Eden Vista Burr Ridge
Inspection history, citations, penalties and survey trends for this long-term care facility in Burr Ridge, Illinois.
- Location
- 6801 Highgrove Boulevard, Burr Ridge, Illinois 60527
- CMS Provider Number
- 146094
- Inspections on file
- 22
- Latest survey
- December 31, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Eden Vista Burr Ridge during CMS and state inspections, most recent first.
Multiple residents who were cognitively impaired and care planned as needing total assistance with ADLs were repeatedly observed with unkempt facial hair, uneven and jagged fingernails with dark debris underneath, and soiled clothing. Despite documented care plans calling for staff assistance with dressing, personal hygiene, and grooming to maintain a well-groomed appearance, residents remained with overgrown facial hair, dirty nails, and stained garments over multiple observations. Several residents verbally expressed that they relied on staff and wanted their facial hair shaved, fingernails cleaned and trimmed, and clothing changed, while nursing leadership acknowledged that providing nail care, dressing assistance, and removal of unwanted facial hair is part of routine nursing care for residents requiring help.
The facility failed to provide ordered IDDSI Level 6 soft & bite-sized mechanically altered diets for four residents with conditions such as dementia, dysphagia, COPD, CHF, malnutrition, and GERD. Despite physician orders and a policy requiring foods to be fork-mashable, cut into small pieces, with soaked bread and no mixed consistencies, residents were repeatedly served regular-texture meals. Observations showed large pieces of pork roast, whole firm vegetables, whole scalloped potatoes, bratwurst with skin, large salad components, and large fresh fruit pieces in liquid, while prescribed items such as slurry bread and strawberry shortcake slurry were not prepared or served. The Culinary Director confirmed that mechanically altered foods were not prepared for these meals and acknowledged that the food sizes and textures did not meet Level 6 soft & bite-sized standards.
Staff failed to follow infection control policies for hand hygiene, glove use, and Enhanced Barrier Precautions (EBP) during medication administration and incontinence/toileting care for multiple residents. A nurse handled and opened capsule medications with bare hands after touching environmental surfaces and without hand hygiene before mixing them into food for a resident. CNAs providing incontinence and toileting care to several residents, including one on EBP for a leg wound, did not wear complete PPE as required, used the same soiled gloves to perform both contaminated and clean tasks such as cleaning perineal areas, applying barrier cream and clean briefs, adjusting clothing, repositioning residents, and touching bed controls, and frequently failed to perform hand hygiene after glove removal or before moving from dirty to clean activities.
Surveyors found that staff failed to implement ordered contracture management and positioning interventions for two residents with significant contractures and functional limitations. One resident with hemiplegia and a left-hand contracture had a care plan and therapy documentation for use of a resting hand splint, but over multiple observations the hand remained tightly clenched with no splint, palm protector, or substitute device in place, and only a thin dressing was used on the palm. Another resident with dementia, functional quadriplegia, and contractures was repeatedly observed in bed with contracted upper and lower extremities and adducted legs rubbing together, without the recommended wedge or pillow between the knees, despite care plan and therapy notes calling for positioning and pillow placement for comfort and skin protection.
A resident with multiple chronic conditions, including hypothyroidism and dysphagia, received Levothyroxine and delayed-release Aspirin in a manner inconsistent with physician orders and manufacturer guidelines, contributing to a medication error rate above 5%. A nurse administered the Levothyroxine and Aspirin mid-morning after the resident had already eaten, and crushed both medications, converting the delayed-release Aspirin to an immediate-release form, despite orders specifying Levothyroxine as a time-sensitive dose to be given early in the morning on an empty stomach. Staff interviews confirmed that Levothyroxine (Synthroid) is expected to be given before breakfast on an empty stomach, and that nurses are expected to follow pharmacy recommendations and physician orders, which did not occur in this instance.
The facility failed to maintain sanitation and food safety standards, affecting all 22 residents. Observations revealed dirty kitchen equipment, improperly stored and unlabeled food, and inadequate hand hygiene by a food service worker. These actions violated the facility's policies on food safety, dishwashing, and sanitation.
The facility failed to adhere to its Water Management Plan for Legionella, with inadequate eyewash station checks and no chlorine testing. An LPN did not follow Enhanced Barrier Precautions or hand hygiene protocols during medication administration, failing to sanitize equipment between residents and not wearing a gown for a resident on EBP. These actions violated the facility's policies on infection control.
The facility did not meet the nutritional needs of its residents by failing to provide the required servings of fruits/vegetables and grains/breads as per their policy. This affected 15 residents on Regular and/or No Added Salt diets. The menus, reviewed by a corporate dietitian, lacked the necessary servings on multiple days across four weeks, despite guidelines specifying the required daily servings.
