Elevate Care North Branch
Inspection history, citations, penalties and survey trends for this long-term care facility in Niles, Illinois.
- Location
- 6840 West Touhy Avenue, Niles, Illinois 60714
- CMS Provider Number
- 145630
- Inspections on file
- 38
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Elevate Care North Branch during CMS and state inspections, most recent first.
A cognitively impaired resident with dementia, severe cognitive impairment, anxiety, and a documented history of wandering into other residents’ rooms and difficulty with redirection entered another confused resident’s room and did not leave when told. The second resident began yelling and, by her own account, hit the intruding resident in the face while trying to push her out, resulting in a small open area or scratch under the eye. Staff reported hearing a commotion and, upon arrival, found that the altercation had already occurred. This sequence of events shows the facility did not adequately identify and intervene to prevent resident-to-resident physical abuse as required by its abuse prevention policy.
Two residents at moderate and high risk for falls experienced incidents due to the facility's failure to follow its Fall Prevention Program and implement care plan interventions. One resident with multiple comorbidities fell twice in the dialysis unit after attempting to get up unassisted, while another resident with severe cognitive impairment fell while wearing improper footwear, despite care plan instructions. Staff did not provide adequate supervision or ensure interventions were followed, leading to preventable falls.
Staff failed to honor a resident's right to refuse a mechanical lift transfer, proceeding with the transfer despite the resident's clear objections and complaints of pain. The resident, who had significant medical conditions and was cognitively intact, experienced pain, loss of dignity, and emotional distress as a result. Documentation of the refusal, education, and follow-up care was lacking, and staff cited safety concerns and care plan recommendations as reasons for not accommodating the resident's wishes.
A resident requiring partial to moderate assistance with eating was left to eat independently, resulting in soiled clothing, dirty fingernails, and a poorly positioned lunch tray. Staff failed to provide a clothing protector and did not ensure proper tray setup, contrary to facility policies on dignity and mealtime assistance.
A resident with multiple medical conditions, including a history of falls and heart failure, was found in bed without access to their call light, which was placed behind the bed. The resident could not locate the call light, despite a care plan intervention requiring it to be within reach. Both an LPN and the DON confirmed that call lights should always be accessible, in accordance with facility policy.
A resident with significant medical and functional needs was not provided with necessary assistance during meals, resulting in soiled clothing and personal items, and was also observed to have long, dirty fingernails. Staff confirmed that CNAs are responsible for both meal setup and nail care, but these duties were not performed according to facility policy.
A resident with multiple risk factors and existing skin issues experienced worsening rashes, fungal infections, and developed a new open wound that went unrecognized and undocumented by staff. Required weekly assessments, documentation, and timely updates to the care plan were not completed, and staff failed to communicate changes in the resident's skin condition to the wound care nurse and physician as per facility policy.
A resident with a gastrostomy tube, tracheostomy, and history of respiratory issues was left lying flat in bed after receiving medication via the feeding tube, contrary to physician orders and facility policy requiring head-of-bed elevation. Nursing staff did not assess respiratory status or promptly clean oral secretions, and the DON incorrectly stated that bed elevation was unnecessary when the feeding tube was off. These failures resulted in inadequate care for tube feeding management.
A nurse administered insulin to a resident using a vial that belonged to another resident, without verifying the medication label against the medication administration record as required by facility policy. Facility leadership confirmed that staff should not borrow medications and should use the convenience box if needed. The resident had diabetes and was ordered insulin per sliding scale.
A resident was administered Azithromycin without a documented clinical indication or evidence of infection, despite normal lab results and no symptoms. The facility failed to follow its antibiotic stewardship protocols, including proper use of McGeer's Criteria and required documentation.
An expired multi-dose insulin vial with an unreadable open date was found in the medication cart for a resident with Type 2 Diabetes Mellitus. The LPN confirmed the insulin should have been discarded and reordered, but it remained in the active supply past its expiration date, contrary to facility policy requiring timely removal and disposal of expired medications.
A dietary aide was observed working in the kitchen without a hair net, contrary to facility policy requiring all dining services staff to wear hair restraints in food production and serving areas. Both the dietary manager and administrator confirmed that hair nets are expected to be worn to prevent hair from contacting exposed food, potentially affecting all residents consuming food from the kitchen.
