, leading to widespread issues with roaches, gnats, and flies affecting all residents. Observations and interviews revealed pests in residents' rooms and common areas, with reports of food and clutter contributing to the problem. The facility's pest control policy was not consistently followed, with treatments occurring every other week instead of weekly as recommended.
The facility failed to maintain a safe environment by not addressing mold in resident living areas. Mold was observed in the rooms of three residents, with the Maintenance Director confirming the presence of mold and acknowledging that staff should have reported the issue. The facility's Preventative Maintenance Policy, which requires regular audits to identify concerns like discolored ceiling tiles, was not effectively implemented.
The facility failed to provide daily wound treatments as ordered for two residents, leading to missed care and altered records. One resident with chronic ulcers reported infrequent bandage changes, while another with dementia called the police due to lack of care. Treatment records showed missing entries, and staff confirmed nurses were responsible for weekend care if no wound nurse was available.
A resident with multiple mental health diagnoses was reportedly handled roughly by a CNA during a brief change. The family member reported the incident to nursing staff, but it was not escalated to the Administrator as required by the facility's policy. The DON acknowledged a conversation with the CNA but claimed not to have been informed about the rough handling. The LPN confirmed the report was made to her and relayed to the DON. The Administrator stated an investigation should have been initiated, and the incident reported to the state.
A resident with multiple health conditions had stained bed linens that were not changed as needed, despite being reported by a family member to the nursing staff and social services. Observations confirmed the presence of old stains on the linens. The DON was unaware of the reports, and there was no indication of the resident refusing linen changes.
A resident with severe malnutrition and multiple health issues was not provided with adequate nutritional care. The facility failed to follow dietary orders, document food intake accurately, and honor the resident's food preferences. Despite recommendations for advanced nutritional shakes, the facility did not implement these or consult with the resident's family about dietary preferences. Observations showed the resident struggled with meals due to missing teeth and hand contractures, leading to insufficient food intake.
A resident with multiple health issues, including rheumatoid arthritis and hand contractures, was not provided with the appropriate mechanical soft diet as ordered. The resident struggled to eat tough, uncut chicken due to missing teeth, and the assisting LPN did not offer alternative foods or cut the meat, resulting in the resident consuming only a small portion of the meal. The facility's policy on dietary orders was not followed, leading to this deficiency.
A resident dependent on staff for toileting was sent to the hospital without receiving necessary incontinent care, resulting in a dignity issue. The LPN had instructed a CNA to provide care, but the CNA failed to do so and did not inform the nurse of the need for assistance. The DON confirmed the resident should have been cared for before the transfer.
A resident with a history of self-harming behavior and multiple medical conditions sustained a fracture to her right arm due to inadequate supervision and failure to follow behavior management policies. Despite exhibiting aggressive and self-harming behaviors, the facility did not provide one-to-one monitoring or administer prescribed interventions, resulting in the resident's injury.
Two residents were involved in an incident where one resident, admitted with Schizophrenia, physically assaulted another resident in the hallway. The facility failed to conduct adequate pre-admission screening and assessment of the assailant's potential for aggressive behavior, as required by their abuse policy. The incident occurred during an admission assessment, and the assailant was discharged against medical advice later that day.
Failure to Obtain Informed Consent and Document Behaviors for Psychotropic Dose Increases
Penalty
Summary
The deficiency involves the facility’s failure to follow its psychotropic medication policy by not obtaining informed consent for multiple increases in a resident’s Seroquel (quetiapine) dosage and by not documenting behaviors or non-pharmacological interventions to justify those increases. The resident, who has a history of major depressive disorder, schizoaffective disorder, morbid obesity, iron deficiency anemia, and vitamin D deficiency, reported being concerned that staff were giving him higher doses of Seroquel than the 100 mg he believed he should receive and stated he did not consent to the dosage changes and had been refusing the medication. Record review showed that his Seroquel dose was progressively increased from 100 mg at bedtime to as high as 600 mg at bedtime over several physician orders. When surveyors requested consent documentation for these increases, the facility produced a form that the resident had refused to sign, and there was no documentation that the resident’s guardian had been informed of or consented to the dosage increases, despite the facility’s policy requiring informed consent from the resident or guardian for psychotropic medications and dosage increases. Behavior monitoring records ordered for the resident showed no documented behaviors for the months reviewed, even though the resident’s guardian reported he had requested a medication review because the resident was always worrying about others and frequently calling the police, and believed the resident was on 100 mg of Seroquel without being informed of any increases. The ADON acknowledged that if a resident is not exhibiting behaviors, they probably should not be on psychotropic medications and confirmed that the behavior monitoring sheets showed no behaviors. A psychiatrist and a psychiatric nurse practitioner both stated that staff were supposed to document behaviors as ordered and that informed consent was required for psychotropic medications and dosage increases, but also indicated they based treatment decisions on their observations and staff reports. An LPN reported that the resident wanted the Seroquel decreased, but the psychiatric team refused, and she was not aware of any behaviors. The facility’s psychotropic medication policy required routine documentation of behaviors and resident response to the medication, as well as informed consent prior to prescribing psychotropic medications, which was not followed in this case.
Failure to Assess and Provide Restorative Care for Hand Contracture
Penalty
Summary
The deficiency involves the facility’s failure to assess and address a resident’s restorative needs related to a left-hand contracture. During observations on two separate days, the resident was seen in a wheelchair with the left wrist contracted and the fingers tightly flexed into a fist, without any device in place to prevent further contracture. When asked, the resident reported that staff had not come to encourage exercises for the arm and hand. The resident’s care plan indicated that the resident would engage in active range of motion (AROM) to all four extremities, but there was no evidence that this was being implemented for the contracted left hand. The restorative nurse stated that they were new, worked with the therapy department to determine needed services, and were not aware that the resident’s hand was contracted. The therapy manager also reported that no one had informed therapy of the contracture. Upon direct assessment, the therapy manager asked the resident to open the hand and stretch the wrist, which the resident attempted but reported pain. The therapy manager stated the resident would benefit from a left-hand resting splint. Facility policies and the restorative nurse job description require evaluation of newly admitted residents for restorative appropriateness, quarterly and with change of condition, coordination with therapy disciplines for rehabilitation plans of care, and supervision of rehabilitative/restorative equipment such as splints, but these processes were not carried out for this resident’s hand contracture.
Failure to Complete Required Community Survival Skills Assessments per Policy
Penalty
Summary
The facility failed to follow its Community Access Determination policy requiring Social Services to complete community survival skills assessments upon admission and quarterly for all residents, and additionally when residents request outside passes. During an interview, the Social Services staff member (V9) stated that these assessments are completed quarterly, annually, and when a resident requests an outside pass. However, review of the electronic medical records showed that for one resident (R10), the last documented community survival skills assessment was dated 3/31/25, and no subsequent assessments were present. V9 initially suggested that a more recent assessment might not be visible because it was not locked, but was informed that even in-progress assessments would appear in the record, confirming that no later assessment had been completed. Record review for three additional residents showed similar gaps in required assessments. R1’s last community skills assessment was dated 7/9/25, R17’s was dated 8/1/25, and R18’s was dated 9/8/25, with no evidence of quarterly assessments thereafter as required by the facility’s policy. The facility also produced a document titled “admission, quarterly, annual, and significant change assessments,” which indicated that community skills assessments are completed on admission, with significant change, and annually, a schedule that did not align with the written Community Access Determination policy. When asked if this document was a policy, the DON (V2) and ADON (V8) did not initially respond; after consulting with the Administrator (V1), V2 stated it was not a policy but a document listing assessments and their timing. The facility’s formal guidelines for community access determination, dated 2/8/23, specify that community skills assessments are to be completed by Social Services upon admission and quarterly for all residents, which was not followed for the four residents reviewed.