A facility failed to provide a SNF-ABN to a resident at the end of their Medicare Part A stay. The resident's Medicare coverage ended, but they remained in the facility without receiving the required notice. A social services staff member admitted to not providing the SNF-ABN due to unawareness of the resident's continued stay. The facility lacked documentation to show the notice was given.
The facility failed to provide written notification of its bed hold policy to residents or their representatives during hospital transfers, as required by federal law. This deficiency was identified in two residents, who were transferred to the hospital multiple times without proper documentation or communication of the bed hold policy. The facility's policy requires written notice at the time of transfer, but this was not adhered to, resulting in incomplete and improperly handled documentation.
A resident with significant weight loss was not reviewed by a dietitian upon readmission from the hospital, and the facility failed to provide necessary nutritional interventions or obtain weekly weights as ordered. The resident, with a history of severe malnutrition and other medical conditions, experienced a 14% weight loss. Nutritional supplements were not reordered, and the dietitian was not informed of the resident's condition until late January.
A resident's G-tube placement and patency were not verified before medication administration, contrary to facility policy. The nurse administered medication without aspirating for residuals or flushing the tube, as required. The regional nurse consultant confirmed the expectation to follow these procedures.
The facility failed to identify and monitor resident-specific behaviors to assess the effectiveness of psychotropic medications for three residents. Generic behavior lists were used instead of individualized symptoms, and behavior monitoring was vague and inconsistent. This deficiency was evident in residents with diagnoses of psychosis, anxiety, dementia, and depression, whose care plans lacked specific behavior assessments and monitoring documentation.
The facility failed to adhere to its policy of promptly responding to call lights and providing timely incontinence care, affecting three residents. One resident with multiple health issues was left in soiled briefs for hours, causing skin irritation. Another resident and their family reported long wait times for assistance, with records showing delays exceeding an hour. A third resident experienced similar delays, with call light response times reaching up to 85 minutes. These deficiencies indicate a systemic issue with the facility's call light response system.
The facility failed to ensure medications were present and administered for a resident with recurrent diarrhea, did not notify the physician about the missing medications, and did not complete lab testing or respond to stool incontinence in a timely manner. These delays resulted in the addition of a third medication and the resident experiencing increased weakness and skin irritation.
The facility failed to maintain kitchen hygiene and proper food storage, affecting all 26 residents. Observations included uncovered facial hair, improperly stored and expired food items, inadequate sanitization practices, and lack of proper hair coverings for staff. Facility policies on food storage, personal cleanliness, and sanitization were not followed.
The facility failed to assist residents with their ADL needs in a timely manner. One resident waited 30 minutes for staff to answer her call light and was left on the toilet, another reported waits as long as two hours, and a third resident's call light was unanswered for over two hours. The facility's policy states that call lights should be answered promptly, but staff reported difficulties in completing tasks and responding to call lights due to workload and lack of assistance from nurses.
A resident with severe protein-calorie malnutrition and significant weight loss did not receive the recommended nutritional supplements due to a delay in entering the Dietician's orders. Despite the facility's policy to act on such recommendations within 24 hours, the supplements were not provided, and the resident's care plan was not updated accordingly.
The facility failed to follow proper infection control protocols, including the use of appropriate disinfecting wipes for CDIFF and single-use port protector caps for a PICC line. Staff did not adhere to hand hygiene guidelines, leading to deficiencies in care and increased risk of infection for residents.
The facility failed to offer and document influenza and pneumococcal immunizations for two residents. Both residents' records lacked documentation of vaccine consent or refusal, and the admission checklist was missing from the EMR and paper chart. Interviews with the ADON and DON confirmed the lapse in following the facility's vaccination policies.
The facility failed to offer or document the COVID-19 immunizations for two residents upon their admission. Both residents' records lacked documentation regarding the administration or refusal of the COVID-19 vaccine, and the facility's policy on vaccine education and documentation was not followed.