A resident on contact isolation for C. diff was observed with soiled clothing and belongings, and staff failed to follow proper hand hygiene and PPE protocols, including using hand sanitizer instead of soap and water and not changing gloves appropriately. A CNA disposed of contaminated items in regular trash and did not use isolation bags, while a visitor entered the room without being educated or provided with PPE. The facility lacked a clear policy for contact isolation setup and did not provide isolation-specific disposal containers.
A resident, who was cognitively intact and always incontinent, was not checked for incontinence for at least four hours, resulting in them being soaked in urine. The CNA on duty did not change the resident despite their request for assistance. The resident reported screaming for help throughout the night and stated they were last changed around 1 or 2 am and again at 7:15 am. The facility's policy requires residents to be checked approximately every two hours.
A resident's financial confidentiality was breached when the Business Office Manager mistakenly sent the resident's bank statements to an incorrect external recipient. The resident, who has multiple medical conditions, is his own decision maker, with a family member acting as a substitute decision maker. This breach was discovered during an email review after the family member provided bank statements to prove a payment to the facility.
Two residents with end-stage renal disease were improperly dosed with Valtrex, an antiviral medication, without necessary renal adjustments. One resident was hospitalized due to toxic encephalopathy, while the other experienced confusion and hallucinations. The facility's policy requires safe medication administration, which was not followed.
A resident with a history of falls and significant medical conditions sustained a knee fracture due to the facility's failure to implement its fall prevention program. The resident's room was inadequately lit, with safety equipment improperly positioned, and the call light out of reach. Staff interviews revealed inconsistencies in assessing and documenting the resident's condition, and the facility's investigation into the incident was inconclusive.
A resident with a complex medical history experienced a prolonged elevated heart rate and respiratory distress, but the facility failed to promptly notify the primary care physician or send the resident to the hospital. Despite multiple interventions by staff, the necessary escalation to emergency services was delayed until the resident's family intervened, leading to the resident's death.
A resident with complex medical needs experienced an elevated heart rate and respiratory distress, but the facility failed to notify the PCP in a timely manner. Despite interventions by a respiratory therapist and a pulmonary NP, the PCP was informed only after all interventions were exhausted, leading to a delay in higher-level care.
An LPN failed to follow proper infection control practices by wearing potentially infectious PPE outside a resident's room and disposing of it improperly, despite the facility's policy and available disposal bins. This affected a resident on contact isolation due to influenza and potentially impacted 16 other residents on the same wing.
The facility failed to ensure that low air loss mattresses were set at appropriate weight settings for five residents, leading to potential risks for pressure ulcers. Observations revealed that the weight settings on the mattresses were significantly higher than the residents' actual weights, and the DON acknowledged the issue. The residents had severe medical conditions, and the Wound Care Coordinator confirmed that incorrect settings increase the risk for pressure injuries.
The facility failed to follow its medication administration policy by leaving medication carts unlocked and unattended, leaving medications on top of the cart, and leaving medications at a resident's bedside. These actions posed significant safety risks to residents.
The facility failed to feed a resident in a dignified manner and did not provide adequate feeding assistance to another resident with a history of weight loss. One resident was fed by a CNA who was standing, contrary to policy, and another resident with weight loss was not encouraged or assisted to eat her meal.
The facility failed to ensure that residents who were self-administering medications had a self-medication administration evaluation, a care plan, and a physician's order in place. One resident was observed with nasal sprays and another with supplements, both without the necessary documentation and approvals at the time of the surveyor's visit.
Failure to Prevent Resident-to-Resident Physical Abuse Involving a Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident (R2) from resident-to-resident physical abuse in accordance with its abuse prevention policy. R2, an elderly female with dementia, severe cognitive impairment (BIMS score 4/15), anxiety, and behavioral disinhibition, had a history of wandering into other residents’ rooms and difficulty with redirection, as documented in nursing notes and psychiatric evaluations. Despite these known behaviors, R2 continued to wander and enter other residents’ rooms, including being described as going to other residents’ rooms, fighting with staff when redirected, and having decreased tolerance for environmental stimulation and personal space intrusions. On the date of the incident, R2 wandered into the room of another confused resident, R1, who was attempting to leave her room as R2 was entering. R1 reported that a lady came into her room, would not leave despite being told to get out, and that she began yelling and trying to push the lady out. R1 stated she felt bad about hitting the other resident in the face but said she was trying to get her out of the room when the resident would not listen. Staff witnesses reported hearing a loud noise and voices from R1’s room and, upon arrival, found that an altercation had already occurred in which R1 had hit R2 in the face. Following the altercation, staff assessments documented that R2 had a small open area or scratch/redness under the left eye, with no bleeding, bruising, swelling, or reported pain, and that R2 was calm and not in distress. R1 was assessed and found to have no injuries. Interviews with nursing and social services staff confirmed that R2 had become lost and confused and attempted to enter R1’s room, leading to a disagreement and R1 striking R2 in the face before staff could intervene. The facility’s abuse prevention policy requires protection of residents from all forms of abuse, including resident-to-resident abuse, but the facility did not adequately identify and intervene to prevent this resident-to-resident physical abuse incident involving R2 and R1.
