Elevate Care Chicago North
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 2451 West Touhy Avenue, Chicago, Illinois 60645
- CMS Provider Number
- 145484
- Inspections on file
- 55
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Elevate Care Chicago North during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, non-verbal status, and multiple complex medical conditions developed a small superficial skin alteration on the buttocks that was reported by a CNA to an LPN, but the LPN did not document the issue or any intervention in the medical record. The wound care team was not contacted until several days later, and the Wound Care Coordinator obtained a physician order and initiated treatment only after this delay, despite facility policies and RN/LPN responsibilities requiring timely communication and intervention for changes in condition.
A resident with multiple diagnoses received medications from an LPN who did not consistently document administration in the eMAR immediately after giving the medications. Audit reports showed that medications scheduled for specific times were often documented hours later, contrary to facility policy and staff expectations.
Five residents with various medical and mental health conditions were able to obtain and consume alcohol in a supervised area, despite facility policy requiring a physician order for alcohol use. Staff observed the group drinking, detected the smell of alcohol, and confirmed the incident via camera footage, but were unable to determine how the alcohol was acquired. The event highlighted a lapse in supervision and policy enforcement.
Two residents with significant physical and cognitive impairments experienced physical and verbal abuse from a CNA, including rough handling, a physical assault resulting in facial injury, and removal of food trays. Both residents reported pain, distress, and mental anguish. The CNA involved stated she had not received abuse training and was unaware of the abuse coordinator, and the facility failed to ensure residents were free from mistreatment.
A CNA was allowed to work with residents without receiving mandatory abuse prevention and reporting training, as required by facility policy. Two residents reported experiencing physical and verbal abuse from this CNA, including rough handling and being struck, with one resident displaying visible injuries. The CNA confirmed not receiving abuse training and was unaware of the Abuse Coordinator's identity.
Several residents did not receive respiratory care in accordance with physician orders and facility policy, including incorrect oxygen flow rates, improper bed positioning for a ventilator-dependent resident, and failure to properly date and store oxygen nasal cannula tubing. Staff confirmed these lapses during interviews, and observations showed equipment was not maintained or used as required.
Surveyors observed that multiple food items in the kitchen were not properly labeled or dated, including sliced ham, grape jelly, shredded mozzarella cheese, and sour cream. The Food Service Director and Registered Dietitian confirmed that labeling and dating are required by facility policy to ensure food safety. This deficiency had the potential to affect all residents receiving food prepared in the kitchen, including those with NPO orders.
Staff and a visitor failed to wear required PPE, including gowns and gloves, when entering rooms of residents on contact isolation or enhanced barrier precautions. Observations included a staff member adjusting a resident's brief and an agency RN providing care to two residents, all without proper PPE, despite posted signage and facility policy. A visitor was also seen in a resident's room on contact isolation for C. diff without PPE. Facility leadership confirmed that all staff and visitors should follow posted PPE requirements to prevent infection transmission.
A resident with significant medical needs was observed receiving incontinence care without privacy measures in place, as both the door and privacy curtain were left open and the staff member did not wear the required gown. The staff member acknowledged the lapse in providing privacy and use of PPE, contrary to facility policy.
A resident with quadriplegia and total ADL dependence did not have access to a specialized call light that accommodated his disability. The standard call light was found on the floor and out of reach, and the resident reported being unable to use it due to paralysis. Despite care plan documentation and facility policy requiring accessible call systems, the resident was left to rely on yelling or using a phone to request help, which was not consistently effective.
The facility did not refer several residents with mental health diagnoses for required PASARR Level II evaluations, resulting in outdated or missing screenings. Staff interviews and record reviews confirmed that PASARR re-evaluations were not conducted after changes in assessment procedures, and the facility lacked a PASARR policy.
A resident with severe cognitive impairment and multiple medical conditions was not provided with required one-to-one feeding assistance or proper upright positioning during meals, as specified in the care plan. The resident was observed attempting to eat a pureed diet unassisted while in bed at a 45-degree angle, contrary to facility policy and staff expectations. Staff interviews confirmed that the resident should have received hands-on feeding assistance and been positioned upright to ensure safe swallowing.
Two residents with communication barriers did not receive appropriate communication assistance. One resident who spoke a foreign language had no communication board available and staff relied on family for translation. Another resident with a speech deficit was unable to communicate pain to staff, who left without resolving his needs. The facility's policy requires language assistance, but it was not effectively implemented.
Two residents did not receive appropriate care: one did not have their Midline catheter dressing changed and documented as ordered, with staff unclear on responsibilities and documentation inaccurate; another experienced persistent low blood pressure that was not promptly reassessed or reported to a physician by an LPN, despite ongoing symptoms and facility policy requiring such action.
A resident with a left hand contracture and multiple chronic conditions did not have a physician-ordered palm protector applied as required by their care plan. Observations showed the device was not in place during several checks, and staff interviews indicated a lack of awareness about the device's application and monitoring responsibilities.
A resident with an indwelling urinary catheter and multiple medical conditions was observed with their urinary drainage bag lying directly on the floor, contrary to facility policy and standard infection control practices. Both an RN and the DON confirmed that the bag should have been hooked to the bed to prevent infection risk, as outlined in the facility's catheter care policy.
A resident with multiple chronic conditions did not receive prescribed Tramadol and Creon as ordered, due to medication unavailability and prescription issues. Despite delivery confirmation for Creon, nursing staff could not locate it, and Tramadol was not filled because of a missing provider signature. The resident experienced pain, vomiting, and diarrhea as a result.
A resident with multiple chronic conditions and intact cognition was found self-administering Creon and storing Tramadol in their room without a physician's order or assessment for self-administration. The resident reported keeping medications due to missed doses by staff, and staff confirmed that no assessment or care plan was in place, contrary to facility policy.
A resident with significant medical and mobility issues was found with their call light on the floor and out of reach while in bed, despite care plan and facility policy requiring it to be accessible. Multiple staff, including LPNs and the DON, confirmed that call lights should always be within reach for residents.
Two residents with complex medical conditions were found to have undated oxygen tubing in use, despite physician orders, care plans, and facility policy requiring the tubing to be changed and dated regularly. Nursing staff confirmed that dating the tubing was their responsibility, but observations showed this was not done for the residents reviewed.
Multiple residents experienced a lack of a safe, clean, and homelike environment due to missing ceiling panels, exposed cords, chipped paint, broken furniture, and unaddressed maintenance issues. Staff were sometimes unaware of needed repairs, and cleaning tasks were inconsistently completed due to workload. Facility policies did not fully address residents' rights to a clean and comfortable environment.
Two residents who were dependent on staff for toileting and personal care did not receive timely incontinence care, with some CNAs limiting changes to three times per shift regardless of need. Both residents reported delays and being left in soiled conditions for extended periods, despite care plans and facility policies requiring prompt response and care after each episode. Staff interviews confirmed these practices, which did not align with facility expectations or policies.
A facility failed to provide timely incontinence care for several residents, leading to improper nursing care. Residents experienced significant delays in receiving assistance, often waiting over an hour for care. Despite being able to verbalize needs, residents were left in soiled conditions due to staff not adhering to the facility's policy of checking and changing every two hours. The Director of Nursing acknowledged the unacceptable response times and emphasized the importance of timely care.
A resident with a history of aggressive behavior punched another resident in the face after becoming upset when redirected from taking food off a cart. The incident occurred at the nurses' station, where the second resident, who has multiple diagnoses including Hemiplegia and Vascular Dementia, was unable to defend themselves. Witnesses confirmed the aggressive behavior, and the affected resident experienced fear and subsequent seizures. The facility's response was inadequate, failing to uphold policies on abuse prevention and residents' rights.
A resident with severe cognitive impairment and total dependence on staff for ADLs did not receive adequate oral care, grooming, and hair washing as per the facility's schedule. Observations showed poor hygiene, with discolored teeth and matted hair. Staff interviews confirmed neglect in scheduled care, and the care plan was not individualized to meet the resident's needs, leading to deficiencies in care practices.
A resident with epilepsy and on anticoagulant therapy was punched in the face by another resident, leading to seizures. The facility failed to document vital signs, seizure details, or send the resident to the hospital, as required by their care plan and policy. Staff interviews revealed inconsistencies in the response and documentation of the incident.
A resident with severe contractures was observed without the required bilateral palm protectors, as specified in their care plan. The facility's staff, including the Restorative Director and DON, confirmed the oversight, which could potentially lead to further contractures. The deficiency was identified through observation and staff interviews.
A facility failed to follow a resident's care plan by not maintaining a spare tracheostomy tube at the bedside for emergencies. The resident, with chronic respiratory failure and ventilator dependence, was observed without the required spare tube. Both the respiratory therapist and the DON confirmed the necessity of having a spare tube readily available to ensure airway patency in emergencies.
A resident fell during a mechanical lift transfer due to the use of an incorrect lift pad and lack of a second caregiver, contrary to facility policy. The incident was not investigated, and no report was submitted to the health department. The resident sustained an indeterminate age fracture, and the CNA involved was suspended.