Failure to Provide Needed Assistance With Personal Hygiene and Grooming
Penalty
Summary
The deficiency involves the facility’s failure to provide needed assistance with personal hygiene and grooming for multiple residents who were care planned as dependent on staff for ADLs. One resident with severe cognitive impairment and diagnoses including unspecified dementia required total assistance with upper body dressing and personal hygiene per the admission MDS and care plan. On two consecutive days, this resident was observed in the dining room with long curling facial hair above the lips, uneven and jagged fingernails with chipped nail polish and dark substances underneath, and a soiled shirt with white stains and food debris. The resident stated she needed staff assistance and wanted her facial hair removed, fingernails cleaned and trimmed, and her shirt changed, despite an active care plan that included interventions for assistance with dressing and personal hygiene to maintain a well-groomed appearance. Another resident with diagnoses including diabetes with chronic kidney disease, glaucoma, and rheumatoid arthritis, and who was moderately cognitively impaired, was assessed on the MDS as requiring total assistance with personal hygiene. This resident was observed in bed on two separate days with long facial hair above the lips and on the chin, and long, jagged fingernails with black substances underneath. The resident reported needing staff assistance for facial hair removal and nail care and expressed a desire to have facial hair shaved and fingernails trimmed and cleaned. The DON was present during one observation and acknowledged the resident needed staff assistance with nail care and shaving, despite the resident’s active care plan identifying an ADL self-care performance deficit and interventions for assistance with personal hygiene. A third resident with unspecified Alzheimer’s disease and unspecified dementia, assessed as severely cognitively impaired and totally dependent on staff for upper body dressing and personal hygiene, was observed in the dining room wearing a shirt with food debris and having uneven, mostly jagged fingernails with black substances under some nails. The following day, the resident’s fingernails remained uneven and jagged with dark material under some nails, and the ADON acknowledged that nail care was needed. This resident’s care plan documented an ADL self-care performance deficit with a goal of a well-groomed appearance and interventions for assistance with dressing and personal hygiene/grooming. A fourth resident, a 91-year-old with dementia, diabetes, and muscle wasting, whose MDS showed a need for assistance with grooming and hygiene, was repeatedly observed over several days with unkempt, overgrown facial hair and jagged, uneven, dirty fingernails with black/brown substance underneath. This resident verbally stated a desire to have fingernails clipped and facial hair shaved. The DON later stated it is part of nursing care and services to assist all residents needing help with nail care, dressing, and removal of unwanted facial hair to maintain personal hygiene and grooming, yet these needs were not met for the observed residents.
Failure to Provide Ordered IDDSI Level 6 Soft & Bite-Sized Diets
Penalty
Summary
The deficiency involves the facility’s failure to provide IDDSI Level 6 soft and bite-sized mechanically altered diets as ordered for four residents. Facility diet reports and physician orders showed that these residents were prescribed a regular diet with Level 6 Soft & Bite Sized texture and Level 0 thin liquids. Speech therapy recommendations for one resident specified a mechanical soft/thin diet with small bites, slow rate, and diet advancement only with speech therapy involvement. Despite these orders and the facility’s own policy defining Level 6 soft and bite-sized foods as items that can be mashed with a fork, cut into pieces no larger than 1.5 cm x 1.5 cm, with bread soaked and no regular dry bread or mixed consistencies, the meals prepared and served did not meet these requirements. On multiple observed meals, residents on Level 6 diets were served food in regular texture and size rather than mechanically altered form. At a lunch observation, two residents on Level 6 diets received pork roast in large cut pieces, whole California medley vegetables with large, firm pieces of cauliflower, broccoli, and carrot slices, and whole scalloped potatoes, identical to regular diet meals. They were not served the prescribed strawberry shortcake slurry dessert listed on the Level 6 menu. At a dinner observation, one resident on a Level 6 diet was served bratwurst sausage with the skin on, cut into large slices, along with a salad containing large pieces of lettuce, tomato, and cucumber with skin, and large slices of peaches, half strawberries, and chunks of melon in liquid, instead of the specified soft and bite-sized preparations and bread slurry. The Culinary Director acknowledged during observation that the bratwurst pieces and salad components were too large for a soft and bite-sized diet and confirmed that for this diet, food pieces should be no larger than the tines of a fork. The Culinary Director also stated that the slurry bun, defined as bread softened in milk, was not prepared or served. Additionally, during an initial kitchen observation, the Culinary Director identified one resident on a puree diet and four residents on mechanically altered diets, yet there was no mechanically altered food prepared for the lunch meal, despite the Level 6 menu specifying roast beef and roasted vegetables in small bite-sized pieces without skin, a slurry bread roll with margarine, and crustless cherry pie. These observations, interviews, and record reviews demonstrate that the facility did not prepare or serve meals in accordance with the ordered Level 6 soft and bite-sized diet and its own IDDSI-based policy for four residents.