Failure to Follow Fall Prevention Program and Care Plan Interventions
Penalty
Summary
The facility failed to follow its Fall Prevention Program policy, resulting in inadequate prevention of fall incidents and failure to implement care plan interventions for residents assessed as moderate and high risk for falls. One male resident with multiple complex diagnoses, including chronic osteomyelitis, diabetes, chronic kidney disease, and congestive heart failure, experienced two falls in the dialysis unit. Despite being identified as moderate risk for falls upon admission and high risk after the first incident, the resident was not adequately supervised or assisted during dialysis treatments. Both falls occurred when the resident, experiencing leg cramps, attempted to get up without staff assistance after expressing his need to move. Staff were either occupied with other patients or not immediately present at the chair side, and the care plan intervention to reinforce education about not getting up unassisted was not effectively implemented. Another female resident with severe cognitive impairment, Alzheimer's disease, and multiple comorbidities also experienced a fall. She was found on the floor in a prone position after attempting to walk toward staff while wearing improper footwear. Her care plan included an intervention to ensure she wore appropriate footwear or nonskid socks when ambulating or mobilizing in a wheelchair, but at the time of the incident, she was wearing slippers, which contributed to her fall. The staff identified the root cause as the resident not wearing appropriate footwear, despite this being a documented intervention in her care plan. The facility's Fall Prevention Program policy outlines the need for individualized risk assessment, implementation of appropriate interventions, and ongoing monitoring to ensure effectiveness. However, in both cases, the facility did not ensure that care plan interventions were followed or that adequate supervision and preventive measures were in place, resulting in falls for residents at known risk. Documentation and communication lapses were also noted, with staff repeating verbatim documentation and not ensuring interventions were updated or effectively communicated to all care providers.
Failure to Honor Resident's Right to Refuse Mechanical Lift Transfer
Penalty
Summary
Staff failed to respect a resident's right to refuse care when they disregarded his expressed refusal to be transferred via mechanical lift following his return from dialysis. The resident, who had a history of right hip osteoarthritis, left foot amputation, and other significant medical conditions, was assessed as cognitively intact and dependent on staff for transfers. Despite the resident's clear verbal refusal and complaints of pain during the transfer, two CNAs proceeded with the mechanical lift transfer, citing the resident's care plan and safety concerns as justification. During the transfer, the resident experienced significant right hip pain, described as bone-on-bone friction, and expressed emotional distress and loss of dignity. The resident reported that he attempted to stop the transfer and communicated his wishes to staff, but his objections were ignored. After the transfer, there was no documentation of staff providing pain assessment, pain medication, or follow-up care, and the resident stated that no one checked on him or addressed his pain. Interviews with facility staff, including CNAs, therapy staff, and nursing leadership, revealed a lack of documentation regarding the resident's refusal and the education provided about transfer options and risks. The care plan did not reflect the resident's preferences or recent changes in his condition prior to the incident. Staff training records showed gaps in recent in-service education on resident rights. The facility's policy emphasized resident autonomy and the right to refuse care, but this was not upheld in practice during the incident.
Failure to Maintain Resident Dignity and Provide Proper Mealtime Assistance
Penalty
Summary
A resident with a history of hypertensive heart and chronic kidney disease, end stage renal disease, and monoplegia of the upper limb was observed during mealtime requiring partial to moderate assistance with eating, as documented in her assessment. Despite this, the resident was left to eat independently, resulting in food being spread over her chest, lap, and soiling her pillow and cellphone. The lunch tray was not positioned within easy reach, and the resident was using both a spoon and her hands to eat. Additionally, her fingernails were observed to be long and dirty, with black matter present, and no clothing protector was provided to prevent soiling. Staff interviews revealed that the CNA was responsible for nail care and tray setup, but the assigned CNA denied setting up the tray and confirmed that it should have been placed closer to the resident. The DON acknowledged that CNAs are expected to ensure proper tray placement and that a food protector was not used for this resident. Facility policies reviewed emphasized the importance of maintaining resident dignity, proper assistance during meals, and preventing soiling of clothing, but these were not followed in this instance.