The facility failed to discard food in the main cooler after the use-by date and did not date frozen meat products in the main freezer. During a kitchen tour, expired grape jelly and undated frozen meat were found. The Food Service Director confirmed that all foods should be dated and discarded by their use-by dates, as per facility policies. This failure potentially affects 122 residents receiving an oral diet.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents requiring wound care, those with multiple pressure injuries, and a resident with a dialysis access device. Observations revealed missing EBP signage and PPE bins, and staff did not consistently follow EBP protocols, increasing the risk of infection transmission.
The facility failed to maintain proper accounting of resident personal funds for five residents, leading to them not receiving their entitled monthly allowances. The Financial Coordinator admitted to not documenting communications with the Social Security Administration and other relevant actions, resulting in mismanagement of funds. The Director of Social Services confirmed that the Business Office was responsible for managing resident funds, but necessary documents were not submitted, and records were inadequately maintained.
The facility failed to provide communication boards or books for four residents who primarily speak Spanish, despite their care plans requiring these aids. Staff confirmed that these residents should have had communication boards at their bedside, but none were found during the surveyor's observations.
The facility failed to ensure that pressure-reducing air mattresses were set according to the residents' weight, leading to potential complications in wound healing and prevention. Observations and staff interviews confirmed that the settings were incorrect for multiple residents, contributing to the deficiency.
The facility failed to secure their Central Supply Room, making it accessible to residents and visitors, and did not remove a space heater posing a fire hazard from a resident's room. The Central Supply Room contained over-the-counter medications and other equipment, and the space heater was provided by the facility despite being against policy.
The facility failed to provide safe and appropriate respiratory care by not dating and labeling oxygen tubing, improperly storing nebulizer equipment, and not administering oxygen as ordered. These deficiencies affected several residents, increasing the risk of infection and improper oxygen therapy.
The facility failed to follow its medication storage and labeling policies, resulting in medications not being stored in locked compartments, insulin not labeled with open/expiration dates, and expired insulin not discarded. Additionally, a resident's personal refrigerator contained facility medications, and another resident had multiple medications at their bedside without a self-administration assessment.
The facility failed to label and date food items, monitor refrigerator temperatures daily, discard expired food, and clean residents' personal refrigerators regularly. This deficiency was observed in the refrigerators of four residents, with expired and spoiled food items found, and temperature logs not updated for months. Staff were unclear about their responsibilities, leading to inconsistent adherence to facility policies.
A resident with limited mobility and chronic pain requested a change in their shower schedule from Friday evening to Saturday morning. Despite multiple requests and confirmation from the Assistant Social Services Director, the facility did not update the schedule, failing to honor the resident's preference as outlined in their care plan and facility policies.
The facility failed to document the code status of two residents accurately and did not educate one resident on Advanced Directives. One resident's POLST form indicated 'Do Not Attempt Resuscitation' and 'Selective Treatment,' but only the DNAR status was entered into the electronic medical record. Another resident's POLST form indicated 'No CPR' and 'Comfort-focused treatment,' but the medical record incorrectly documented the resident's code status as 'Full.'
The facility failed to refer a resident with mental health diagnoses for a PASRR Level II assessment after the initial 30-day approval period expired. The oversight was confirmed by the Social Service Director and Consultant, who acknowledged that the necessary re-screening had not been conducted in a timely manner.
The facility failed to provide timely incontinence care for a resident with Hemiplegia, Right Hand Contracture, and Vascular Dementia. The resident was found with a soaking wet incontinence pad and stated they had been waiting for hours for assistance, despite pressing the call light. A CNA admitted to not having seen the resident yet, and the DON confirmed that caregivers are expected to perform rounds every two hours.
A facility failed to ensure a resident's wrist splints were used as per the care plan and did not update the care plan to reflect the resident's preference not to wear them. The resident, diagnosed with quadriplegia, was observed without the splints and expressed a preference to manage without them. Despite this, the care plan was not updated, leading to a deficiency in care.
The facility failed to prevent a urinary drainage bag from touching the floor for a resident with multiple diagnoses, including a Stage 4 pressure ulcer and Chronic Kidney Disease. The bag was observed on the floor without any protective cover, increasing the risk of infection. Both a Licensed Practical Nurse and the Infection Prevention Director confirmed that this practice violates infection control policies.
The facility failed to follow physician orders and provide house nutritional supplements for two residents. One resident with adult failure to thrive and another on renal dialysis did not receive their prescribed supplements, leading to confusion among staff about the process for delivering these supplements.
The facility failed to follow a physician's order and dietary recommendation for a resident's enteral feeding rate. The resident, who was underweight and had pressure ulcers, was supposed to receive Nepro 1.8 at 70 ml/hr for 18 hours but was observed receiving it at 45 ml/hr and at another time, the feeding was turned off. The Director of Nursing and Registered Dietitian confirmed the importance of adhering to the prescribed feeding rate.
A resident with a documented egg allergy received a breakfast tray containing scrambled eggs, contrary to their meal ticket indicating the allergy and other food preferences. The resident's medical history includes several chronic conditions, and the dietary staff acknowledged the error, emphasizing the importance of following meal tickets to prevent allergic reactions and ensure residents receive appropriate food.
The facility failed to ensure accurate medical records for a resident diagnosed with adult failure to thrive. Despite an order for a house supplement to be administered three times a day, the resident did not receive the supplements. Interviews with staff revealed confusion and miscommunication regarding the responsibility for administering the supplements, and a review of the Medication Administration Record showed inaccurate documentation.
The facility failed to revise and implement appropriate fall prevention interventions and provide adequate supervision for a resident at risk for falls. Despite multiple falls and a moderate fall risk assessment, the care plan was not updated with new interventions after each fall, leading to repeated falls and injury.
The facility failed to provide 1:1 feeding assistance to three residents, resulting in significant weight loss for one resident and inadequate documentation of feeding assistance for two others. Despite requests and dietary assessments indicating the need for assistance, the facility did not consistently provide or document the required support.
Delay in Initiation and Documentation of Wound Care Treatment
Penalty
Summary
The facility failed to provide timely wound care according to orders and established procedures for one resident with a left gluteal skin alteration. The resident, who is severely cognitively impaired, non-verbal, and has multiple significant diagnoses including chronic respiratory failure with hypoxia, tracheostomy, dysphagia, encephalopathy, and dependence on supplemental oxygen, was admitted on an unspecified date. On 1/23/26, an unidentified CNA reported to an LPN that the resident had a small superficial skin alteration on the buttocks. The LPN stated she reported this to the wound team but did not document the intervention or the skin issue in the resident’s medical record, acknowledging that if it is not documented, it is considered not done. The Wound Care Coordinator later stated he could not recall being informed of the skin alteration on 1/23/26 and only contacted the physician for a treatment order on 1/27/26. The physician’s order for wound care to the left gluteal area, including cleansing with normal saline, applying zinc oxide paste, and covering with silicone bordered foam every day and as needed, was dated 1/28/26, and the Treatment Administration Record shows the initial wound treatment dated 1/27/26. The DON stated it was her expectation that nurses provide timely nursing interventions to prevent further tissue breakdown and acknowledged that treatment was not started until about three days after the skin alteration was first reported, although she described the wound as very small. The facility’s change in condition policy requires timely communication of medical care problems to the attending physician, and the RN/LPN job description requires timely notification of the medical director. The delay between the initial report of the skin alteration and the initiation and documentation of wound treatment constitutes the deficiency.
Failure to Timely Document Medication Administration in eMAR
Penalty
Summary
The facility failed to ensure that staff documented the administration of medications immediately after they were given to a resident. Review of medication administration records for one resident with diagnoses including dementia with mood disturbance, hypertensive heart disease, and adjustment disorder with depressed mood, showed that a licensed practical nurse (LPN) often documented medication administration hours after the medications were scheduled and administered. Audit reports revealed that medications scheduled for specific times were administered and documented significantly later, with some evening medications scheduled for 6pm being documented as late as 9:51pm or 10:06pm. The resident was cognitively intact at the time of the deficiency, as indicated by a BIMS score of 15. Interviews with the LPN and another staff member confirmed that the expectation is for nurses to document medication administration in the electronic Medication Administration Record (eMAR) immediately after giving the medications. The LPN acknowledged that she sometimes delayed documentation, possibly waiting until the next medication pass to sign off in the eMAR. Facility policy also requires documentation in the MAR immediately after administration. This failure to document timely affected the resident reviewed for pharmaceutical services.
Failure to Prevent Unauthorized Alcohol Consumption
Penalty
Summary
The facility failed to provide adequate supervision to prevent residents from obtaining and consuming alcohol on the premises. Five residents, all with varying medical diagnoses such as cerebral palsy, morbid obesity, heart disease, COPD, and mental health disorders, were found drinking alcohol together in a dining room. These residents had BIMS scores indicating intact or mildly impaired cognition. Staff, including a nurse and a CNA, observed the group drinking from plastic cups and detected the smell of alcohol. The incident was confirmed through camera footage, and one resident later admitted to drinking alcohol in a written statement. The facility's policy requires a physician order for alcohol consumption, but no such orders were present for any of the involved residents. The event was reported by staff who witnessed the group in the act and attempted to intervene, but the residents refused to allow a search of their belongings. The nurse notified the physician and the resident's power of attorney, and a urine test was ordered for one of the residents. Despite the facility's policy and the presence of supervision, the residents were able to access and consume alcohol without authorization, and the source of the alcohol could not be determined. The lack of effective supervision and failure to enforce policy led to an unsafe environment for the residents involved.