Failure to Follow Hand Hygiene, Glove Use, and EBP PPE Requirements During Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection prevention and control policies regarding hand hygiene, glove use, and use of PPE, including Enhanced Barrier Precautions (EBP), for multiple residents. A nurse administering medications to one resident handled capsule medications with bare hands after touching various objects and surfaces, without performing hand hygiene, and then opened the capsules and mixed their contents into applesauce for the resident to ingest. Another nurse later stated that staff are supposed to sanitize their hands before opening capsules and avoid touching anything prior to handling medications to prevent contamination. For a resident on EBP due to a leg wound requiring wound care, two CNAs provided incontinence care after the resident had a bowel movement and was wet with urine. They wore gloves but did not don complete PPE as required for residents on EBP. One CNA used double gloves to clean the perineal area, then removed only the outer gloves and, with the remaining gloves still on, applied barrier cream and a new incontinence brief. After removing the second pair of gloves, the CNA assisted the resident to dress without performing hand hygiene. The DON later stated that staff must wear complete PPE when providing direct care to residents on EBP to prevent potential spread of infection or cross contamination. Additional deficiencies were observed during incontinence and toileting care for other residents. One CNA assisted a resident to the toilet, cleaned the perineum, removed a soiled brief, applied a clean brief, pulled up the resident’s pants, and assisted the resident back to a wheelchair while wearing the same soiled gloves and without hand hygiene between dirty and clean tasks. The same CNA, when providing incontinence care to another resident, cleaned the perineum, applied a new brief, repositioned the resident, and straightened bed linens while wearing the same soiled gloves, then removed PPE and left the room without hand hygiene. Another CNA, assisted by a second CNA, cleaned a resident’s anal and perineal areas while wearing gloves, then, using the same soiled gloves, applied a clean brief, pulled up the resident’s pants, and touched the bed control. This CNA later acknowledged not removing the soiled gloves or performing hand hygiene before proceeding to clean tasks, contrary to the facility’s hand hygiene and PPE policies, which require glove removal and hand hygiene after contaminated tasks and before moving to clean tasks.
Failure to Implement Contracture Management and Positioning Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide and apply recommended devices for contracture management and positioning to residents with known contractures, as outlined in their care plans and therapy recommendations. One resident, a 78-year-old under hospice care with hemiplegia and a left-hand contracture, had a care plan intervention specifying application of a left-hand splint on for 12 hours and off for 12 hours. A therapy form documented that a resting hand splint had been provided but was missing. Across multiple observations over several days, the resident was repeatedly seen in bed with the left arm and hand contracted and the hand tightly clenched, with fingers digging into the palm. There was no resting hand splint, palm protector, carrot splint, or rolled towel in use or present in the room. A CNA reported that the resident used to have a carrot splint and was using only a thin dressing on the palm to protect the skin from fingernails. Another resident, a 73-year-old with dementia, functional quadriplegia, and contractures of the upper and lower extremities, had therapy documentation indicating contractures and a need for cuing to relax limbs and pillow placement to increase comfort and decrease skin breakdown. This resident’s care plan identified contracture, quadriplegia, and chronic pain syndrome, with interventions including non-pharmacological pain mechanisms such as comfortable positioning. During multiple observations over several days, the resident was seen resting in bed with contracted hands, wrists, and bilateral lower extremities. The lower extremities were contracted and adducted, with the skin of the legs touching and rubbing together, and there was no wedge pillow or other pillow placed between the knees, despite the documented need for such positioning support.
Improper Administration of Time-Sensitive and Delayed-Release Medications
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders and manufacturer recommendations, resulting in a medication error rate of 7.69% (2 errors out of 26 opportunities) during a medication pass observation. A 92-year-old resident with dementia, dysphagia, hypertension, tachycardia, and hypothyroidism had physician orders for Levothyroxine Sodium 50 mcg to be given once daily as a time-sensitive medication at 6 AM (earliest 5 AM) and Aspirin 81 mg delayed-release once daily for VTE. On December 29, 2025, at 10:23 AM, a nurse administered multiple medications to this resident, including Levothyroxine and Aspirin, after the resident had already eaten breakfast, and crushed both medications, which converted the Aspirin delayed-release tablet into an immediate-release dose. The manufacturer’s recommendation for Levothyroxine specified administration on an empty stomach, 30 minutes to 1 hour before breakfast with a full glass of water, and staff interviews confirmed the expectation that Synthroid (Levothyroxine) should be given early in the morning on an empty stomach to ensure optimal absorption, but this was not followed in the observed administration. The administrator stated that nurses are expected to relay pharmacy recommendations to the physician and follow physician instructions and orders, and another nurse confirmed that Synthroid is normally given at 6 AM before breakfast on an empty stomach to increase effectiveness, indicating that the observed practice for this resident deviated from both the physician’s time-sensitive order and the manufacturer’s administration guidelines.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain proper sanitation and food safety standards in the kitchen, affecting all 22 residents. During an inspection, it was observed that the area behind and between large cooking equipment was covered in food splatters, dust, and loose particles. Equipment hoses, cords, and back panels were also found to be dirty. Additionally, a package of hot dogs was stored in the walk-in cooler without a label or date, and was placed above raw Swiss steak, which had leaked blood into the pan. Cooked bratwurst was initially stored below the raw meat, posing a risk of cross-contamination. The facility's food service manager admitted that staff relied on memory to determine food discard dates, which is not in compliance with the facility's policy requiring labeling and dating of stored food. Furthermore, a food service worker was observed serving food and handling various items without performing proper hand hygiene. After serving food and coffee to a resident, the worker removed her gloves and put on new ones without washing her hands. She continued to handle food and clean surfaces with the same gloves, violating the facility's hand washing policy. The facility's policies on food safety, dishwashing, and sanitation were not adhered to, as evidenced by the lack of proper hand hygiene and the improper storage and labeling of food items.