Failure to Follow Grievance and Belongings Policies for Missing Personal Phone
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance and belongings policies in response to a resident’s report of a missing personal cell phone. The resident reported that her phone went missing from her room during a specific time window while she was out of the room and stated she informed the Social Service Director, nurses, and CNAs. She reported that the Social Service Director wrote the information down but did not provide her a copy, and that staff told her they would find the phone and return it. The resident documented on an activity calendar the date and time she reported the missing phone to the Social Service Director and later noted that a cell phone was found in a medication storage room. She stated that the Social Service Director never followed up with her and that she was afraid to continue asking about her phone because she feared getting in trouble and not receiving help with a community pass and discharge. A pre-admission hospital record confirmed the phone number the resident reported as her personal phone number. Staff interviews and record review showed that the grievance process was not followed and belongings were not fully inventoried. An RN acknowledged that the resident had informed her months earlier about the missing phone and that she told the resident to talk to social services but did not follow up or report the concern. A CNA also stated the resident had reported the missing phone to her, yet the facility’s grievance binder contained no grievance related to the missing phone. A grievance/opportunity resolution form produced by the facility lacked the name of the person completing it and only noted that the resident had a phone since admission and that another resident may have taken it. The resident’s belongings inventories did not list the phone or several other personal items visible in the admission photo and in the resident’s room, and neither inventory sheet contained the resident’s signature. The facility’s belongings policy required all belongings to be recorded and signed for, and the grievance policy required all concerns to be documented in writing, overseen by the Social Service Director, with resolutions expected within 72 hours and maintained in a grievance binder for at least three years.
Failure to Prevent and Properly Investigate Resident-to-Resident Physical Assault
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse prevention policy to protect residents from resident-to-resident physical abuse. A resident with a history of psychosis, schizophrenia, bipolar disorder, auditory hallucinations, and prior hospitalization for aggressive behavior entered another resident’s room, became upset about what he believed was expired or spoiled milk, and began yelling. According to the assaulted resident and multiple resident witnesses, the aggressor struck the resident on the right side of the head with a milk carton, pushed her onto the bed, grabbed her upper arms, and shook her violently, continuing to hit her until another resident intervened and staff arrived. The assaulted resident reported pain in her right forearm and behind her right ear. Witness statements from two other residents consistently described the aggressor on top of and hitting the victim, and one resident physically pulled the aggressor away and stood between them. The aggressor’s medical record showed multiple psychotropic medications ordered for psychosis, schizophrenia, and bipolar disorder, but the MAR documented frequent refusals of these medications over an extended period, both before and after a recent hospitalization for aggressive behavior. There was no documentation that the attending physician or psychiatrist was notified each time these psychotropic medications were refused, and nurse practitioner notes during this period recorded “no concerns from the nursing staff.” The facility’s abuse investigation relied on written statements from residents but did not include any staff interviews regarding the event and concluded there was no credible evidence that abuse occurred, despite multiple resident accounts that the aggressor was hitting the victim. This sequence of events and omissions reflects a failure to follow the facility’s abuse prevention policy and to adequately address and monitor a resident with known psychiatric diagnoses and aggressive behavior, resulting in a resident-to-resident physical assault.
Failure to Supervise Aggressive Resident Resulting in Resident-to-Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate supervision and monitoring for a resident with a known history of aggressive behavior, which allowed him to enter another resident’s room and assault her. The aggressive resident had multiple behavior care plans noting severe mental illness, including schizophrenia, psychosis with hallucinations, and bipolar disorder, with documented poor impulse control, lack of sound judgment, and a history of physically abusive behavior when agitated. His care plans included interventions such as administration of psychoactive medications as ordered, behavior tracking, reporting abnormalities to the physician, and daily monitoring and supervision. The medical record documented repeated noncompliance with medications, impaired comprehension, delusions, paranoid and disorganized thought processes, poor self-awareness, and auditory hallucinations, with social services counseling attempts that were not successful in improving his medication compliance. Despite these known risks and documented behaviors, the resident was able to access another resident’s room without effective supervision. The assaulted resident reported that the aggressive resident entered her room, became upset about a milk carton he believed was expired, yelled at her, struck her on the right side of the head with the milk carton, pushed her onto the bed, grabbed her upper arms, and shook her violently. Another resident reported hearing screaming and smacking sounds, then seeing the aggressive resident hitting the victim and intervening by pulling him off and standing between them. A roommate corroborated that the aggressive resident was hitting the victim, and another roommate stated she saw him on top of the victim punching her in the face before other residents and staff intervened. These events demonstrate that the facility did not provide adequate supervision and monitoring to prevent the aggressive resident from entering another resident’s room and engaging in physical and verbal assault, despite his known behavioral risks and documented need for close supervision.
Failure to Prevent and Control Illicit Drug Use and Distribution
Penalty
Summary
The facility failed to maintain an effective contraband policy to prevent illicit drugs from being brought into, distributed, and used within the facility. Multiple residents were found to have tested positive for fentanyl and opiates, with two residents experiencing significant medical emergencies as a result. One resident was observed slumping forward in a wheelchair, became cyanotic, and required Narcan administration after testing positive for opiates and fentanyl. Another resident was transported to the hospital for a change in condition and also tested positive for fentanyl and opiates metabolites. Both residents had a history of substance abuse and were cognitively intact at the time of the incidents. Interviews and record reviews revealed that the facility did not have a plan to determine how illicit drugs were entering the premises. There were reports and witness statements indicating that drugs were being brought in and distributed by both residents and possibly staff, including allegations of a female night staff member supplying drugs. The facility's investigation into staff involvement was inconclusive, and there was a lack of documentation regarding interviews and searches. Additionally, the facility's contraband policy was not effectively enforced, as evidenced by the discovery of drug paraphernalia in resident rooms and ceilings, and by multiple residents admitting to purchasing and using illicit substances within the facility. Staff interviews indicated gaps in communication and awareness regarding residents' substance use and related hospitalizations. There was also a lack of clarity among staff about when to administer Narcan, and the facility failed to present a policy or practice related to its use. The facility's response to suspicious behavior, drug screening, and supervision was inconsistent, and documentation of investigations and interventions was incomplete. These failures affected not only the residents who experienced overdoses but also had the potential to impact all residents reviewed for illicit substance or contraband issues.
Failure to Document and Monitor Effectiveness of Controlled Substance Administration
Penalty
Summary
The facility failed to follow its medication administration policy and did not consistently monitor or document the effectiveness of pain medication for a resident receiving high alert medications. Interviews with the Assistant Director of Nursing and a Licensed Practical Nurse revealed that staff were not accurately documenting the administration of hydrocodone-acetaminophen in the Medication Administration Record (MAR) at the time of administration, as required by facility policy. The MAR and controlled substance sheets for the resident showed discrepancies, with the controlled substance being signed out twice daily but not always recorded in the MAR. The LPN acknowledged that documentation was not completed every time the medication was administered and could not provide a reason for the omission. Review of the resident's physician order sheet confirmed an order for hydrocodone-acetaminophen to be given every 12 hours as needed for pain, and the resident's care plan included interventions for pain management and monitoring effectiveness. However, there was no consistent documentation in the medical record indicating that nursing staff monitored the effectiveness of the pain medication as required. The facility's policy specified that the person administering medication must initial the MAR before administration and that late entries should be documented if missed, but these procedures were not followed in this case.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain Homelike Environment Due to Improperly Secured Window Drapes
Penalty
Summary
The facility failed to maintain a homelike environment for residents by not ensuring that window drapes in multiple resident rooms were properly secured to the curtain rods, tracks, or hooks. During a facility tour, surveyors observed that the window drapes in the rooms of ten residents were falling from their fixtures, with some rooms using towels to cover window openings created by the fallen drapes. Maintenance staff acknowledged the issue when it was brought to their attention, attributing it to housekeeping, but the problem persisted throughout the day. One resident reported having repeatedly requested assistance from social services to have her curtains washed and rehung due to their condition. The Director of Nursing confirmed that resident rooms should be clean, sanitary, and homelike, and that window drapes should not be falling. The facility's housekeeping policy requires maintaining a safe and sanitary environment, but the observed conditions did not meet these standards.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that care provided did not align with the established orders or the expressed wishes and objectives of the resident. The report does not specify the exact nature of the orders or preferences that were not followed, nor does it provide details about the resident's medical history or condition at the time of the deficiency.