Failure to Protect Residents from Abuse and Ensure Staff Training
Penalty
Summary
Two residents experienced abuse and mistreatment by a certified nurse assistant (CNA) during the provision of care. One resident, a seventy-one-year-old with hemiplegia, hemiparesis, dysphagia, vascular dementia, and major depression, required maximum assistance with activities of daily living (ADLs) and was dependent for transfers and mobility. During care, the resident reported that the CNA was rough, causing pain, and despite requests to stop, the CNA continued. The resident then pulled the CNA's hair in an attempt to make her stop, after which the CNA punched the resident in the mouth. This resulted in the resident sustaining a swollen, discolored lip and jaw, with ongoing pain. Multiple staff and family members observed the injuries, and the resident consistently reported the incident to staff, family, and the nurse practitioner. The CNA did not report the incident and denied hitting the resident when questioned. Another resident, a seventy-year-old with hemiplegia, hemiparesis, dysphagia, COPD, and reduced mobility, reported that the same CNA was repeatedly rough during care, verbally rude, and removed the resident's food tray before meals could be eaten. The resident described the CNA as cruel and disrespectful, causing increased pain and mental anguish. The resident reported these incidents to the administrator, stating that the CNA's actions made him feel bad about himself and less than a man. The administrator did not recall being told about these concerns prior to the surveyor's interview. The facility's policy affirms residents' rights to be free from abuse, neglect, and mistreatment. However, the CNA involved in both cases stated she had not received abuse training and was unaware of the abuse coordinator. The incidents were substantiated based on resident reports, observed injuries, and staff interviews, indicating a failure to protect residents from abuse and to ensure staff were adequately trained and aware of abuse prevention protocols.
Failure to Provide Required Abuse Training to CNA
Penalty
Summary
The facility failed to implement and maintain an effective abuse training program for one of three employees reviewed. Specifically, a Certified Nurse Assistant (CNA) did not receive abuse training upon hire, during orientation, or at any point during employment, as confirmed by both the CNA and the Human Resources representative. The CNA was hired in April and had been working with residents without the required abuse prevention and reporting training, which is mandated by facility policy to be completed before any employee works with residents. The CNA was also unaware of the identity of the facility's Abuse Coordinator. During the survey, two residents reported incidents of physical and verbal abuse by the CNA, including being handled roughly during care, being punched in the mouth, and being spoken to in a rude and disrespectful manner. One resident displayed visible injuries consistent with their account. The CNA denied the allegations but confirmed that no abuse training had been provided. The facility's policy requires all staff to receive abuse training upon hire, and this training should be documented in the employee's file, but this was not done in this case.
Failure to Follow Physician Orders and Proper Storage Protocols for Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for several residents by not following physician orders and established care plans. One resident with chronic respiratory failure and hypoxia was observed with their oxygen concentrator set at 3 liters per minute, despite a physician's order for 2 liters per minute via nasal cannula. The nasal cannula tubing was found on the floor and not in use, and staff confirmed the oxygen setting was incorrect. Another resident, who was ventilator dependent and severely cognitively impaired, was found lying in bed with the head of bed elevated only 10 to 20 degrees, contrary to the physician's order and care plan requiring elevation above 45 degrees. The resident was noted to be flushed and gasping for air until staff intervened to reposition and suction the resident. Additionally, the facility did not maintain proper storage and labeling of oxygen nasal cannula tubing for two residents. In one case, a resident's oxygen tubing was found hanging on a wheelchair, touching the floor, undated, and not stored in a plastic bag. In another case, a resident's nasal cannula tubing was hanging on the oxygen concentrator tank, also undated and not in a plastic bag. Staff acknowledged that the tubing should be dated and stored in a plastic bag when not in use to prevent contamination and maintain hygiene. The facility's own policies require oxygen to be delivered according to physician orders and for equipment to be maintained and stored properly. Interviews with staff, including the interim DON and respiratory therapists, confirmed that these expectations were not met in the observed cases, resulting in deficiencies in respiratory care for the affected residents.
Failure to Properly Label and Date Food Items in Kitchen
Penalty
Summary
The facility failed to ensure that food items in the kitchen were properly labeled and dated, as required by facility policy and professional standards. During observations, surveyors found several food items in the walk-in refrigerator and reach-in cooler that were either missing use by dates, opened dates, or any labeling at all. Specifically, a sliced ham was only labeled with the date it was sliced, a large container of grape jelly had no label or date, an opened bag of shredded mozzarella cheese was only labeled with a delivery date, and a container of sour cream was missing both an opened date and a use by date. The Food Service Director confirmed that all items should be labeled with delivery, opened, and use by dates, and acknowledged that the lack of labeling made it impossible to determine how long items had been open or if they were still safe to use. Interviews with the Food Service Director and Registered Dietitian emphasized the importance of labeling and dating food items to prevent serving spoiled or expired food to residents. The facility's own policies require all food items to be labeled with the name of the food and the date by which it should be consumed or discarded, as well as the date opened and appropriate use-by date for items removed from original containers. The failure to follow these procedures was observed to have the potential to affect all 130 residents receiving food from the facility's kitchen, including 26 residents with NPO (nothing by mouth) orders.
Failure to Ensure Proper PPE Use for Contact Isolation and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) by both staff and visitors when entering rooms of residents on contact isolation or enhanced barrier precautions. In one instance, a staff member was observed adjusting a resident's brief without wearing a gown, despite signage indicating the need for both gown and gloves for high-contact care activities. The staff member acknowledged the omission and confirmed awareness of the required PPE. The facility's interim Director of Nursing confirmed that not wearing the required PPE could lead to the spread of infection, and the facility's policy specifies the use of gowns and gloves for residents with indwelling medical devices or those at risk for multi-drug-resistant organism (MDRO) transmission. A visitor was observed inside a resident's room on contact isolation for Clostridium difficile without wearing a gown or gloves, despite clear signage and facility policy requiring such precautions. The infection preventionist stated that both staff and visitors should be informed and educated about the necessary PPE, and that the visitor should have been notified and required to wear the appropriate equipment. The facility's guidelines reinforce the use of contact precautions for residents with infections that can be transmitted by direct or indirect contact. Additionally, an agency registered nurse was observed providing care to two residents on enhanced barrier precautions without wearing a gown, despite signage and facility policy. The nurse admitted to not receiving a report about the required precautions and acknowledged the need to wear a gown. The interim Director of Nursing stated that all staff, including agency personnel, are expected to follow facility policy and signage regarding PPE use for residents on enhanced barrier precautions, especially during high-contact care activities.
Failure to Provide Privacy and Proper PPE During Resident Care
Penalty
Summary
A deficiency occurred when staff failed to provide privacy during incontinence care for a resident with multiple complex medical conditions, including Type 2 Diabetes Mellitus with Hyperglycemia, Acute Kidney Failure, Dependence on Renal Dialysis, Gastrostomy, Hypertensive Heart Disease, Shaken Infant Syndrome, Cerebral Palsy, Epilepsy, Abnormalities of Gait and Mobility, Polycystic Ovarian Syndrome, and Blindness in both eyes. The resident's MDS BIMS indicated that the resident was rarely or never understood. During an observation, a staff member was seen adjusting the resident's brief with the door and privacy curtain open, and the roommate's privacy curtain also open, exposing the resident during care. The staff member did not wear the required gown while providing care, despite Enhanced Barrier Precaution signage at the room entry. The staff member acknowledged that privacy should have been provided and that appropriate PPE, including a gown and gloves, should have been used. Facility policy requires staff to provide privacy and maintain resident dignity during care, but these procedures were not followed during the observed incident.
Failure to Provide Accessible Call Light for Resident with Quadriplegia
Penalty
Summary
A resident with quadriplegia and multiple complex medical conditions, including neuromuscular dysfunction, stage 4 pressure ulcer, and total dependency for all activities of daily living, was found without access to a specialized call light. The resident's care plan documented the need for a call light to be within reach and specified the use of a bell for assistance, but during observation, the standard call light was found on the floor and out of reach. The resident reported being unable to use the standard call light due to paralysis and stated that he previously used an air-activated (blow) call light in another unit, but this was not provided after his recent readmission. As a result, the resident relied on yelling for staff or using a cell phone to call for help, which was not always effective, especially at night. Staff interviews confirmed that the resident should have a call light that accommodates his disability and that the current arrangement did not meet his needs. The facility's policy requires that all residents have access to a call light within easy reach and that alternative devices be provided for those unable to use standard call lights. Despite these policies and the resident's documented needs, the appropriate specialized call light was not provided, resulting in the resident lacking a reliable means to request assistance.