Failure to Follow Water Management and Infection Control Protocols
Penalty
Summary
The facility failed to adhere to its Water Management Plan for Legionella, as evidenced by the maintenance director's inadequate weekly checks of the eyewash stations and the failure to perform required chlorine testing. The maintenance director demonstrated a check of the eyewash station that lasted only one to two seconds, contrary to the plan's requirement for a three-minute flush. Additionally, the hot water temperatures recorded were consistently below the control limits set by the facility's plan, and there was no documentation of biannual legionella testing for 2023 or 2024. The maintenance director admitted to not having chlorine testing kits and not sending legionella samples to the laboratory since August 2023. The facility also failed to follow Enhanced Barrier Precautions (EBP) and hand hygiene protocols during medication administration. An LPN was observed not performing hand hygiene before and after entering a resident's room, not wearing a gown for a resident on EBP, and not sanitizing a blood pressure cuff between uses on different residents. The LPN handled medications and resident care activities without changing gloves or performing hand hygiene, despite the facility's policies requiring these actions to prevent infection transmission. The facility's policies on hand hygiene, isolation precautions, and cleaning of resident care equipment were not followed, as demonstrated by the LPN's actions. The LPN acknowledged the failure to perform hand hygiene and sanitize equipment between resident uses, which are critical steps in preventing the spread of infections. The regional nurse consultant confirmed the importance of these practices, emphasizing the need for hand hygiene before and after resident care and the use of PPE for residents on EBP.
Facility Fails to Meet Nutritional Standards in Menu Planning
Penalty
Summary
The facility failed to meet the nutritional needs of its residents by not providing the minimum required servings of fruits/vegetables and grains/breads as per their own policy. This deficiency was identified through interviews and record reviews, affecting 15 residents who were on Regular and/or No Added Salt diets. The facility's menus, which were supposed to be reviewed by a corporate dietitian, did not include the required servings of fruits/vegetables on multiple days across four weeks. Specifically, the menus lacked at least 5 servings of fruits/vegetables on several days each week and failed to provide at least 6 servings of grains/breads on various days. The Food Service Manager, identified as V9, confirmed that the menus were reviewed by the corporate dietitian but was unable to identify the missing servings when reviewing the menus. The facility's Menu Planning Guide, dated November 2023, specifies that the Regular/No Added Salt menus should include foods that meet or exceed the Dietary Reference Intakes for older adults, including 5 or more servings of vegetables and fruits and 6 or more servings of grains daily. Despite this guideline, the facility's menus did not comply with these nutritional standards, leading to the deficiency.
Failure to Provide SNF-ABN to Resident
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF-ABN) to a resident, identified as R225, at the end of their Medicare Part A stay. R225's Medicare Part A Skilled Services began on October 10, 2024, and the last covered day was November 14, 2024. However, the facility did not issue the SNF ABN form to R225, who remained in the facility until November 19, 2024, when they were discharged to a local hospital. On January 28, 2025, a social services staff member, V18, acknowledged that R225 did not receive the SNF ABN form because V18 was unaware that R225 would remain in the facility after the last covered day. V18 also stated that the SNF ABN should be provided two days before the last covered day to allow the resident or their representative time to appeal if desired. The facility lacked documentation to show that R225 received the SNF ABN form before the end of their Medicare Part A coverage.
Failure to Provide Written Bed Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to provide written notification of its bed hold policy to residents or their representatives during hospital transfers, as required by federal law. This deficiency was identified in two residents, R4 and R5, out of a sample of 12. R5, who had severe cognitive impairment and multiple health issues, was transferred to the hospital multiple times from August 2024 to January 2025. However, the facility did not document any discussion of the bed hold policy with R5 or her representative during these transfers. The BEDHOLD AGREEMENT-TRANSFER NOTICE forms provided by the facility were either incomplete or incorrectly dated, indicating a lack of proper communication and documentation. R4, a female resident, was transferred to the hospital on January 11, 2025, due to symptoms of congestion and a chest x-ray showing possible atelectasis, pneumonia, or edema. The Bed Hold Agreement form in R4's electronic medical record was uploaded on January 2, 2025, but was unsigned and undated. It was later presented to the surveyor with a handwritten date of January 11, 2025, and an electronic signature from the social services representative, V18, but lacked details such as the hospital to which R4 was discharged. V18 admitted to not discussing the bed hold policy with residents or their representatives at the time of discharge, nor providing them with a copy of the form. The facility's policy, dated October 12, 2021, requires that written notice of the bed hold policy be provided to residents and their representatives at the time of transfer for hospitalization or therapeutic leave. Despite this policy, the facility failed to comply, as evidenced by the incomplete and improperly handled documentation for R4 and R5. This lack of adherence to policy and federal requirements resulted in the identified deficiency during the survey.