Failure to Maintain Operational Elevators
Penalty
Summary
The facility failed to ensure that all elevators were operational, resulting in only one of two elevators functioning during the survey. On observation, the left elevator was not responding to the call button and displayed a static number. Maintenance staff confirmed that the elevator had been repaired the previous day but had broken down again, noting that elevator malfunctions have been an ongoing issue. The maintenance staff was unable to specify which elevator had been serviced and was unaware of the specific cause of the repeated breakdowns. Service records indicated recent work on one elevator, but documentation did not clearly identify which car was serviced. Multiple residents reported delays in elevator service due to only one elevator being operational. The facility census indicated 191 residents, and the elevators are used for transporting meals, staff, visitors, laundry, and housekeeping between floors. The Director of Nursing confirmed the reliance on elevators for daily operations. The facility's building maintenance policy did not include protocols or information specific to elevator maintenance or operation.
Failure to Verify Escort Identity for Supervised Community Pass
Penalty
Summary
The facility failed to follow its protocol for supervised community passes by not verifying the identity of the individual who signed out a resident for a community pass. Specifically, a resident with a significant history of substance abuse, multiple injuries, and a care plan indicating she was not capable of unsupervised outside pass privileges was allowed to leave the facility. The pass request form listed a specific individual as the escort, but the ID scanned and attached did not match the name on the form. Staff interviews revealed that the process for verifying the escort's identity was not followed because the receptionist, who was responsible for scanning the ID, was occupied with other duties and did not interact with the person taking the resident out. As a result, the resident left the facility on a supervised pass and did not return. The nurse on duty followed the process of scanning the ID and handing it to the receptionist, but the mismatch in identity was not caught. The facility's policy on community passes did not clearly outline the supervised pass procedure, contributing to the failure. The administrator confirmed that the police were not notified when the resident did not return, and did not consider the incident to be an elopement.
Failure to Provide Timely Podiatry Services for Diabetic Residents
Penalty
Summary
The facility failed to provide timely foot care treatment and ensure follow-up visits with a podiatrist for residents at risk for foot disorders, specifically for two residents with diabetes. One resident, who was cognitively intact, reported not having seen a foot doctor for a long time despite requesting to see one. Upon observation, this resident's toenails were found to be long, discolored, and thick. Physician orders allowed for podiatrist visits, and the last documented podiatrist visit was several months prior, with a recommendation for a follow-up in nine weeks that was not documented as completed. Another resident, also cognitively intact and with diabetes, showed the surveyor long, thick, discolored, and curling toenails, and stated not recalling the last podiatrist visit despite requesting one. Physician orders indicated the need for podiatry services, but the last documented visit was also several months prior, with a follow-up recommendation that was not documented as completed. Staff interviews revealed that residents are added to a list for podiatrist visits upon request, but there was no evidence provided that these residents received timely follow-up as ordered. The facility's policy requires regular foot assessments and podiatrist referrals for diabetics, which was not followed in these cases.
Failure to Monitor and Investigate Illicit Drug Use Resulting in Resident Overdose
Penalty
Summary
The facility failed to have a system in place for monitoring and investigating how illicit drugs entered the facility, to be alerted when illicit drugs were present, and to prevent resident use and possible drug overdose. This deficiency was identified after a resident with a known history of substance abuse obtained and used illicit drugs while in the facility, resulting in a drug overdose that required the administration of Narcan and emergent hospital transfer. Interviews and record reviews revealed that the facility did not conduct an investigation into how the drugs were brought in or how the resident accessed them, nor did they follow up with involved residents or staff regarding the incident. The resident involved had a documented history of substance abuse, including cocaine, marijuana, and alcohol, and had previously been admitted to behavioral health and substance abuse treatment centers. On the day of the incident, the resident was found unresponsive in another resident's room, and staff administered Narcan after observing symptoms consistent with opioid overdose. The resident later admitted to using heroin with another resident. Despite this, there was no documentation of an investigation into the overdose, and key staff members, including the DON and administrator, did not follow up with staff or residents to determine the source of the drugs or to assess the situation further. Other residents and staff reported knowledge or suspicion of drug use and distribution within the facility, including observations of abnormal behaviors and direct admissions of drug use. The facility's policies required reporting, recording, and investigating all accidents and unusual occurrences, including those requiring emergency services or resulting in hospitalization. However, these procedures were not followed in this case, as there was no accident report or investigation into the overdose incident, and the facility did not notify the appropriate parties or take steps to identify and address the source of the illicit drugs.
Failure to Provide Required Substance Abuse Services and Supports
Penalty
Summary
The facility failed to follow its own policies and procedures for providing services and supports for chemical dependence and substance abuse for two residents. One resident, a male with a history of schizophrenia, depression, suicidal ideation, and substance use disorder, was not offered substance abuse group programming despite expressing a history of substance abuse and a desire to participate. The resident reported that he was told he could not attend the group because his substance abuse history was not documented at admission, even though he later disclosed his history to staff. The care plan for this resident included individual counseling but did not address group participation, and attendance records confirmed he was not included in the substance abuse group sessions. Another resident, a female with diagnoses including epilepsy, psychotic disorders, bipolar disorder, and psychoactive substance abuse disorder, was not consistently provided with psychiatric, group, or behavioral health counseling and services as indicated by her history and care plan. Although her records documented a history of substance abuse and she was encouraged to participate in group sessions, documentation showed she only attended one group session and there was no evidence of one-to-one substance abuse counseling. Multiple staff interviews confirmed that discussions about her substance use were not consistently occurring during psychiatric or social work sessions, and her care plan interventions were not fully implemented. These failures resulted in the female resident using illicit substances within the facility, leading to an overdose that required emergent transfer to a local hospital. The facility's own policies required offering appropriate treatment and rehabilitative services to residents with substance abuse problems, but these were not consistently provided or documented for the residents in question. Staff interviews revealed gaps in communication, assessment, and follow-through regarding substance abuse history and the provision of necessary support services.
Failure to Transcribe and Implement Physician Orders for Foot Monitoring
Penalty
Summary
The facility failed to follow professional standards of care by not transcribing and implementing physician orders to monitor a resident's right foot for increased discoloration, assess pedal pulse, and monitor temperature changes. The resident had a history of occlusion and stenosis of the right carotid artery, essential hypertension, anemia, and chronic ischemia. After the resident complained of discoloration in her right foot, a nurse practitioner assessed the foot, noted it was cool to the touch with edema, and ordered a doppler ultrasound, which was negative for DVT. Despite the negative result, the plan was to monitor the foot for changes, but the nurse practitioner did not specify a time frame for monitoring and only gave a verbal order to an unidentified nurse. Subsequent interviews revealed that the LPN who cared for the resident after an unwitnessed fall was unaware of any orders to monitor the right foot and did not perform a head-to-toe assessment. The CNA reported the presence of a blister and that the foot was wrapped by a nurse. The medical doctor confirmed the resident's chronic ischemia and agreed with the monitoring orders. However, review of the resident's physician order sheet and progress notes showed no documentation of orders or monitoring for the right foot on the relevant dates. The facility's policy requires all physician orders to be transcribed and implemented, but this was not done in this case.