Failure to Refer Residents for Required PASARR Level II Evaluations
Penalty
Summary
The facility failed to refer residents with mental disorders or intellectual disabilities to the appropriate state-designated authority for re-screening and Level II PASARR evaluation as required. Specifically, three residents with diagnoses such as bipolar disorder with psychotic features, schizoaffective disorder, obsessive compulsive disorder, post-traumatic stress disorder, anxiety disorder, and major depressive disorder were not properly evaluated or re-evaluated for PASARR Level II. Documentation for these residents showed either outdated or missing PASARR Level II screenings, despite their medical histories indicating the need for such assessments. In some cases, the initial PASARR screenings were completed years prior to the current assessment company taking over, and no subsequent re-evaluations were performed. Interviews with the Social Services Consultant revealed a lack of awareness and follow-through regarding PASARR requirements, with admissions that residents had not been re-evaluated after changes in the assessment process or company. Additionally, the facility did not have a PASARR policy in place, and PASARR Level I screenings were only recently completed for the affected residents after surveyor inquiry. The absence of timely and appropriate PASARR Level II referrals and evaluations was confirmed through record review and staff interviews.
Failure to Provide 1:1 Feeding Assistance and Proper Positioning During Meals
Penalty
Summary
The facility failed to provide one-to-one feeding assistance and proper positioning during meals for a resident with severe cognitive impairment and multiple medical diagnoses, including dementia, flaccid hemiplegia, and dysphagia. The resident's care plan specified a mechanically altered, pureed diet, nectar consistency liquids, and required the head of bed to be elevated during meals, as well as one-to-one feeding assistance due to impaired self-feeding ability. Despite these documented interventions, the resident was observed in bed at a 45-degree angle, attempting to eat a pureed diet without staff assistance. The resident's left hand was flaccid and not being used, and no staff were present to assist or monitor the resident during the meal. Staff interviews confirmed that the resident should have been positioned upright and provided with one-to-one feeding assistance as per the care plan. The LPN and Interim DON both acknowledged that eating at a 45-degree angle could lead to aspiration, and the Restorative Director stated that the resident was care planned for one-to-one feeding assistance and should be upright while eating. Facility policy also required residents to be positioned at 60 to 90 degrees during meals. The failure to follow the care plan and facility policy resulted in the resident not receiving the required assistance and positioning during mealtime.
Failure to Provide Communication Assistance for Residents with Language and Communication Barriers
Penalty
Summary
The facility failed to ensure that communication assistive materials were readily accessible for a resident who speaks a foreign language and did not provide appropriate communication tools for another resident with a communication deficit. In the first instance, a resident whose preferred language is Urdu was observed without any communication board or binder in their room, and staff relied on the resident's family member for translation. The LPN interviewed was unsure if any staff spoke the resident's language and did not provide an alternative method of communication when the family member was unavailable. In the second case, a resident with multiple medical diagnoses and a communication deficit was observed attempting to communicate pain to staff, but was not understood. The staff member left the room without resolving the resident's needs and did not return, later stating she could not find another staff member to assist. The resident was later found crying and was able to communicate his pain when approached by the DON. The speech pathologist confirmed that the resident could communicate his needs verbally, though softly, and emphasized the importance of staff paying close attention. The facility's policy states that language assistance services should be offered to all residents with communication barriers, but these services were not effectively provided in these cases.
Failure to Provide Proper Midline Catheter Care and Manage Hypotension
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate care for a resident with a Peripherally Inserted Midline Catheter. The resident had orders for the Midline dressing to be changed every seven days on the night shift for IV therapy. Observations revealed that the dressing was not labeled or dated, and the resident reported the dressing had not been changed as scheduled. Staff interviews confirmed that Licensed Practical Nurses (LPNs) were not responsible for changing Midline dressings, and the Registered Nurse (RN) acknowledged the dressing should have been changed and labeled. Documentation on the Medication Administration Record (MAR) was inaccurate, as an LPN had signed for a dressing change that did not occur. The facility's policy required dressings to be changed at specific intervals and properly documented, which was not followed in this case. Another deficiency was identified in the management of a resident's low blood pressure. The resident, who had multiple medical diagnoses and moderate cognitive impairment, reported feeling weak and tired after her blood pressure was found to be low by an LPN. Despite repeated low readings, the LPN did not promptly recheck the blood pressure or notify the physician as required. The resident expressed concern about her condition, and subsequent readings continued to show hypotension. The Director of Nursing confirmed that the LPN should have monitored the blood pressure more frequently and notified the physician when the medication did not improve the resident's condition, as per facility policy. Both deficiencies were supported by direct observations, staff and resident interviews, and record reviews. The facility failed to follow its own policies and physician orders regarding catheter care and the management of significant changes in a resident's condition, resulting in lapses in care for two residents.
Failure to Apply Physician-Ordered Palm Protector for Contracture Management
Penalty
Summary
A deficiency was identified when staff failed to follow a physician's order for a resident with a left hand contracture. The resident, who had diagnoses including COPD, chronic respiratory failure with hypoxia, dementia, and depression, was dependent on staff for dressing, grooming, and personal hygiene. The physician's order and care plan specified that a left hand palm protector should be applied at all times or as tolerated, with removal only during activities of daily living and as needed. The care plan also required monitoring for skin irritation, redness, and pain. During observations, the resident was found without the left hand palm protector on multiple occasions, including while sleeping in bed and during feeding assistance. Staff interviews revealed a lack of awareness regarding the application of the device, with a CNA stating that restorative staff applied the device and not knowing its name. The Restorative Director confirmed the importance of following orders for assistive devices to maintain function and prevent further contracture, and stated that nurses and CNAs should monitor the use of such devices. The facility's policy on splint application emphasized proper use for support and contracture prevention.
Urinary Drainage Bag Found on Floor, Breaching Infection Control Policy
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including benign prostatic hyperplasia, obstructive and reflux uropathy, hematuria, chronic kidney disease stage 3, cognitive communication deficit, weakness, and gait abnormalities, was observed with an indwelling urinary catheter. The resident was found lying in bed with the urinary drainage bag placed directly on the floor next to the bed. This observation was made by both a nursing supervisor (RN) and later confirmed by the Director of Nursing, who both acknowledged that the urinary drainage bag should not be in contact with the floor due to infection control concerns. The facility's own policy on urinary catheter care, dated 02/14/19, specifies that urinary drainage bags and tubing must be positioned to prevent them from touching the floor, in order to reduce the risk of infection. Despite this policy, the drainage bag was not properly secured and was left on the floor, constituting a failure to follow established infection prevention guidelines for residents with indwelling catheters.
Failure to Administer Ordered Medications Resulting in Resident Pain and GI Symptoms
Penalty
Summary
The facility failed to provide routine medications as ordered for a resident with multiple medical diagnoses, including type 2 diabetes, chronic kidney disease, hypertension, major depressive disorder, and chronic ulcer. The resident had physician orders for Tramadol for pain and Creon for indigestion, but the medication administration records showed that both medications were marked as not available on several occasions. Despite documentation that Creon was delivered to the facility, nursing staff did not administer it because it could not be located in the medication cart. Additionally, Tramadol was not provided because the prescription was not properly signed and thus not filled by the pharmacy. As a result of not receiving the prescribed medications, the resident experienced pain, vomiting, and diarrhea. The resident reported not receiving the pancreatic enzyme or pain medication and stated that the lack of Creon led to gastrointestinal symptoms and inability to get out of bed. The resident also reported keeping medication in his drawer and self-administering due to inconsistent administration by nursing staff. Interviews with facility staff confirmed the medication was not given as ordered, and that the failure to provide Creon could have contributed to the resident's symptoms.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
A resident with diagnoses including type 2 diabetes, chronic kidney disease, hypertension, major depressive disorder, and long-term insulin use was not assessed for self-administration of medications. The resident had an intact cognitive status, as indicated by a BIMS score of 15, and had physician orders for Creon and Tramadol. Despite this, the resident was found to have pill bottles of both medications in their room and self-administered Creon without a physician's order or documented assessment for self-administration. The resident reported keeping medications in their drawer due to previous instances where the facility failed to provide medications as ordered, resulting in pain, vomiting, and diarrhea. Staff interviews confirmed that the resident did not have an order or assessment for self-administration, and that Tramadol, a controlled substance, should not have been at the bedside. The facility's policy requires a written physician order and assessment before a resident can self-administer or retain medications in their room. Review of the resident's records showed no such order or care plan in place for medication self-administration.
Call Light Not Accessible to Resident with Complex Medical Needs
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including end stage renal disease, heart failure, diabetes, respiratory failure, dysphagia, dementia, and impaired mobility, was found to have their call light cord on the floor behind the head of their bed while they were sleeping. The resident's care plan specifically required that the call light be within reach due to their high risk for falls and need for assistance. During observation, the call light was not accessible to the resident, and this was confirmed by a Licensed Practical Nurse (LPN) who acknowledged the call light was on the floor and not in the correct position. The LPN then repositioned the call light to be within reach. Interviews with multiple staff members, including LPNs and the Director of Nursing (DON), confirmed that the facility's expectation and policy is for call lights to be within easy reach of residents at all times. The facility's written policy also states that all residents capable of using a call light should have it available and accessible at the bedside or another reasonable location. The failure to ensure the call light was within reach for this resident constituted a failure to reasonably accommodate the resident's needs and preferences as outlined in their care plan and facility policy.