Failure to Provide Adequate Nutritional Care for Resident
Penalty
Summary
The facility failed to ensure a resident with significant weight loss was reviewed by a dietitian upon readmission from the hospital, did not provide necessary nutritional interventions, and did not obtain weekly weights as ordered by the physician. The resident, who had a history of severe protein-calorie malnutrition and other complex medical conditions, experienced a 14% weight loss over a short period. Despite having a physician's order for weekly weights, the facility did not consistently obtain these measurements, missing several weeks in January 2025. Additionally, the resident's nutritional supplements were not reordered upon readmission from the hospital in December 2024, and the dietitian was not informed of the resident's condition until late January 2025. The resident required assistance with feeding and had difficulty swallowing, yet the facility did not make a timely referral to the dietitian. The dietitian confirmed that they were not notified of the resident's hospitalizations and readmissions, which contributed to the oversight in nutritional care. The physician acknowledged that the lack of nutritional supplements may have contributed to the resident's weight loss.
Failure to Verify G-tube Placement Before Medication Administration
Penalty
Summary
The facility failed to verify the placement and patency of a resident's gastrostomy tube (G-tube) before administering medication. This deficiency was observed during a medication administration for a male resident with a history of hemiplegia, hemiparesis, dysphagia following cerebral infarction, and type 2 diabetes mellitus. The nurse, identified as V6, administered medication through the resident's G-tube without aspirating to check for residual gastrointestinal fluid or flushing the catheter, which are necessary steps to ensure the tube's proper placement and patency. The facility's policy on administering medications through a feeding tube requires staff to verify the placement of the feeding tube by checking for residuals and flushing the tube with water. However, during the observation, these steps were not followed by the nurse. The regional nurse consultant, V3, confirmed that the staff is expected to check for proper placement and patency of the G-tube before use, as outlined in the facility's policy. This oversight in following the established procedure led to the deficiency noted in the report.
Failure to Monitor Resident-Specific Behaviors for Psychotropic Medication Effectiveness
Penalty
Summary
The facility failed to identify resident-specific behaviors to monitor the effectiveness of psychotropic medications for three residents. The documentation survey report revealed that residents were being monitored for a generic list of behaviors rather than individualized symptoms. This lack of specificity in behavior monitoring was evident in the cases of three residents who were reviewed for unnecessary psychotropic medications. One resident, admitted with diagnoses including unspecified psychosis, anxiety, and dementia with behaviors, had a care plan that did not specify target behaviors for monitoring. Despite being on antidepressant and antipsychotic medications, the behavior monitoring was vague and not resident-specific, with several shifts lacking any behavior monitoring documentation. Another resident, diagnosed with depression, had no assessment to determine specific behaviors indicative of depression, and their care plan lacked resident-specific behaviors to monitor the effectiveness of the prescribed antidepressant. A third resident, also diagnosed with depression, had a care plan that included monitoring for signs and symptoms of depression, but the behavior tracking records did not align with the symptoms listed in the care plan. The facility's policy required assessments to identify specific behaviors and document the resident's response to non-pharmacological interventions, but this was not adhered to, leading to the deficiency.
Failure to Respond Promptly to Call Lights and Provide Timely Incontinence Care
Penalty
Summary
The facility failed to follow its policy to answer call lights promptly and provide timely incontinence care to residents, affecting three out of four residents reviewed. One resident, R3, who has multiple diagnoses including diabetes, heart disease, and dementia, was found in bed with a strong odor of stool in the room. R3 reported that his incontinence brief had not been changed since 5:00 AM, despite having a bowel movement shortly after. He expressed frustration with the call light system, stating that pressing the call light during shift changes or meal times was ineffective. When R3 pressed the call light during an interview, it took over 13 minutes for staff to respond, during which time R3 was found with stool caked on his skin, causing discomfort and redness. Another resident, R4, who has conditions such as heart failure and COPD, also reported long wait times for call light responses. R4's family had previously raised concerns about call light response times, with records showing an average response time of 29 minutes and some instances exceeding an hour. Despite these concerns being forwarded to the Director of Nursing, the issue persisted, indicating a systemic problem with call light response times in the facility. A third resident, R1, who was discharged home, had a history of multiple diagnoses including spinal injuries and heart failure. During R1's stay, call light logs revealed response times exceeding 45 minutes on several occasions, with one instance taking 85 minutes. The facility's policy, which mandates prompt response to call lights, was not adhered to, contributing to the deficiencies observed. The lack of timely response to call lights and incontinence care highlights a significant lapse in the facility's adherence to its own policies, impacting the quality of care provided to residents.