Failure to Prevent Resident-to-Resident Physical Abuse Due to Lack of Supervision
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in the assaulted resident being sent to the hospital for evaluation of facial trauma. The incident occurred in the dining room, where a resident with a fractured ankle was using a chair to elevate his leg. Another resident attempted to take the chair, and when told to leave it, physically assaulted the first resident by punching him in the face. At the time of the incident, there was no staff present in the dining room to monitor the residents, despite multiple residents being present in the area. Interviews and record reviews revealed that both residents involved had intact cognition according to their BIMS scores, and neither had care plans addressing susceptibility or predisposition to abuse prior to the incident. Staff statements confirmed that the dining room was not consistently monitored, particularly during shift changes or when staff were occupied with other duties such as charting. The only CNA on duty for the unit reported alternating monitoring duties with nurses, but at the time of the altercation, no staff were present in the dining room. Documentation from the LPN, hospital, and police corroborated the occurrence of a physical altercation, with the assaulted resident sustaining swelling to the left eye and being sent to the hospital for further evaluation. The facility's abuse prevention policy emphasized the need for resident assessment and staff supervision to prevent abuse, but observations and staffing records indicated inadequate supervision in common areas, contributing to the incident.
Failure to Assess and Manage Resident's New Onset Hip Pain
Penalty
Summary
A resident with multiple medical conditions, including a history of falls, cognitive impairment, and mobility issues, experienced a new onset of right hip pain that was first documented by the therapy director. The therapy director reported the pain and a change in the resident's ambulatory status to the interdisciplinary team and nursing staff. Despite this notification, there was a lack of timely and thorough pain assessment and documentation by nursing staff. The assistant director of nursing and the family nurse practitioner both assessed the resident and ordered an x-ray, with the nurse practitioner instructing nursing staff to administer PRN pain medication as ordered. However, there was no documentation of pain medication being administered, and the medication administration record did not reflect any pain medication given during the relevant period. Nursing staff interviews revealed inconsistent accounts regarding the administration of pain medication. One LPN stated that pain medication was given but not documented, while another nurse reported not administering any pain medication because the resident did not verbally complain of pain during their shift. There was also a failure to document pain assessments or reviews in the resident's records, despite clear changes in the resident's condition and reports of significant pain. The facility's pain management policy requires assessment and documentation of pain, including onset, location, severity, and use of a pain rating scale, but these steps were not followed in this case. The resident remained in pain for approximately 24 hours before being hospitalized, where a right femoral neck fracture was confirmed and surgical intervention was performed. The lack of timely pain assessment, documentation, and administration of PRN pain medication resulted in the resident experiencing unmanaged pain prior to hospitalization. Progress notes and interviews confirm that the facility did not adhere to its own pain management and assessment policy during this incident.
Failure to Notify Physician of Resident's Refusal of Psychotropic Medication
Penalty
Summary
A deficiency occurred when the facility failed to notify a physician after a resident refused a scheduled psychotropic medication. The resident, who had diagnoses including Schizoaffective Disorder, Paranoid Schizophrenia, and Obsessive-Compulsive Disorder, was assessed as having intact cognition and a history of refusing care, including medications. The resident's care plan required staff to carry out the prescribed medication regimen and report any changes or complications to the physician. On the scheduled date, the resident refused a long-acting injectable psychiatric medication, as documented in the Medication Administration Record. However, there was no documentation in the progress notes that the physician was notified of this refusal. Staff interviews revealed that the LPN on duty was unsure if the resident received the scheduled medication and admitted to not documenting or notifying anyone about the refusal. The psychiatric nurse practitioner confirmed that they were not informed of the missed dose, which could have contributed to the resident's subsequent behavioral decline. The DON stated that nurses are expected to re-offer the medication and notify the physician if refusal persists, as well as document the refusal in the resident's chart. The absence of documentation and physician notification following the medication refusal constituted the deficiency.
Verbal Abuse Incident by Staff Member
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, specifically a former Social Service Aide/Smoking Monitor, identified as V3. The incident occurred when the resident, R1, requested a cigarette from V3 during designated smoking time. V3 refused the request and responded inappropriately by calling R1 a derogatory term. This interaction was witnessed by another resident, R2, who confirmed the use of inappropriate language by V3. The incident was reported to a Licensed Practical Nurse (LPN), V2, who then informed the facility's Administrator/Abuse Coordinator, and a police report was filed to document the verbal aggression. R1, who was cognitively intact with a BIMS score of 15, was admitted to the facility with multiple diagnoses, including mental and behavioral issues, anxiety, and depression. The facility's Abuse Prevention Program policy defines abuse as including verbal abuse, which was violated in this instance. V3's personal file revealed a prior disciplinary action related to unsatisfactory work and attitude, as well as dishonest practices concerning smoking materials. This history suggests a pattern of behavior that was not adequately addressed, leading to the incident of verbal abuse against R1.
Ineffective Pest Control Program Leads to Cockroach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of cockroaches within the premises. The Facility Pest Control Agreement, dated 12/1/2002, outlined a targeted pest control service for roaches with bi-monthly visits, yet observations and interviews revealed ongoing issues. On 2/22/25, live cockroaches were observed in two separate rooms, and multiple residents reported seeing cockroaches in their rooms, with one resident stating they see them every day. Housekeeping staff on both the second and third floors confirmed seeing live cockroaches daily, indicating a persistent problem. The Facility Grievance Opportunity Resolution Forms documented resident concerns about pests, with actions taken including deep cleaning and pest control treatments. Despite these measures, the problem persisted, as evidenced by the continued presence of cockroaches and frequent complaints from residents. The Activity Director noted receiving complaints about roaches a couple of times a week from various residents, and although pest control services were reportedly called and scheduled, the issue remained unresolved. The facility's administrator acknowledged the pest control visits but could not explain why the cockroaches were not being eradicated.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to follow care plan interventions and implement appropriate fall prevention measures for a resident with a history of falls and multiple risk factors, including cerebral vascular attack, hemiplegia, and mild cognitive deficit. The resident required substantial staff assistance for transfers and had multiple falls related to general weakness, poly-pharmacy, poor coordination, and use of medications. Despite having a care plan with specific interventions such as ensuring the call light was within reach, reminding the resident to use the call light for assistance, and conducting physical therapy evaluations, these interventions were not consistently implemented. The resident experienced three falls in their room during unassisted transfers from bed to wheelchair, with no injuries noted. Each fall report documented the need for a physical therapy evaluation, but the facility could not provide evidence of these evaluations being conducted. The Director of Nursing confirmed that the falls occurred during unassisted transfers and acknowledged that care plan interventions and proper footwear should have been followed. The facility's administrator noted that the resident was non-compliant and that fall interventions need to be resident-specific and consistently followed.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to prevent a resident from eloping, despite being assessed as unable to navigate safely and independently in the community. The resident, a male with a history of seizures, unspecified psychosis, dementia, and other medical conditions, was admitted to the facility with a care plan that required supervised smoking and community access. On the day of the incident, the resident left the facility unsupervised and was later found intoxicated by local police, having been without access to his ordered medical care. The incident was reported to the facility's Social Service Director by a staff member who noticed the resident was missing. The staff conducted a headcount after a bed alarm went off, realizing the resident was not present. Despite the resident's care plan indicating he required supervision, the facility did not have an authorized pass policy in place, and the resident was able to exit through a basement back door. The facility's supervision policy was not effectively implemented, as the resident was able to leave without being noticed by staff. The facility's response to the incident was delayed, with the resident's emergency contact being notified the following day. The police were called, and a missing person report was filed. The facility's administrator acknowledged that the resident was discharged in the system as if he had left against medical advice, although no AMA form was signed. The lack of immediate action and effective supervision contributed to the resident's elopement and subsequent intoxication, highlighting deficiencies in the facility's safety and supervision protocols.