Failure to Date Oxygen Tubing for Residents on Oxygen Therapy
Penalty
Summary
The facility failed to follow its policy regarding the labeling of oxygen tubing for two residents who were receiving continuous oxygen therapy. Both residents had complex medical histories, including conditions such as end stage renal disease, heart failure, diabetes, respiratory failure, and other chronic illnesses. Physician orders and care plans for both residents specified that oxygen tubing and related equipment should be changed regularly, with instructions to change and date the tubing weekly or every night shift on a specified day. However, during observations, surveyors found that the oxygen tubing in use for both residents was not labeled with the date it was last changed, as required by facility policy. Interviews with nursing staff, including LPNs and the DON, confirmed that the expectation was for oxygen tubing to be dated when changed, and that this responsibility fell to the nursing staff, particularly the night shift. Despite this, the tubing observed on both residents was not dated, and one resident was unaware of how often their tubing was changed. The facility's written policy clearly stated that all disposable respiratory equipment must be labeled with the date when placed in use, but this procedure was not followed for the two residents reviewed.
Failure to Maintain a Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for eight residents on the second floor, as evidenced by multiple observations of environmental deficiencies. Surveyors noted missing ceiling panels with exposed cords near the main elevators, missing floor trims, chipped paint in several resident rooms, broken or damaged furniture such as dressers and bed rails, and unaddressed maintenance issues. Residents reported that repairs were slow to be addressed, with one resident stating that a broken overhead light and a loose bed side rail had not been fixed despite being reported to staff. Additionally, rooms were observed to have dirt, dust, chipped drywall, and missing bathroom tiles, with some furniture in disrepair and closet doors not properly secured. Housekeeping staff indicated that daily cleaning tasks, including window cleaning, were sometimes not completed due to workload. Maintenance staff were unaware of several outstanding repair needs, and maintenance logs did not reflect requests for repairs in the affected rooms. The Director of Nursing acknowledged ongoing construction on the second floor and agreed that damaged or missing items should be addressed promptly. The facility's maintenance policy requires a safe and operable environment, but the Resident Rights policy did not include the right to a clean, comfortable, and homelike environment.
Failure to Provide Timely Incontinence Care for Dependent Residents
Penalty
Summary
The facility failed to provide timely incontinence care for two residents who were dependent on staff for activities of daily living, specifically toileting and personal hygiene. One resident, with diagnoses including lumbar radiculopathy, neuropathy, morbid obesity, and osteoarthritis, was documented as cognitively intact but fully dependent on staff for toileting. This resident reported that a CNA refused to change them until after lunch, regardless of need, and that this practice occurred on multiple occasions. The resident also described an incident where they had to wait until the next shift to be changed after requesting assistance at night. Staff interviews confirmed that some CNAs limited incontinence care to three times per shift, regardless of the resident's needs, and that delays in care often resulted in the resident being left in soiled linens and clothing for extended periods. Another resident, also cognitively intact and with diagnoses including morbid obesity and diabetes, reported similar issues with delayed incontinence care. This resident stated that some CNAs would respond to call lights but not return for hours to provide needed care. The care plans for both residents required staff to anticipate and meet needs, keep call lights within reach, and respond promptly to requests for assistance. Facility policies also required incontinence care to be provided after each episode and for residents to be checked approximately every two hours. Interviews with nursing staff and review of facility policies confirmed that the expectation was for residents to be changed and cleaned as needed, without arbitrary limits. However, staff practices did not align with these expectations, as some CNAs admitted to only performing incontinence care a set number of times per shift, regardless of the residents' actual needs. This resulted in residents experiencing discomfort and being left in soiled conditions, contrary to facility policy and care plan requirements.
Delayed Incontinence Care for Residents
Penalty
Summary
The facility failed to provide timely incontinence care for four dependent residents, leading to improper nursing care. Resident 1 (R1) had multiple diagnoses, including bowel and bladder incontinence, and was at risk for skin integrity issues. Despite being able to verbalize needs, R1 often found themselves soiled, particularly in the mornings, due to delayed care from the previous shift. Certified Nurse Aide (CNA) V15 reported that R1 frequently complained about not being cleaned promptly, and there were no grievance forms related to these concerns. Resident 5 (R5) also experienced delayed incontinence care, sometimes waiting up to two hours, especially during shift changes or mealtimes. R5, who was alert and oriented, required assistance with activities of daily living and expressed frustration over the delayed response to call lights. Similarly, Resident 9 (R9) was left in soiled incontinence products for an extended period after requesting care. Despite being cognitively intact and dependent on staff for toileting hygiene, R9 had to wait over an hour for CNA V16 to return and provide the necessary care. Resident 4 (R4) reported being changed only once or twice per shift, contrary to the facility's policy of checking and changing residents every two hours. R4's requests for assistance were often met with delays, and there were instances where call lights were turned off without providing care. The Director of Nursing (V2) acknowledged that the staff's response time was unacceptable and emphasized the importance of timely care. However, the facility's failure to adhere to its policies resulted in significant delays in providing necessary incontinence care to these residents.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident, R2, from physical abuse, resulting in an incident where another resident, R1, punched R2 in the face. R1, who has diagnoses including Schizophrenia and Unspecified Intellectual Disabilities, displayed aggressive behavior after being redirected from taking food off a cart. R1's behavior care plan noted a history of agitation and aggressive behavior when redirected, which was not effectively managed in this instance. R2, who has diagnoses including Hemiplegia, Vascular Dementia, and Schizoaffective Disorder, was sitting at the nurses' station when the incident occurred and was unable to defend himself. The incident took place when R1, after finishing lunch, attempted to take food from a cart and was redirected by a CNA, V8. R1 became upset, began throwing items, and subsequently struck R2, who was nearby. Witnesses, including V8 and V17, confirmed that R1's behavior escalated after being redirected and that R1 intentionally hit R2. R2 was observed to be crying and expressed fear of further attacks from R1. Following the incident, R2 experienced seizures, which were noted in the progress notes. Interviews with staff, including the Assistant Director of Nursing and the Director of Nursing, revealed that R1's behavior was known to be impulsive and aggressive when upset. Despite this knowledge, the facility's response to R1's behavior was inadequate, leading to the physical abuse of R2. The facility's policies on abuse prevention and residents' rights emphasize the need for a safe environment free from abuse, which was not upheld in this situation.
Failure to Provide Adequate ADL Care and Individualized Care Plan
Penalty
Summary
The facility failed to provide adequate care and develop an individualized plan of care for a resident (R3) who was dependent on assistance for activities of daily living (ADLs). R3's Minimum Data Set indicated severe cognitive impairment and total dependence on staff for oral care, toileting, personal hygiene, and dressing. Despite having a care plan that required oral care every shift and as needed, observations revealed that R3's oral hygiene was neglected, with discolored teeth and buildup of mucus and debris around the mouth. Additionally, R3's hair was oily, matted, and unkempt, indicating a lack of regular grooming and hair washing, which was supposed to occur at least twice a week. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and a Certified Nursing Assistant (CNA), confirmed that R3's grooming and hygiene needs were not being met as scheduled. The ADON admitted uncertainty about when R3's hair was last washed, and the CNA acknowledged that oral care had not been performed that morning. The Director of Nursing (DON) emphasized the importance of regular grooming and hygiene to prevent infections, especially given the facility's higher incidence of multi-drug resistant organisms. However, the observations and staff statements indicated that these basic care needs were not being fulfilled. The Restorative Director, responsible for ADL care plans, admitted that R3's care plan was not individualized and did not specify the extent of care required for oral hygiene, bathing, or grooming. The facility's policies on oral hygiene, bathing, and nail care outlined the expectations for maintaining resident cleanliness and dignity, but these were not adhered to in R3's case. The lack of an individualized care plan and failure to provide scheduled care resulted in R3's poor hygiene and grooming, highlighting deficiencies in the facility's care practices.
Failure to Follow Seizure Protocol and Document Care
Penalty
Summary
The facility failed to adhere to a resident's care plan and seizure policy, resulting in inadequate assessment and documentation of a resident's seizure activity following an incident of physical abuse. The resident, who has a history of epilepsy and is on anticoagulant therapy, was punched in the face by another resident. Despite the occurrence of seizures post-incident, there was no documentation of vital signs, type of seizure, level of consciousness, or any neuro checks, as required by the care plan and facility policy. The resident involved, who has diagnoses including hemiplegia, vascular dementia, and epilepsy, was sitting at the nurses' station when the incident occurred. The resident was reportedly struck in the face, resulting in redness and subsequent seizures. Despite the resident's condition and the potential for complications due to anticoagulant therapy, there was no record of the resident being sent to the hospital for further evaluation, nor was there adequate documentation of the seizure activity. Interviews with staff revealed a lack of clarity and consistency in the response to the incident. The Assistant Director of Nursing and other staff members failed to document critical information regarding the resident's condition and the actions taken. The facility's Director of Nursing stated that the expectation is to call emergency services after a seizure, yet there was no confirmation that this protocol was followed. The lack of documentation and adherence to policy highlights significant deficiencies in the facility's handling of the incident.