Call Light Not Accessible to Resident as Required by Care Plan
Penalty
Summary
A deficiency was identified when a resident with a history of falls, hypertensive heart disease with chronic diastolic congestive heart failure, type 2 diabetes, hyperlipidemia, and a right femur fracture was found in bed without access to their call light, which was located behind the bed. The resident was unable to locate the call light when asked. The resident's care plan specifically required that the call light be kept within reach due to their medical conditions. Staff, including an LPN and the Director of Nursing, confirmed that call lights are required to be accessible to residents at all times and should not be placed behind the bed. The facility's policy also mandates that all residents capable of using a call light must have it available and easily accessible at the bedside or another reasonable location.
Failure to Provide Required ADL Assistance and Nail Care
Penalty
Summary
A deficiency was identified when a resident with a history of hypertensive heart and chronic kidney disease, end stage renal disease, and monoplegia of the upper limb was not provided adequate assistance with activities of daily living (ADLs), specifically nail care and meal assistance. The resident's assessment indicated a need for partial to moderate assistance with eating due to self-care performance deficits. During observation, the resident was found eating independently in her room, with food scattered on her chest, lap, and soiling her clothes and personal items. The lunch tray was not properly positioned for accessibility, and no clothing protector was used to prevent soiling, contrary to facility policy. Additionally, the resident was observed to have long, dirty fingernails with visible black matter, indicating a lack of nail care. Staff interviews confirmed that CNAs are responsible for both nail care and proper meal setup, but these tasks were not completed as required. The facility's policies on feeding and nail care were not followed, as evidenced by the lack of a clothing protector during meals and the failure to maintain nail hygiene during ADL care.
Failure to Monitor and Document Worsening Skin Conditions and New Wounds
Penalty
Summary
The facility failed to ensure ongoing assessment and monitoring of a resident's skin condition, resulting in a lack of identification and timely intervention for new or worsening skin impairments. Upon admission, the resident had multiple risk factors and existing skin issues, including rashes and fungal infections on the hands and neck, and was identified as being at risk for skin impairment. Physician orders and facility policy required regular skin assessments, documentation, and prompt notification of changes to the physician and family. However, observations revealed that the resident had visible worsening of skin conditions, including reddened, swollen, and thickened fingers, dirty nails, and rashes on multiple areas, which were not documented or communicated as required. During care, staff observed an open wound in the perianal area, which had not been previously identified or reported to the wound care nurse or documented in the resident's records. The wound care nurse and other staff were unaware of the new wound and the worsening of the resident's skin conditions. Additionally, there was no weekly documentation in the progress notes regarding the resident's rashes and fungal infections, despite these being present since admission. The wound care nurse also failed to update the resident's wound/skin care plan in a timely manner, as required by facility policy. Interviews with staff indicated a lack of awareness and communication regarding the resident's skin status, with responsibilities for assessment and documentation not being consistently followed. The facility's own policies outlined the need for regular assessment, documentation, and prompt notification of changes, but these were not adhered to, resulting in missed identification and treatment of new and worsening skin issues for the resident.
Failure to Elevate Head of Bed and Manage Secretions During Enteral Medication Administration
Penalty
Summary
A deficiency occurred when a resident with a gastrostomy tube and multiple complex medical conditions, including pneumonia, chronic respiratory failure, anoxic brain damage, and a tracheostomy, was observed lying flat in bed with the feeding tube connected to an enteral feeding pump that was turned off. The resident had large oral secretions draining from both sides of the mouth and onto the neck, and whitish secretions were visible. The resident's care plan and physician orders required the head of the bed to be elevated, especially during and after medication administration via the gastrostomy tube, to prevent complications such as aspiration. However, after medication was administered through the gastrostomy tube, the nurse failed to elevate the head of the bed and did not assess the resident's respiratory status or clean the oral secretions. The Director of Nursing acknowledged that the bed should have been elevated, but later stated it was not necessary since the feeding tube was off, despite facility policy requiring the head of the bed to be elevated to 30-45 degrees for at least 30 minutes after medication administration. The facility's own policies on gastrostomy tube care and enteral medication administration were not followed, as the resident remained flat for nearly an hour after medication was given, and oral secretions were not promptly managed. These actions and inactions led to a failure to provide appropriate care and services to prevent possible complications for the resident receiving enteral nutrition and medications.