Removal Plan
- The facility will continue to provide a safe environment for the residents through written policies and procedures to prevent elopement and to use as a baseline to maintain a secure resident environment.
- The facility initiated an investigation. It has been determined that the resident exited the facility from the basements back door.
- Director of Social Services, Assistant Director of Social Services and PRSCs has re-assessed facility residents' elopement risk assessment and community survival skill assessments.
- The facility has provided an elopement binder to all facility units with pictures identifying residents at risk for elopement.
- Director of Social Services, Assistant Director of Social Services and PRSCs have re-screened and assessed all residents to determine any factors that would put them at risk for elopement.
- Director of Social Services, Assistant Director of Social Services and PRSCs will continue to meet and assess all residents upon admission, quarterly, annually, and with change in condition or behavioral observations that may put the resident at risk for elopement.
- Administrator, Director of Social Services and all staff will continue to monitor residents for potential signs of elopement.
- Staff were re-educated but not limited to the facility elopement policy and procedures.
- DON/Designee will in-service all newly hired staff at the time of hire on the facility's elopement policy.
- DON/Designee will in-service staff out on leave or on vacation upon their return to work.
- Elopement binders have been placed on all facility units including the front reception area.
- All exit doors have been rechecked to ensure all alarms are functioning properly and to check staff response time.
- The facility Assistant Administrator conducted an ad hoc QA meeting which reviewed the facility elopement policy as it relates to safeguarding current and future residents from elopement.
- Quality Assurance will audit random resident files to ensure the risk for elopement has been properly assessed and care planned.
- The Administrator/Designee will perform weekly audits on all newly admitted and readmitted residents to ensure the risk for elopement has been properly assessed and care planned.
- As part of the Quality Assurance Committee the Administration/DON will in-service all staff monthly on the elopement policy for a period of two months.
Delayed Response to Call Lights in LTC Facility
Penalty
Summary
The facility failed to adhere to its call light policy, resulting in delayed responses to residents' needs. This deficiency was observed in five residents, including a female resident with Schizoaffective Disorder, COPD, and Stage 3 Chronic Kidney Disease, who reported waiting up to an hour for assistance during the night. As a result, she experienced discomfort from being left wet for extended periods. Another resident with Polyneuropathy and Reduced Mobility also reported similar delays, expressing concerns about potential urine burns from prolonged exposure to wet diapers. During an observation, a male resident with Chronic Pain Syndrome and other significant health issues had his call light activated for an extended period without response from nearby staff, including a Licensed Practical Nurse and a Certified Nursing Assistant. Despite being in proximity, staff members did not respond to multiple activated call lights, including those of two other residents. The Director of Nursing confirmed that all staff are expected to respond to call lights promptly, regardless of the resident's assignment, as per the facility's policy.
Failure to Document and Resolve Grievance Regarding Resident Care
Penalty
Summary
The facility failed to adhere to its grievance policy and procedures by not documenting, investigating, or resolving a concern reported by a resident's family member. The resident, a female with a history of polyneuropathy, reduced mobility, and chronic embolism and thrombosis, was left in a chair for 17 hours due to a mechanical lift not being charged. The family member reported this grievance to the facility, but it was not documented or addressed in a timely manner. Interviews with staff revealed that the Assistant Director of Nursing was unaware of the complaint, and the Psychosocial Rehabilitation Services Coordinator had reported the grievance to the Director of Nursing or Assistant Director of Nursing. However, the grievance was not documented in the facility's records until several days later, indicating a failure to follow the facility's grievance policy, which requires documentation and resolution of concerns within 72 hours.
Medication Administration Failure Due to Insufficient Staffing
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to administer medications as ordered to 34 residents on the third floor. On Christmas Day, only one nurse was assigned to the day shift on the third floor, which resulted in medications not being administered to residents in rooms 301-311 and 326-334. The Licensed Practical Nurse (LPN) on duty, responsible for rooms 312-325, did not accept responsibility for the other medication cart and informed management of her inability to cover the entire floor. Despite being aware of the staffing shortage, the Director of Nursing (DON) did not provide additional support or coverage. The deficiency affected residents with various medical conditions, including dementia, psychosis, seizures, depression, hypertension, and chronic obstructive pulmonary disease. One resident reported not receiving medications on Christmas morning, and the LPN confirmed that medications were not administered to the entire floor. The DON, who was new to the position, acknowledged the staffing issue but was under the impression that the LPN would cover the entire floor. The facility lacked a holiday staffing plan, and the absence of a second nurse on the third floor was attributed to a call-off and the DON's inability to find a replacement. The facility's administrator and DON were not aware of any complaints or issues with medication administration until the survey. The administrator stated that there was no staffing policy in place and acknowledged the need for a holiday rotation plan. The deficiency was considered an isolated incident, and the DON accepted responsibility for the situation, noting that the facility typically staffs two nurses per shift on each floor, except for nights when only one nurse is assigned to the first and third floors.
Medication Administration Failure on Holiday
Penalty
Summary
The facility failed to provide medications as ordered by the prescriber to 34 residents on the third floor during the day shift on Christmas Day. This deficiency was identified through interviews and record reviews, revealing that medications were not administered to residents from the front cart on the third floor. The residents affected included those with various diagnoses such as dementia, psychosis, seizures, depression, hypertension, and chronic obstructive pulmonary disease. The Medication Administration Records (MAR) for December 2024 documented that medications were not given on the specified day shift. Interviews with residents and staff highlighted the issue of understaffing on the third floor during the holiday. A Licensed Practical Nurse (LPN) working that day stated that she was responsible only for her assigned residents on the back hall and did not administer medications to the residents on the front cart. The Director of Nursing (DON) was aware of the staffing shortage and the LPN's refusal to cover the entire floor, yet no alternative arrangements were made to ensure all residents received their medications. The DON and the LPN had differing accounts of the expectations and communications regarding medication administration on that day. The facility's policy and procedure for administering medications emphasize the responsibility of the Director of Nursing Services to supervise medication administration and ensure compliance with physician orders. However, the failure to provide medications as ordered was not communicated to the prescribers, and no corrective actions were documented in the report. The lack of medication administration on Christmas Day was not reported to the Nurse Practitioner or the Administrator, indicating a breakdown in communication and adherence to established protocols.