Failure to Administer Medications and Respond to Incontinence
Penalty
Summary
The facility failed to ensure that medications were present for a resident with recurrent diarrhea and did not notify the physician about the missing medications. Additionally, the facility did not complete lab testing in a timely manner and failed to respond promptly to the resident's stool incontinence. These delays in treatment resulted in the addition of a third medication and the resident experiencing increased weakness and skin irritation. The resident, who has diagnoses including congestive heart failure, muscle weakness, and enterocolitis due to Clostridium difficile, was admitted to the facility and required staff assistance for mobility using a walker. The care plan indicated a risk for further skin breakdown due to decreased mobility. On the day of the survey, the resident's call light had been unanswered for over an hour, and the resident's family member reported that the resident had been having diarrhea for five days. Despite orders for fidaxomicin and metronidazole, the medications had not been administered, and the physician was not notified about the delay. The resident's condition worsened, leading to the addition of Vancomycin. The surveyor observed the resident calling for assistance and found the resident's buttocks excoriated and covered in stool. The Director of Nursing confirmed that the medications were not administered as ordered and that there was no documentation of the physician being notified about the delay.
Failure to Maintain Kitchen Hygiene and Food Storage Standards
Penalty
Summary
The facility failed to maintain the kitchen in a manner that prevents foodborne illness, affecting all 26 residents in the long-term care unit. During a kitchen tour, it was observed that the cook/kitchen supervisor had uncovered facial hair, and various food items were improperly stored. The ice cream cooler had an open and uncovered container of mint chocolate chip ice cream. In the dry storage area, several blue bags containing raisins, craisins, chocolate chips, and vermicelli were not labeled or dated. Additionally, two dented cans of peaches were found, which the kitchen supervisor acknowledged should not be used due to potential contamination. The walk-in cooler contained sour cream, coleslaw, and salad dressings that were either not in their original containers or expired. The walk-in freezer had unlabeled and undated bags of chicken tenders, chicken breast chunk fritters, and seasoned potato wedges. The reach-in cooler had cinnamon apple sauce without any dates. The sanitizer for the three-compartment sink was not within the safe range, and the meat slicer was found with crusts and debris particles. The flour and oatmeal bins were past their use-by dates, and the vents over the cooking area were dusty. Logs for testing the three-compartment sink or sanitization buckets were not maintained. Staff members were also observed without proper hair coverings, and personal food items were found in the nourishment refrigerator, which is against facility policy. The facility's policies on food storage, personal cleanliness, and sanitization were not followed. The food storage chart indicated specific durations for the freshness of various food items, which were not adhered to. The facility's policy on personal cleanliness required all dietary staff and anyone entering the kitchen to wear approved hair restraints, which was not consistently practiced. The sanitization and cleaning schedule policy mandated that all refrigerated and prepared foods be covered, labeled, and dated, which was also not followed. The facility's failure to comply with these policies and maintain proper kitchen hygiene and food storage practices poses a risk of foodborne illness to the residents.
Failure to Assist Residents with ADLs in a Timely Manner
Penalty
Summary
The facility failed to assist residents with their Activities of Daily Living (ADL) needs in a timely manner. Resident R173 was observed sitting on the side of the bed in a t-shirt and disposable underpants, stating that it took staff about 30 minutes to answer her call light and that she was left on the toilet waiting for staff to return. The surveyor observed nursing staff at the nursing station and two nursing staff walking by R173's room without addressing the call light. It took 26 minutes for non-nursing staff to respond to R173's call light. R173's MDS dated 4/8/24 shows moderate cognitive impairment and requires partial/moderate staff assistance with most ADLs. R173's care plan dated 4/3/24 shows an ADL self-care performance deficit related to back pain. Resident R18 reported that staff are slow to respond to call lights on the second and third shifts, with waits as long as two hours. R18 has had to get up in his wheelchair to find staff assistance. R18's MDS dated 4/1/24 shows he is cognitively intact and requires substantial/maximal staff assistance with ADLs. R18's care plan dated 3/27/24 includes an ADL self-care performance deficit related to impaired mobility and multiple fractures. Resident R7's call light was unanswered for two hours and 26 minutes. R7's MDS dated 4/6/24 shows moderate cognitive impairment and requires substantial staff assistance with ADLs. R7's care plan dated 3/26/24 shows an ADL self-care deficit and a risk for falls related to Parkinson's Disease and Lewy body dementia. The facility's policy states that call lights should be answered promptly, but staff reported difficulties in completing tasks and responding to call lights due to workload and lack of assistance from nurses.