Failure to Apply Bilateral Palm Protectors as Ordered
Penalty
Summary
The facility failed to adhere to the care plan for a resident, identified as R3, who required bilateral palm protectors due to actual contractures. R3's medical history includes chronic respiratory failure, dependence on a ventilator, and multiple other serious conditions. The care plan, dated October 13, 2024, specified the application of bilateral palm protectors to prevent further contractures. However, during an observation on January 26, 2025, it was noted that R3 was only wearing a palm protector on the left hand, while the right hand, which also had contractures, was without the necessary device. This oversight was confirmed by the Restorative Director, who was unsure why the right hand protector was not applied. The Director of Nursing and the Restorative Director both acknowledged the importance of the palm protectors in preventing further contractures. The facility's policy on the application of splints emphasizes proper application for support and prevention of contractures. Despite this, the failure to apply the right hand protector as ordered was observed, which could potentially lead to further contractures. The deficiency was identified through a combination of observation, interviews with staff, and review of R3's medical records, highlighting a lapse in following the prescribed care plan for the resident.
Failure to Maintain Spare Tracheostomy Tube at Bedside
Penalty
Summary
The facility failed to adhere to a resident's care plan by not ensuring an additional tracheostomy tube was available at the bedside for emergencies. This deficiency was identified during an observation and interview process. The resident, who was admitted with multiple complex medical conditions including chronic respiratory failure and dependence on a ventilator, was found without a spare tracheostomy tube at the bedside. The care plan specifically required that a spare tracheostomy tube of the same size be kept at the bedside to manage potential emergencies, such as accidental dislodgement of the existing tube. During the survey, the respiratory therapist confirmed the absence of the spare tracheostomy tube and acknowledged the necessity of having one readily available to maintain the resident's airway in case of an emergency. The Director of Nursing also stated that staff are expected to ensure spare tracheostomy tubes are accessible at all times to quickly re-establish the airway if needed. The facility's respiratory care program emphasizes the importance of following care practices to provide safe and effective respiratory care, yet this protocol was not followed in this instance.
Failure to Ensure Safe Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure safe mechanical lift transfers for a resident, resulting in a fall incident. The incident occurred when a Certified Nursing Assistant (CNA) attempted to transfer the resident from the bed to a specialty chair using a mechanical lift. The CNA used the wrong lift pad, which did not support the resident, causing her to slip and fall to the floor. The CNA admitted to being the only person conducting the transfer, despite the facility's policy requiring two caregivers for mechanical lift transfers. The resident fell on her upper back, and the CNA was subsequently suspended for three days by the former Director of Nursing. The incident was not properly investigated, as the former Director of Nursing, who was the falls coordinator at the time, did not complete an investigation. Additionally, a reportable incident was not submitted to the Illinois Department of Public Health. The current Director of Nursing confirmed the absence of an investigation binder for the fall. The resident was transferred to an outside hospital, where an x-ray revealed an age indeterminate fracture of T12/L1, but it was unclear if the fracture resulted from the fall. The facility's policy mandates the use of mechanical lifting devices with two caregivers for residents needing assistance, which was not followed in this case.
Failure to Discard Expired Food and Date Frozen Meat Products
Penalty
Summary
The facility failed to ensure food in the main cooler was discarded after the use-by date and failed to ensure frozen meat products were dated inside the main freezer. During an initial kitchen tour, a container of grape jelly was found in the main cooler with a label indicating it was prepared on 3/29 and had a use-by date of 4/31. Additionally, a pack of frozen sausages and a pack of frozen meat with no labeled dates were found in the freezer. The Food Service Director confirmed that all foods stored in the coolers and freezer are supposed to be dated to follow the first in, first out policy, and that prepared foods should be discarded on the use-by date for food safety. The facility's policies on food storage and food temperatures require that all foods be covered, labeled, and dated, and that stock be rotated to ensure freshness and quality. The policies also state that high-risk foods should be consumed, sold, or discarded by their use-by dates. The facility's roster documents 161 residents residing in the facility, with 39 residents who are NPO (Nothing By Mouth). This failure has the potential to affect 122 residents in the facility who are receiving an oral diet.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to provide Enhanced Barrier Precautions (EBP) while delivering wound care to a resident, as observed when a wound care nurse did not wear a protective gown despite signage indicating the necessity. The Infection Prevention Director confirmed that staff are expected to comply with posted instructions to prevent infection transmission. Additionally, it was noted that wound care nurses also perform other care activities, increasing the risk of cross-contamination if EBP is not followed consistently. Another deficiency was identified when a resident with multiple pressure injuries and a documented need for EBP did not have the appropriate signage or Personal Protective Equipment (PPE) bin outside their room. A nurse incorrectly stated that only standard precautions were necessary, contradicting the facility's EBP policy, which requires PPE for high-risk activities involving residents with wounds or indwelling medical devices. A third deficiency involved a resident receiving hemodialysis via a femoral access device, who also lacked EBP signage and a PPE container outside their room. The Infection Prevention Director acknowledged that the resident should have been on EBP due to the dialysis access site, which increases infection risk. The absence of EBP signage and documentation in the resident's electronic health record further highlighted the facility's failure to adhere to its own infection control policies.
Failure to Maintain Resident Personal Fund Accounting
Penalty
Summary
The facility failed to maintain proper accounting of resident personal funds for five residents. During a Resident Council interview, multiple residents expressed concerns about not receiving their entitled monthly allowances. The Financial Coordinator (V38) explained the process of managing resident funds, including interactions with the Social Security Administration (SSA) and the facility's Resident Fund Management Services (RFMS). However, it was found that several residents' incomes were either stopped, suspended, or unaccounted for, leading to residents not receiving their allowances. The Financial Coordinator admitted to not documenting communications with SSA and other relevant actions, which contributed to the mismanagement of funds. For instance, R4's income stopped coming to the facility approximately two years ago, and despite attempts to resolve the issue, no documentation was provided. Similarly, R22 and R55's incomes were in suspension, and R138's pension was unaccounted for, with no clear information on where the funds were going. The lack of proper documentation and follow-up actions led to these residents not receiving their entitled funds. The Director of Social Services (V8) confirmed that the Business Office, specifically V38, was responsible for managing resident funds and applying for benefits. Despite this responsibility, V38 failed to submit necessary documents and did not maintain adequate records of communications with SSA. This lack of proper fund management and documentation resulted in residents not receiving their personal allowances, violating their rights as outlined in the facility's Resident Funds policy and Residents' Rights for People in Long Term Care Facilities.
Failure to Provide Communication Aids for Non-English Speaking Residents
Penalty
Summary
The facility failed to follow the residents' comprehensive care plans to ensure communication boards or books were readily accessible at all times for four residents who primarily speak Spanish. The deficiency was identified through observations, interviews, and record reviews. Specifically, residents R30, R63, R49, and R71, who all have the ability to understand and express ideas and wants, did not have the required communication aids in their rooms. This lack of communication aids was confirmed during interviews with the residents, who were unable to communicate effectively in English, and through the surveyor's observations that no communication boards or binders were present in their rooms. Staff members, including a Registered Nurse, the Director of Life Enrichment and Director Guest Relations, and the Social Service Director, acknowledged that these residents should have communication boards at their bedside to assist with communication. The facility's policy on Language Assistance Services mandates that language assistance services be offered to all residents with language or communication barriers. Despite this policy, the necessary communication aids were not provided, leading to a failure in ensuring effective communication for these residents.
Improper Settings on Pressure-Reducing Mattresses
Penalty
Summary
The facility failed to ensure that pressure-reducing air mattresses were set according to the residents' weight for five residents reviewed for pressure ulcers. This deficiency was identified through observation, interview, and record review. The incorrect settings on the low air loss mattresses were observed on multiple occasions, and staff confirmed that the settings did not match the residents' weights, which is critical for preventing pressure ulcers and promoting wound healing. One resident, with a weight of 285.2 lbs, was observed lying on a mattress set at 420, which was not appropriate for her weight. Another resident, weighing 165.4 lbs, was found on a mattress set at 320, which was also incorrect. The wound care nurse confirmed that incorrect settings could lead to complications, including worsening of existing wounds or the development of new wounds. Similar issues were found with other residents, including one with a weight of 111.6 lbs whose mattress was set between 250-280 lbs, and another resident weighing 147.2 lbs whose mattress was set at 210 lbs. The facility's policy on pressure ulcer prevention did not include procedural instructions for the use of low air loss mattresses and their settings. This lack of guidance contributed to the improper settings observed. Staff interviews revealed that the responsibility for ensuring correct mattress settings was shared among all care providers, but this was not consistently followed, leading to the identified deficiencies.