Failure to Administer Seizure Medications on Christmas Day
Penalty
Summary
The facility failed to administer significant medications to five residents on the day shift of December 25, 2024. This deficiency was identified through interviews and record reviews, revealing that seizure medications were not given to the residents as prescribed. The residents affected included those with conditions such as dementia, psychosis, seizures, and other chronic illnesses. The Medication Administration Records (MAR) for December 2024 documented that medications like Divalproex Sodium, Levetiracetam, Keppra, and Depakote were not administered at the scheduled times. Interviews with residents and staff highlighted the absence of a nurse on the third floor during the day shift on Christmas Day, which contributed to the missed medication doses. One resident reported not receiving their seizure medication for about four days due to an insurance issue and the facility's inability to verify the medication they brought with them. The Licensed Practical Nurse (LPN) on duty confirmed that they only administered medications to a portion of the residents on their assigned side of the floor, as they were not responsible for the entire floor and did not have the keys for the other medication cart. The Director of Nursing (DON) was aware of the staffing shortage but did not ensure that all residents received their medications. The DON stated that they were not informed of any medication delivery issues or residents missing doses. The facility's policy on medication administration emphasizes the responsibility of the DON to supervise medication administration and ensure compliance with physician orders. However, the lack of communication and coordination among staff led to the failure in administering medications as required.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident, identified as R2, from physical abuse by another resident, R3. R2, a male with severe cognitive impairment and multiple psychiatric diagnoses, reported being punched in the chest by his roommate, R3. This incident was not witnessed by staff, but R2 was found with a bruise on his chest by a CNA during morning care. R2 consistently reported that R3 was the assailant, although R3 denied any physical interaction with R2. R2's medical records indicate that he has severe cognitive impairment and is dependent on staff for most activities of daily living. On the day of the incident, R2 was found with discoloration on the left side of his chest, which was later diagnosed as a contusion. Despite R2's severe cognitive impairment, he was able to communicate that he was punched by his roommate, leading to his transfer to a hospital for further evaluation. The facility's response included separating the residents and notifying relevant parties, including the police. However, the initial failure to prevent the altercation and protect R2 from harm constitutes a deficiency in the facility's abuse prevention program. The facility's policy defines abuse as the willful infliction of injury, and the incident highlights a lapse in ensuring resident safety and adherence to this policy.
Failure to Follow Menu and Serve Planned Meals
Penalty
Summary
The facility failed to adhere to the planned menu, resulting in all 211 residents not receiving the specified meals on two separate occasions. On December 18, 2024, during lunch service across all nursing units, residents were served one slice of white bread instead of the planned 1/2 slice of garlic Texas toast. Similarly, on December 20, 2024, during breakfast service, residents were not served the planned oatmeal and scrambled eggs with cheese. Instead, they received cream of wheat hot cereal and scrambled eggs without cheese. Additionally, there was a shortage of cold cereal and toast, leading to some residents, such as one who requested cold cereal, leaving the dining room without eating breakfast. The dietary manager, V8, acknowledged the discrepancies in meal service, noting that additional cold cereal was available in the kitchen but was not requested by the staff. The kitchen staff, V13, confirmed the use of incorrect serving utensils and the absence of cheese in the scrambled eggs. These observations and interviews highlight the facility's failure to follow the menu and ensure residents received the meals as planned, impacting the nutritional needs of the residents.
Inadequate Dining Supplies During Meal Service
Penalty
Summary
The facility failed to provide adequate dining supplies during a lunch meal service on the third floor nursing unit, affecting all 75 residents. Observations revealed that initially, 45 residents received their meals on plastic plates, but the staff ran out of these plates, resulting in the remaining 30 residents being served on Styrofoam plates. Additionally, the staff ran out of plastic cups with handles, leading to 10 residents receiving coffee in Styrofoam cups without handles. Furthermore, 25 residents were not provided with napkins as the supply ran out. Despite the shortage, the dining room staff did not notify the kitchen to replenish the necessary items. A subsequent tour of the kitchen confirmed that there were sufficient supplies available, but they were not requested by the dining room staff.
Failure to Initiate Timely Falls Care Plan for Resident
Penalty
Summary
The facility failed to follow its care plan policy by not initiating an individualized falls care plan with interventions for a resident at moderate risk for falls. This deficiency was observed in a resident who had transferred from another long-term care facility and had a documented history of falling and generalized weakness. Despite the resident's ability to make needs known, as indicated by a perfect BIMS score, the facility did not implement fall precautions immediately upon admission. The resident was observed on multiple occasions with the call light cord out of reach, and had visible injuries consistent with a fall. The restorative nurse, responsible for investigating falls and updating care plans, did not investigate the resident's fall that occurred shortly after admission. Although the resident was educated on seeking assistance with transfers and physical therapy evaluation, these interventions were not documented in the care plan. The care plan was not initiated until several days after the fall and was backdated, indicating a lapse in timely and appropriate care planning as per the facility's policy.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to follow its fall risk and post-fall assessment policy, which resulted in a deficiency affecting a resident identified as R2. Upon admission, R2 was not accurately assessed for fall risk, and necessary fall prevention interventions were not implemented immediately. Observations revealed that R2's call light cord was consistently out of reach, and R2 had visible injuries, including discoloration and swelling on the left side of the face, indicating a fall had occurred. Despite these signs, the facility did not conduct a thorough investigation or update R2's care plan with appropriate interventions. The Restorative Nurse, V6, acknowledged responsibility for investigating falls and updating care plans but admitted to not investigating R2's fall on 12/11/24. Although V6 was informed of the interventions to be put in place post-fall, these were not documented in R2's care plan. Additionally, the Director of Rehabilitation, V7, failed to prioritize R2 for skilled therapy despite R2's history of falls and a decline in functional abilities noted in transfer paperwork. R2 was not evaluated by physical and occupational therapy, and the fall incident report was not provided to the surveyor. R2's medical records indicated a history of falls, generalized weakness, and a need for assistance with ambulation. However, the fall risk review and post-fall review inaccurately noted no history of falls within the last three months and did not account for R2's medications or predisposing conditions. The facility's policy required a fall risk assessment at admission and a post-fall assessment with immediate interventions, but these were not completed as required, leading to the deficiency.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for its residents, as evidenced by pervasive odors of urine and unclean conditions in several rooms on the third floor. Observations revealed that rooms were dirty, with garbage on the floors and brownish stains, and a strong urine smell was present in the hallway and several resident rooms. Residents reported that their rooms had not been cleaned for several days, and housekeeping staff confirmed that they were unable to clean all rooms due to staffing shortages. The housekeeping department was understaffed, with only one housekeeper assigned to the third floor, who could not clean all resident rooms. The Housekeeping Director reported that they were not receiving sufficient cleaning supplies, such as bleach, to maintain cleanliness standards. The facility's owner was unaware of the supply shortages and staffing issues, indicating a lack of communication and oversight. Several residents were affected by the facility's failure to provide clean linens and mattresses. Residents reported that their bed linens were wet and stained, and some mattresses were soiled and needed replacement. The Director of Nursing confirmed that soiled linens should be changed immediately, and mattresses should be replaced if stained. However, the facility's policies were not being followed, leading to unsanitary conditions for the residents.
Failure to Maintain Sanitary Conditions in Meal Service
Penalty
Summary
The facility failed to adhere to its policy and procedures for serving food under sanitary conditions, affecting all 66 residents receiving meals on the 2nd floor. Observations revealed that meal trays were left uncovered on skeleton carts, with gnats flying around the food. Despite the presence of clean lids on the dietary aides' food service cart, they were not utilized. A Certified Nursing Assistant (CNA) mentioned that meal tray lids were typically unavailable, which led to their non-use. Another CNA admitted to not noticing the absence of lids during meal delivery, acknowledging the risk of contamination. The Director of Nursing confirmed that food trays should be covered to prevent contamination and maintain appropriate temperatures, as per the facility's Food Handling Policy, which mandates covering food and beverages during transport from the Dietary Department to residents.