Failure to Follow Dietician's Nutritional Supplement Recommendation
Penalty
Summary
The facility failed to follow the Dietician's recommendation to provide a nutritional supplement to a resident (R1) who experienced significant weight loss. R1, a [AGE] year old female with severe protein-calorie malnutrition, congestive heart failure, and a need for assistance with personal care, lost 15.4 lbs (13.9%) in one month. Despite the Dietician's recommendation on 4/9/24 to provide nutritional supplements and Prostat to support weight and wound healing, these orders were not entered into the resident's POS as of 4/18/24. Observations and interviews confirmed that R1 did not receive the recommended supplements, and no supplements were found at her bedside. The Dietician stated that recommendations are typically entered within 72 hours, but this did not occur in R1's case, leading to a delay in care. The Director of Nursing (DON) acknowledged that the Dietician's recommendations are usually carried out within 24 hours but was unaware of the delay in this instance. The DON could not find the email from the Dietician with the recommendations and admitted that the supplements were not ordered. The facility's policy requires cooperation between nursing staff and the Dietician to monitor and intervene in cases of significant weight changes, but this protocol was not followed, resulting in the resident not receiving the necessary nutritional support in a timely manner.
Failure to Follow Infection Control Protocols
Penalty
Summary
The facility failed to follow proper disinfection protocols to prevent the spread of infection, specifically Clostridium Difficile (CDIFF). One resident, diagnosed with CDIFF, was placed under strict contact isolation. However, a registered nurse (RN) did not use the appropriate bleach wipes to disinfect equipment used in the resident's room. Instead, the RN used purple top Sani-cloth wipes, which are not effective against CDIFF. Additionally, the RN did not wash her hands with soap and water after handling the resident's equipment, as required by the facility's policy. The Director of Nursing (DON) confirmed that the facility did not have the necessary bleach wipes in stock, and other staff members corroborated that the purple top wipes were ineffective against CDIFF. The facility's policy and manufacturer guidelines clearly state that bleach wipes should be used and that handwashing with soap and water is essential after caring for residents with CDIFF. Another deficiency was observed with a resident who had a peripherally inserted central catheter (PICC) line. The RN reused a green disinfecting port protector cap after flushing the PICC line, contrary to standard practice and manufacturer guidelines, which state that these caps are single-use only. The DON and other staff members confirmed that reusing the port protector cap could lead to central line contamination or infection. The resident's care plan indicated a risk for infection and required aseptic and sterile techniques, which were not followed in this instance. The facility's failure to adhere to proper infection control protocols, including the use of appropriate disinfecting wipes and single-use port protector caps, as well as the failure to perform proper hand hygiene, led to deficiencies in the care provided to residents. These actions and inactions directly violated the facility's policies and manufacturer guidelines, putting residents at risk for infection and other complications.
Failure to Document and Offer Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer and document the provision of influenza and pneumococcal immunizations to residents admitted to the facility. This deficiency was identified during an infection control task where the electronic records of two residents, R11 and R124, were reviewed and found to be incomplete. R11, who was admitted with multiple diagnoses including rhabdomyolysis, pleural effusion, congestive heart failure, and chronic obstructive pulmonary disease, had no documentation of influenza vaccine consent or refusal. Similarly, R124, admitted with diagnoses such as trochanteric fracture of the right femur, acute myocarditis, and chronic obstructive pulmonary disease, also had no documentation of influenza and pneumococcal vaccine consent or refusal. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the facility's process for determining vaccine history should take up to a week, and that influenza vaccines are offered to residents upon admission. However, the immunization history for R124 was not completed, and the admission checklist for both R11 and R124 was missing from the electronic medical record (EMR) and paper chart. The facility's policies on seasonal influenza and pneumococcal vaccinations require screening of vaccine history and documentation of consents or refusals in the EMR, which was not adhered to in these cases.
Failure to Document and Offer COVID-19 Vaccination
Penalty
Summary
The facility failed to offer or document the COVID-19 immunizations for two residents, R124 and R172, upon their admission. Both residents' electronic records lacked documentation regarding the administration or refusal of the COVID-19 vaccine. R124 was admitted with multiple diagnoses including a trochanteric fracture of the right femur, acute myocarditis, and chronic obstructive pulmonary disease, among others. Similarly, R172 was admitted with diagnoses such as cardiomyopathy, atrial fibrillation, and chronic respiratory failure. The immunization reports for both residents did not address the COVID-19 vaccines, and there was no documentation of consent or refusal for the immunizations in their records. Interviews with the facility's ADON and DON revealed that the facility's policy required staff to ask new admissions about their vaccine status and offer the vaccine if there was no evidence of prior administration. The ADON stated that the process of determining vaccine history should take up to a week, and the DON confirmed that if a resident refused the vaccine, a signed document should be uploaded into the EMR. However, for both R124 and R172, the immunization history was not completed, and the admission checklist documenting this was missing from both the EMR and paper charts. The facility's COVID-19 Vaccine policy mandated offering the vaccine and documenting education and administration or refusal, which was not followed in these cases.
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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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