Failure to Secure Central Supply Room and Remove Fire Hazard Equipment
Penalty
Summary
The facility failed to secure their Central Supply Room, making it accessible to residents and visitors. During an inspection, the surveyor found the door to the Central Supply Room propped open with no employees present. The room contained over-the-counter medications and other resident care equipment. The Central Supply Coordinator confirmed that residents sometimes come to the area and that the room should be locked. The Assistant Director of Nursing also stated that all medications should be securely stored to prevent access by residents, especially those with behavioral concerns. Additionally, the facility failed to ensure that equipment posing a fire hazard was removed from a resident's room. A surveyor observed a space heater turned on next to a resident's bed. The resident stated that the facility provided the space heater because they were always cold. The Director of Environmental Services confirmed that space heaters are not allowed inside the building due to fire hazards, and residents should not have them in their rooms. The facility's policies on safety and medication storage were not followed, leading to these deficiencies.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for several residents, as observed during the annual recertification survey. Specifically, the facility did not date and label oxygen tubing for a resident on a ventilator, did not label the nasal cannula for another resident, and failed to store a nebulizer machine and mask inside a plastic bag when not in use for another resident. Additionally, the facility did not change oxygen equipment weekly per physician orders for one resident and did not administer oxygen as ordered for another resident. Unused oxygen tubing was also improperly stored in two residents' rooms. One resident was observed on a ventilator with undated oxygen tubing, and staff confirmed that oxygen tubing should be changed and dated weekly to minimize infection risk. Another resident with chronic obstructive pulmonary disease was found using an undated nasal cannula, contrary to the facility's policy. A third resident's nebulizer mask was not stored in a clean plastic bag when not in use, increasing the risk of infection. Another resident reported that their oxygen tubing was changed every 1-2 months, despite orders to change it weekly, and the tubing was observed to be dated over a month prior. Further observations revealed that one resident's oxygen machine was turned off, and the oxygen tubing was not stored in a bag, contrary to the facility's policy. The resident's oxygen therapy order was for continuous oxygen at three liters per minute, but it was found set to two liters per minute. Additionally, a portable oxygen tank with tubing was found on the floor in another resident's room, with no order for oxygen therapy for that resident. The facility's policies on respiratory equipment maintenance and infection control were not followed, leading to these deficiencies.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to follow its Storage of Medications policy, resulting in several deficiencies. Medications were not stored in locked compartments for two residents on two medication carts and one medication storage room. Additionally, individual residents' insulin was not labeled with an open/expiration date, and expired insulin was not discarded as required. Unopened insulin that required refrigeration was found on a medication cart instead of being stored in a refrigerator. These observations were confirmed by staff interviews, where it was acknowledged that the insulin should have been dated upon opening and kept refrigerated until use. The failure to properly store and label medications could potentially lead to ineffective treatment and harm to residents. In another instance, a resident's personal refrigerator contained facility house stock medications, which should have been stored in the locked medication room refrigerator. The Director of Nursing confirmed that no medications should be kept in any resident's personal refrigerator due to the risk of misuse or ingestion by residents. The facility's policy mandates that medications and biologicals be securely stored in locked cabinets or rooms and that expired medications be discarded promptly. The failure to adhere to these policies poses a safety risk to residents. Additionally, a resident was found to have multiple medications at their bedside without a doctor's order for self-administration. The resident had been keeping these medications since admission, and the nursing staff acknowledged that the medications should not be at the bedside. The resident's clinical records did not show any documentation indicating that the resident was assessed and deemed capable of self-administering medications. The facility's policy requires a self-administration assessment to ensure residents can safely manage their medications. The lack of supervision and proper assessment could lead to potential overdoses and adverse health effects for the resident.
Failure to Properly Manage and Monitor Residents' Personal Refrigerators
Penalty
Summary
The facility failed to label and date food items in residents' personal refrigerators, monitor and document refrigerator temperatures daily, discard unlabeled or expired food, and clean the refrigerators regularly. This deficiency was observed in the personal refrigerators of four residents. For instance, one resident's refrigerator contained expired milk, unlabeled and undated sausage and bologna, and was visibly dirty with encrusted food and stains. The resident, who had impaired vision, was unaware of the spoiled food items and gave permission to discard them. Staff members confirmed the food was spoiled and acknowledged that the refrigerators needed cleaning, but there was confusion about who was responsible for these tasks. Another resident's refrigerator contained expired milk cartons, unlabeled and undated potatoes, cooked cabbage, and tofu in sauce. The temperature log for this refrigerator had not been updated for two months. A Licensed Practical Nurse (LPN) confirmed the milk was expired and expressed concern about the potential for the resident to get sick from consuming spoiled food. Similar issues were found in the refrigerators of two other residents, including one with a container of rice and fried chicken that was not labeled or dated. The temperature logs for these refrigerators also had not been updated, and the entries appeared to be identical across multiple logs, suggesting they may have been falsified. The Director of Environmental Services and the Registered Dietitian both emphasized the importance of labeling and dating food items, monitoring refrigerator temperatures, and discarding expired food to prevent foodborne illnesses. However, there was a lack of clarity among staff about who was responsible for these tasks. The facility's policies required daily temperature checks, labeling and dating of food, and regular cleaning of refrigerators, but these procedures were not being followed consistently, leading to the observed deficiencies.
Failure to Honor Resident's Shower Schedule Preference
Penalty
Summary
The facility failed to follow a resident's preference for a shower schedule. The resident, who has an Activities of Daily Living (ADL) self-care performance deficit related to limited mobility, generalized weakness, and pain due to chronic pain and rheumatoid arthritis, expressed a desire to change their shower schedule from Friday evening to Saturday morning. Despite informing the Assistant Social Services Director months ago and sending multiple text messages, the facility did not make the requested change. The resident's care plan included encouraging participation in self-care, but this preference was not honored. On June 4, 2024, the resident confirmed their request to change the shower schedule and showed the surveyor text messages sent to the Assistant Social Services Director. The facility's Floor Shower Schedules, which were confirmed to be up-to-date, still listed the resident's showers as Tuesday mornings and Friday evenings. The Assistant Social Services Director acknowledged the request but indicated it was not finalized. The facility's policies on bathing and resident rights emphasize honoring resident preferences, but these were not followed in this case.
Failure to Document Code Status and Educate on Advanced Directives
Penalty
Summary
The facility failed to follow its policy and standards of professional practice in documenting the code status of two residents. For one resident, the POLST form indicated 'Do Not Attempt Resuscitation' (DNAR) and 'Selective Treatment,' but the electronic medical record only reflected the DNAR status. The Director of Nursing and an LPN confirmed that the selective treatment option was not entered into the electronic medical record, leading to incomplete documentation of the resident's wishes. Additionally, the resident was not educated on Advanced Directives, and the healthcare representative was not engaged in the resident's care as required by the facility's policy. Another resident's POLST form indicated 'No CPR' and 'Comfort-focused treatment,' but the medical record contained multiple progress notes by a Nurse Practitioner that incorrectly documented the resident's code status as 'Full.' The Nurse Practitioner acknowledged the error and the importance of accurate documentation, as incorrect notes could lead to inappropriate medical interventions. The facility's Advance Directive Policy mandates that residents be informed of their rights to accept or refuse treatment and to formulate an advance directive, but this was not adhered to in these cases. The facility's policy requires that upon admission, residents are asked about advanced directives and provided with educational information. Social services are responsible for updating the care plan and informing nursing to change the code status based on the advanced directive. However, the facility failed to ensure that the POLST forms were accurately reflected in the electronic medical records and that residents and their representatives were adequately informed and involved in care decisions, leading to deficiencies in the documentation and implementation of residents' treatment preferences.
Failure to Complete PASRR Level II Assessment for Resident
Penalty
Summary
The facility failed to refer a resident to the appropriate state designated authority for re-screening and Level II referral after the resident's admission extended beyond the initial 30 days. The resident, identified as R55, was admitted with diagnoses including Anxiety Disorder, Schizoaffective Disorder, and Borderline Personality Disorder. The resident's medication regimen included several psychotropic medications. The initial PASRR Level I screening indicated a 30-day Exempted Hospital Discharge approval, requiring re-screening if the stay extended beyond 30 days. However, the facility did not complete the necessary Level II assessment within the required timeframe. During the survey, the Social Service Director and Social Service Consultant confirmed that the Level II assessment had not been conducted as required. The Social Service Consultant acknowledged that the resident's diagnoses warranted a Level II evaluation to determine the need for specialized mental health services. The oversight was identified, and a request for the Level II assessment was submitted only after the surveyor's inquiry. This failure to comply with PASRR requirements potentially affected the resident's care and treatment plan.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to follow their policy and procedure and the comprehensive care plan to ensure timely incontinence care for a dependent incontinent resident. The resident, who has diagnoses including Hemiplegia Affecting Right Dominant Side, Right Hand Contracture, and Vascular Dementia, was found in a room with a strong urine odor, lying in bed with a soaking wet incontinence pad. The resident stated they had moved their bowels and had been waiting for hours for staff to clean them, despite pressing the call light for assistance. This indicates a failure to provide perineal care after each incontinent episode as required by the resident's care plan and the facility's policy on incontinence care. A Certified Nursing Assistant (CNA) covering for another CNA who left due to an emergency admitted to not having seen the resident yet, despite being on the floor for 30 minutes. The Director of Nursing confirmed that caregivers are expected to perform rounds at least every two hours and as needed to ensure residents are dry and receive incontinence care. The facility's policy mandates that incontinent residents be checked approximately every two hours and provided with perineal and genital care after each episode, which was not adhered to in this case.