Failure to Provide Communication Board for Resident with Communication Barrier
Penalty
Summary
The facility failed to ensure that a resident with a communication barrier was provided with the necessary tools to communicate effectively. The resident, a male with a history of Cerebral Palsy, Epilepsy, Other Specified Disorders of the Brain, and Urinary Incontinence, was admitted to the facility and was noted to have extremely limited speech. Despite documentation in the social service progress notes indicating that a communication board would be provided, observations revealed that no such board was available for the resident's use. Staff members, including a Licensed Practical Nurse and a Certified Nursing Assistant, acknowledged the absence of a communication board and admitted to having difficulty understanding the resident's needs. The Director of Nursing indicated that social services are responsible for providing communication boards, but there was a lack of communication between departments to ensure the resident received the necessary support. The Social Services Worker confirmed using a communication board when interacting with the resident due to her own hearing difficulties but failed to leave the board with the resident for ongoing use. This oversight resulted in the resident's communication needs not being adequately met, as documented in multiple social service progress notes highlighting the resident's difficulty in making his needs known.
Failure to Investigate Resident Altercation as Abuse
Penalty
Summary
The facility failed to identify and investigate an altercation between two residents as abuse. Resident 1, a cognitively intact female with diagnoses including anxiety, depression, and PTSD, reported being physically assaulted by Resident 4, who has diagnoses including hypertension, panic disorder, and borderline personality disorder. The incident involved a dispute over a water bottle, during which Resident 1 claimed to have been punched in the chest by Resident 4. Despite the presence of staff members, including a Registered Nurse and a Certified Nursing Assistant, who witnessed the aggressive behavior, the facility did not recognize the incident as a physical altercation or abuse. Interviews with staff revealed a lack of awareness and communication regarding the physical nature of the altercation. The Social Service Director and the Assistant Administrator were not informed of the physical aspect of the incident, and the facility's abuse policy, which requires immediate reporting and investigation of potential abuse, was not followed. The Administrator/Abuse Coordinator stated that the incident was not considered abuse, despite the facility's policy defining abuse as the willful infliction of injury or intimidation resulting in harm or mental anguish. This oversight led to a failure in addressing the altercation appropriately as an abuse incident.
Inadequate COVID-19 Precautions and Monitoring
Penalty
Summary
The facility failed to implement effective transmission-based precautions and infection surveillance during a COVID-19 outbreak, affecting 14 residents and potentially impacting the entire resident population. Discrepancies were noted in the COVID-19 resident tracking system, with positive residents being placed in the same room as those whose isolation had ended. Additionally, a room identified as COVID-19 positive lacked a garbage bin for disposing of used PPE, and a resident expressed concerns about the facility's infection control measures. The facility's infection control policies were not adequately followed, as evidenced by the lack of contact/droplet signage and isolation setups for COVID-19 positive residents. For instance, a resident who tested positive for COVID-19 did not have the required signage or PPE setup outside her room, and her door was left open. Furthermore, the facility's entrance lacked available N95 and surgical masks, and visitors were not consistently informed of the outbreak or provided with masks upon entry. There was also a failure to monitor and document vital signs and symptoms for residents on COVID-19 isolation precautions. Several residents who tested positive for COVID-19 did not have their vital signs monitored or documented, and their care plans were not formulated promptly. The facility's policies on source control, PPE, and resident screening were not effectively implemented, contributing to the deficiencies observed during the survey.
Failure to Notify Responsible Party of Resident's Hospitalization
Penalty
Summary
The facility failed to adhere to its policy regarding the notification of a resident's responsible party about a change in the resident's condition. This deficiency was identified during a survey when it was found that the responsible family member of a resident, referred to as R3, was not notified of the resident's hospitalizations on two separate occasions. The surveyor reviewed the documentation related to R3's hospitalizations and found no evidence that the family member had been informed. During an interview, the Director of Nursing acknowledged that the family member should have been notified about these hospitalizations. The facility's policy mandates that, except in medical emergencies, the resident, their physician or nurse practitioner, and the responsible party must be alerted to any change in the resident's condition, with such communication documented in the resident's medical record or other appropriate documents.
Inadequate Pest Control Measures in Facility
Penalty
Summary
The facility failed to adhere to its pest control policy and procedures, resulting in a widespread pest issue affecting all 202 residents. Observations and interviews revealed the presence of gnats, roaches, and flies in various areas, including residents' rooms and common areas. Multiple residents reported seeing roaches and other pests, with one resident even capturing a photo of a roach in their coffee. Family members also observed flies on food trays left in rooms. The housekeeping supervisor confirmed the presence of roach problems and noted that pest control was only called when notified, with treatments occurring every other week instead of weekly as recommended. The pest control logs and invoices from June to September 2024 documented numerous reports of roaches and other pests throughout the facility. The pest control company identified issues such as food on walls, clutter, and wall openings that hindered effective treatment. Despite these findings, the facility's pest control policy, which mandates regular and as-needed pest control measures, was not consistently followed. The policy also requires food to be covered and stored properly, and the facility to be maintained in a condition that prevents pest harborage, which was not adequately implemented.
Failure to Address Mold in Resident Living Areas
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents by not addressing mold or mold-promoting conditions in resident living areas. This deficiency was observed in the rooms of three residents. One resident's room had four large dark discolored stains with fuzzy growth on the ceiling tiles, which appeared to be mold. The Maintenance Director confirmed that these stains were likely mold and acknowledged that staff should have reported the discolored ceiling tiles. Another resident's room had a large dark discolored stain with fuzzy growth on the ceiling tile directly outside their room, which was also identified as mold by the Maintenance Director. Additionally, a non-occupied room being prepared for new residents had a dark discolored ceiling tile, which the Maintenance Director identified as mold. The facility's Preventative Maintenance Policy requires regular environmental tours and safety audits to identify areas of concern, including ensuring ceiling tiles are free from watermarks or spots. However, the policy was not effectively implemented, as evidenced by the multiple discolored water-stained panels in another resident's room and bathroom, which were becoming discolored and should have been changed. The Maintenance Director admitted that the facility's air conditioning system causes moisture to drop onto ceiling panels, leading to mold growth, particularly in certain areas of the building. Despite the policy's requirement for staff to document observations of discolored ceiling tiles on work order forms, this was not done, resulting in the failure to address the mold issue promptly.
Missed Wound Treatments for Residents
Penalty
Summary
The facility failed to adhere to its wound care policy and procedures, resulting in missed wound treatments for two residents. One resident, a male with a history of skin infection, rheumatoid arthritis, and chronic ulcers, reported that his bandage was changed infrequently, with visible reddish-brown stains on the bandage. His treatment records for July, August, and September 2024 showed multiple missing entries for wound care treatments as ordered by the physician. The records were later modified after a surveyor's review, indicating an attempt to fill in the missing information. Another resident, a male with dementia and peripheral vascular disease, also experienced missed wound treatments. He reported calling the police due to the lack of wound care, with his bandage showing similar reddish-brown stains. His treatment records for August and September 2024 documented missing entries for wound care on specific days. Interviews with facility staff, including the Director of Nursing and a Licensed Practical Nurse, revealed that nurses were responsible for wound care on weekends if no wound nurse was available. The Director of Nursing acknowledged that the absence of documentation indicated that wound care was not provided or refused by the resident.
Failure to Report Abuse Allegation
Penalty
Summary
The facility failed to adhere to its internal reporting requirements for abuse allegations, as outlined in its Abuse Prevention Program Facility Policy and Procedure. This deficiency involved a resident, a male with a history of Schizoaffective Disorder, Adult Failure to Thrive, Dementia, Major Depressive Disorder, Bipolar Disorder, and a History of Falling, who was admitted to the facility. A family member reported that a Certified Nursing Assistant (CNA) handled the resident roughly during a brief change, which led to the resident raising his fist in protest. The family member reported the incident to several nursing staff members, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON). However, the report was not escalated to the Administrator as required by the facility's policy. The Director of Nursing acknowledged having a conversation with the CNA about the family member's dissatisfaction with the CNA's communication but claimed not to have been informed about the rough handling. The LPN confirmed that the family member reported the rough handling to her and that she relayed this information to the DON. The Administrator confirmed that an investigation should have been initiated based on the report of rough handling, and the incident should have been reported to the state within two hours. The failure to report the incident to the Administrator resulted in a lack of investigation and appropriate response to the abuse allegation.
Failure to Change Stained Bed Linens for Resident
Penalty
Summary
The facility failed to ensure that bed linens were changed as needed for a resident who required assistance with activities of daily living. This deficiency was observed in a male resident with a history of local infection of the skin, rheumatoid arthritis, chest pain, cellulitis of the right lower limb, non-pressure chronic ulcer of the right ankle, pulmonary nodule, and pericarditis. The resident was admitted to the facility on April 11, 2024. Observations on September 10 and September 18, 2024, noted that the resident's bed linens and pillowcases had stains that appeared old. A family member reported observing the stained linens during a visit a couple of weeks prior and stated that she had informed all the nurses present and the social services designee. Despite multiple reports to the staff, the issue persisted, and the family member submitted a written report to the state agency. The Director of Nursing was unaware of any reports regarding the soiled linens and stated that certified nursing assistants should change stained linens. There was no indication that the resident refused to allow staff to change his linens.
Failure to Provide Adequate Nutritional Care for Resident
Penalty
Summary
The facility failed to adhere to its policies and procedures for weight management, resulting in inadequate nutritional care for a resident identified as R1. R1, a male resident with multiple health issues including rheumatoid arthritis and severe malnutrition, was not provided with the necessary dietary support. Observations revealed that R1 had difficulty chewing due to missing teeth and hand contractures, yet his meal was not appropriately prepared or assisted with, leading to insufficient food intake. Despite being on a mechanical soft diet, R1's meal preferences were not documented or honored, and he was not encouraged to eat or offered alternatives when he refused his meal. The facility also failed to accurately document R1's food consumption and supplement administration. R1's point of care reports inaccurately recorded his meal intake, and his medication administration record showed inconsistencies with the actual administration of his prescribed protein supplements. R1 expressed a preference for nutritional shakes, which were not provided, and he often declined the facility's protein supplements, describing them as tasting like medicine. Despite recommendations from hospital records for advanced nutritional shakes, the facility did not implement these recommendations or consult with R1's family about his dietary preferences. Interviews with staff and family members highlighted a lack of communication and follow-through on dietary interventions. The dietary manager did not engage with R1's family to determine his food preferences, and the dietitian acknowledged the importance of providing supplements and alternatives that R1 would accept. The facility's policies on weight assessment and resident tray delivery were not followed, contributing to R1's continued weight loss and compromised nutritional status.
Failure to Provide Appropriate Mechanical Soft Diet
Penalty
Summary
The facility failed to adhere to its policy and procedures for providing specialized diets, specifically for a resident who required a mechanical soft diet. The resident, a male with multiple health issues including rheumatoid arthritis and contractures in both hands, was observed struggling to eat his meal due to the toughness of the food provided. Despite having a mechanical soft diet order, the resident was served uncut, tough chicken, which he could not chew due to multiple missing teeth. The Licensed Practical Nurse assisting him did not cut the meat or offer alternative foods, resulting in the resident consuming only 15-20% of his meal. The resident's care plan indicated the need for assistance with meals, including cutting meat and vegetables, due to his physical limitations. The dietitian confirmed the importance of the resident receiving supplements and adequate nutrition, noting his low weight and compromised nutritional status. The facility's policy on resident tray delivery emphasized checking diet orders to avoid errors, which was not followed in this case, leading to the deficiency in care provided to the resident.
Failure to Provide Incontinent Care Before Hospital Transfer
Penalty
Summary
The facility failed to follow the plan of care and provide necessary assistance with activities of daily living for a resident who was dependent on staff for incontinent care. The resident, identified as R4, was noted to be dependent for toileting according to their Minimum Data Set (MDS) and care plan, which specified the need for total assistance in all aspects of hygiene and dressing, including toileting with two assists. On the day of the incident, R4 was sent to the hospital for a change in mental status without receiving the required incontinent care, resulting in the resident being transferred while soiled in urine. Interviews with facility staff revealed that the Licensed Practical Nurse (LPN) responsible for R4's care had instructed a Certified Nursing Assistant (CNA) to clean and change the resident before the hospital transfer. However, the CNA admitted to not providing the necessary care and failing to notify the nurse of the need for assistance. The Director of Nursing (DON) acknowledged that the resident should have been provided with incontinence care prior to the transfer, highlighting the issue as a matter of dignity. The facility's policies on activities of daily living and incontinence care emphasize the importance of preserving function, promoting independence, and maintaining dignity, which were not adhered to in this instance.
Failure to Provide Adequate Supervision for Resident with Self-Harming Behavior
Penalty
Summary
The facility failed to adhere to its behavior management policy for a resident with a history of self-harming behavior, resulting in the resident sustaining a fracture to her right arm. The resident, a female with a history of quadriplegia, multiple sclerosis, anxiety disorder, and recurrent major depressive disorder, was admitted to the facility in March 2022. On the evening of May 5, 2024, the resident became verbally aggressive and attempted to block her room door with her wheelchair, refusing to go to bed. Despite her protests, staff transferred her to bed, during which she attempted to harm herself by trying to slide out of her wheelchair and later out of her bed, resulting in her arm getting caught in the bed rail and sustaining a fracture. The facility's behavior management policy requires one-to-one supervision for residents exhibiting self-harming or aggressive behaviors, which was not provided in this case. The resident's care plan and physician orders included behavior monitoring due to her history of self-harm ideation and suicidal risk. However, during the incident, there was no documentation of one-to-one monitoring or administration of medication for anxiety or aggression, as outlined in the facility's policy. Staff interviews revealed that the resident was known to exhibit such behaviors, yet the necessary interventions were not implemented. The incident report and witness statements indicate that the resident was combative and attempted to harm herself multiple times during the evening. Despite the staff's efforts to prevent her from falling, the lack of continuous monitoring and failure to administer prescribed interventions contributed to the resident's injury. The facility's Director of Nursing acknowledged that one-to-one monitoring was necessary given the resident's behavior, but this was not executed, leading to the deficiency in care.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by an incident involving two residents. One resident, who was admitted with diagnoses including Major Depressive Disorder and Anxiety Disorder, was physically assaulted by another resident who had been admitted from the hospital with a diagnosis of Schizophrenia. The incident occurred when the second resident, during an admission assessment, abruptly left the office of the Psychiatric Rehabilitative Services Coordinator and hit the first resident in the hallway without provocation. The assaulted resident did not sustain injuries requiring hospitalization, and the assailant was discharged against medical advice later that day. The facility's failure to prevent this incident was partly due to inadequate pre-admission screening and assessment of the second resident's potential for aggressive behavior. The facility's abuse policy requires a criminal history background check and assessment of residents' vulnerability to abuse or aggressive behavior, but these steps were not adequately followed. The Psychiatric Rehabilitative Services Coordinator admitted to not probing the hospital records to determine if the second resident was at risk for abusive behavior, which contributed to the incident. The facility's policy also emphasizes creating a resident-sensitive environment, but this was not effectively implemented in this case.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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