Failure to Update Care Plan and Ensure Use of Wrist Splints
Penalty
Summary
The facility failed to ensure a resident's bilateral splints were placed per the plan of care and did not update the care plan to reflect the resident's preferences. The resident, who has a diagnosis of quadriplegia and other significant medical conditions, was observed on multiple occasions without the prescribed wrist splints. The resident indicated a preference not to wear the splints, stating they had not worn them for a while and could manage some movement without them. The resident's care plan and order summary specified the use of wrist splints to prevent contractures, but these were not consistently applied. The restorative nurse confirmed the resident's preference and noted that the care plan should be updated to reflect this. However, the care plan was not updated to document the resident's preference for not wearing the splints, despite the resident's clear communication and cognitive ability to make such decisions. The facility's policies on resident rights and the restorative nursing program emphasize the importance of individualized care plans that reflect resident preferences and needs. Despite these policies, the resident's care plan was not promptly updated to align with their expressed wishes, leading to a deficiency in the care provided. The failure to update the care plan and ensure the use of wrist splints as per the resident's preference highlights a lapse in adhering to the facility's own guidelines and the resident's rights to autonomy and choice in their care.
Failure to Prevent Urinary Drainage Bag from Touching the Floor
Penalty
Summary
The facility failed to prevent a urinary drainage bag from touching the floor for one resident (R318) who was reviewed for urinary catheter care. R318, who has multiple diagnoses including a Stage 4 pressure ulcer, Type 2 Diabetes Mellitus, and Chronic Kidney Disease, was observed lying in bed with the urinary drainage bag on the floor. The bag was not in a privacy cover or any other type of protection to prevent it from directly touching the floor. This observation was confirmed by a Licensed Practical Nurse (V10) who acknowledged that the bag should not be on the floor due to infection control concerns. The Infection Prevention Director (V16) also confirmed that urinary drainage bags should be hooked onto the bed frame and not be on the floor, as this increases the risk of infection. The facility's policy on catheter care, dated 02/14/19, states that urinary drainage bags and tubing should be positioned to prevent them from touching the floor. The failure to adhere to this policy puts residents at a higher risk for potential infections, including urinary tract infections.
Failure to Provide Nutritional Supplements as Ordered
Penalty
Summary
The facility failed to follow physician orders and provide house nutritional supplements for two residents, R108 and R148, out of a total sample of 34 residents. R148, diagnosed with adult failure to thrive, had an active order for a house supplement three times a day. Despite this, R148 reported not receiving the nutritional shakes, and multiple staff members, including nurses and dietary staff, were unclear about who was responsible for providing the supplement. Observations and interviews revealed that R148 did not receive the ordered supplements, and there was confusion among staff about the process for delivering these supplements to residents. Similarly, R108, who has multiple diagnoses including Type 2 Diabetes Mellitus and dependence on renal dialysis, had an order for a renal-specific nutritional supplement once a day. During medication administration, R108 reported not receiving the supplement, and observations confirmed the absence of the supplement on the breakfast tray. Despite the LPN's claim that the supplement was provided, R108 consistently denied receiving it and stated that he only consumed supplements brought by his brother. Further interviews with staff indicated that the renal-specific supplement was not consistently provided to R108 as ordered. The facility's policy on fortified foods and oral nutritional snacks was not followed, leading to a failure in providing the necessary nutritional supplements to the residents. The Registered Dietitian confirmed that the supplements should be available on the floor and administered by the nurses, but this was not happening as required. This deficiency highlights a significant lapse in the facility's adherence to physician orders and nutritional care plans for its residents.
Failure to Follow Physician's Order and Dietary Recommendation for Enteral Feeding
Penalty
Summary
The facility failed to ensure that a physician's order and dietary recommendation for the feeding rate were followed for a resident with enteral feedings. The resident, who was admitted with diagnoses including dysphagia and dementia, was supposed to receive Nepro 1.8 enteral feeding at a rate of 70 ml/hr for 18 hours as per the physician's order and dietary recommendation. However, observations revealed that the resident was receiving the feeding at a rate of 45 ml/hr, and at another instance, the feeding was turned off with the bottle still 75% full. The Director of Nursing confirmed that the expectation was for nurses to follow the doctor's order and that the feeding machine should be programmed accordingly, only to be put on hold for medication and incontinence care. The Registered Dietitian reiterated the importance of following the recommended and ordered enteral feeding rate to ensure the resident maintains or gains weight, given the resident's underweight status and presence of pressure ulcers. The facility's policy on gastrostomy tube feeding and care mandates that nutrients, fluids, and medications be provided as per physician orders. The failure to adhere to these orders and recommendations led to the deficiency noted in the report.
Failure to Follow Resident's Food Allergy and Preferences
Penalty
Summary
The facility failed to follow a resident's food allergy and food preferences, affecting one resident out of three reviewed for nutrition. The resident, who has a documented allergy to eggs, received a breakfast tray that included scrambled eggs, which the resident did not consume. The resident's meal ticket clearly indicated an allergy to eggs and listed other food preferences, such as a dislike for toast and a preference for cold cereal or grits. Despite this, the resident received food items that did not align with these preferences, leading to the resident consuming only the milk from the tray and expressing dissatisfaction with the meal provided. The resident's medical history includes End Stage Renal Disease, Dependence on Renal Dialysis, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus with Hyperglycemia, and other conditions. The resident has a BIMS score indicating intact cognition and has consistently communicated their food allergies and preferences. The dietary staff, including the Registered Dietitian and Food Service Director, acknowledged the error and emphasized the importance of adhering to meal tickets to prevent allergic reactions and ensure residents receive food they will eat. The facility's policy on meal identification and preference cards/tickets requires that food allergies and preferences be documented and followed during meal service. However, the failure to adhere to this policy resulted in the resident receiving inappropriate food items. The Registered Dietitian and Food Service Director both confirmed that the resident should not have received eggs and that the meal tickets should accurately reflect the resident's preferences to avoid such issues in the future.
Failure to Administer and Document House Supplements
Penalty
Summary
The facility failed to ensure accurate medical records for one resident (R148) out of a total sample of 34 residents. R148's medical records indicated a diagnosis of adult failure to thrive and an order for a house supplement to be administered three times a day. However, during the survey, it was found that R148 did not receive the prescribed house supplements. Interviews with various staff members, including a nurse, assistant director of nursing, cook, diet tech, and central supply coordinator, revealed confusion and miscommunication regarding the responsibility for administering the house supplements. The nurse initially claimed that dietary staff provided the supplements, while dietary staff stated that nurses were responsible for administering them. The central supply coordinator also confirmed that no requests for house supplements for R148 had been made by the nursing staff. Further review of R148's Medication Administration Record (MAR) for April and May 2024 showed multiple entries where the nurse had charted the administration of the house supplements, despite admitting during the interview that they did not administer them. The assistant director of nursing confirmed that staff are expected to document accurately whatever they do or do not do. The facility's undated Medical Records policy also mandates accurate documentation. This discrepancy between the documented records and the actual administration of the supplements led to the deficiency noted in the report.
Failure to Revise and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to revise and implement appropriate fall prevention interventions and provide adequate supervision for a resident (R2) who was at risk for falls. R2, who had diagnoses including osteomyelitis, low back pain, unsteadiness on feet, abnormalities of gait/mobility, lack of coordination, and weakness, experienced multiple falls on three separate occasions. Despite being identified as a moderate fall risk, the facility did not update R2's care plan with new interventions after each fall. Specifically, after falls on 10/2/23 and 10/12/23, the care plan was not revised to include new fall prevention measures. Following a fall on 11/27/23, the care plan was updated to include bilateral floor mats and evaluations by PT and OT, but it did not include staff supervision as an intervention. The incident reports and progress notes indicate that R2 fell on 11/27/23 while trying to reach a phone charger, resulting in a laceration above the right eye that required stitches. The Director of Nursing confirmed that the care plan was not updated after the 10/12/23 fall and that staff supervision was not included in the fall prevention interventions. The Medical Director emphasized the importance of implementing measures to prevent falls and the potential harm from unwitnessed falls. The facility's fall prevention program requires that care plans be updated with each fall and that safety interventions, including supervision, be implemented for residents at risk of falls. However, these protocols were not adequately followed for R2, leading to repeated falls and injury.
Failure to Provide 1:1 Feeding Assistance
Penalty
Summary
The facility failed to ensure that 1:1 feeding assistance was provided to three residents, resulting in significant weight loss for one resident. Resident 2 (R2) was admitted with a weight of 202.1 pounds and experienced a progressive weight loss, reaching 144 pounds by the time of discharge. Despite a request from R2's family for feeding assistance due to unsteadiness of hand while eating, documentation shows that feeding assistance was not consistently provided, with 20 out of 29 meals lacking documentation of assistance. Interviews with staff revealed uncertainty about whether feeding assistance was provided, and the medical director confirmed that significant weight loss could lead to malnutrition. The facility's dietary policy requires weekly or bi-weekly weights for residents at nutritional risk, but this was not effectively implemented for R2, leading to a 28.7% weight loss over several months. Resident 3 (R3) and Resident 4 (R4), both diagnosed with quadriplegia, also required 1:1 feeding assistance as per their dietary assessments. However, the documentation survey reports for April 2024 indicated that feeding assistance was not documented for 49 out of 90 meals for R3 and 51 out of 90 meals for R4. The facility's restorative nursing program, which includes eating and swallowing, was not adequately followed, resulting in a lack of documented feeding assistance for these residents. This failure to provide necessary feeding assistance and to document it properly highlights significant deficiencies in the facility's care practices for residents requiring nutritional support.
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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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