Insulin Administered from Another Resident's Supply
Penalty
Summary
A registered nurse prepared and administered insulin to a resident using a multi-dose vial that belonged to a different resident. The nurse did not compare the scheduled medication with the medication label prior to administration, as required by facility policy. When questioned, the nurse stated that it was acceptable to borrow medication from another resident, especially since the original resident needed to leave for dialysis. Further interviews with facility leadership confirmed that staff are instructed not to use medications belonging to other residents and should instead use the convenience box if a medication is not available in the medication cart. The affected resident had a diagnosis of Type 2 Diabetes Mellitus and was ordered to receive Insulin Lispro as per a sliding scale. Facility policy requires verification of the five rights and comparison of the medication and dosage schedule on the MAR with the medication label prior to administration, which was not followed in this instance.
Failure to Monitor and Justify Antibiotic Use
Penalty
Summary
A deficiency was identified when a resident was prescribed and administered Azithromycin without a documented clinical indication for a specific infection. The resident, who was admitted with multiple chronic conditions including respiratory failure, COPD, hypertensive heart disease, and chronic kidney disease with heart failure, was observed to be alert, oriented, and without any signs or symptoms of infection. Medical records and the comprehensive care plan referenced antibiotic therapy for infection but did not specify the type of infection being treated. Laboratory results, including white blood cell counts and daily body temperatures, were within normal limits, and there was no evidence of fever or infection. Further review revealed that the facility's antibiotic stewardship protocols were not followed. The Infection Preventionist was unable to provide a clear reason for the antibiotic prescription and noted that the required McGeer/Antibiotic monitoring form was either incomplete or not properly signed. The form that was eventually presented indicated that the resident did not meet criteria for infection. The facility's policy mandates the use of McGeer's Criteria and proper documentation for antibiotic use, but these procedures were not adhered to in this case.
Expired Insulin Vial Not Removed from Medication Supply
Penalty
Summary
Surveyors observed that a multi-dose insulin vial belonging to a resident with Type 2 Diabetes Mellitus was found in the medication cart with an unreadable open date and an expiration date that had already passed. The insulin vial, labeled as Insulin Lispro, was expired as of 4/11/2025, but remained in the active medication supply as of 4/15/2025. The LPN responsible for the medication cart confirmed that the expired insulin should have been discarded and reordered from the pharmacy. Further review of the resident's records confirmed an active order for HumaLOG (Insulin Lispro) to be administered before meals. The facility's policy requires that all expired medications be removed from the active supply and disposed of according to established procedures, with nurses responsible for labeling medications with the date opened and expiration date. Despite these policies, the expired insulin vial was not removed in a timely manner, resulting in non-compliance with medication storage and labeling requirements.
Failure to Ensure Dietary Staff Wore Required Hair Restraints
Penalty
Summary
During a survey, it was observed that a dietary aide was present in the kitchen without wearing a hair net while food was being prepared. The dietary aide acknowledged that he should have covered his hair with a hair net, and the dietary manager confirmed that hair nets are required. The facility's policy mandates that all dining services staff must wear hair restraints in food production, dishwashing, and serving areas to prevent hair from contacting exposed food. The administrator also stated that he expects dining service staff to wear hair restraints. This lapse in following the facility's policy had the potential to affect 121 residents who consume food from the kitchen.
Failure to Follow Infection Control Practices for Contact Isolation
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices for a resident on contact isolation due to a Clostridium difficile (C. diff) infection. The resident, who was alert but confused, was observed eating independently with food soiling her chest, lap, pillow, and cellphone. Her hands were visibly dirty, with long, unclean fingernails and rashes present on her neck, chest, and forearms. Staff were called to assist, and while one LPN removed food particles and cleaned the resident and her belongings, she used hand sanitizer instead of washing hands with soap and water after contact, despite facility policy and CDC guidelines specifying that handwashing is required after C. diff exposure. During incontinence care, a CNA failed to follow proper glove and hand hygiene protocols. The CNA disposed of a soiled brief in a regular trash can, did not use an isolation trash bin or bag for soiled linens, and placed a soiled towel on the bedside stand. The CNA applied a clean brief without removing gloves or performing hand hygiene between tasks, and when prompted, changed gloves without hand hygiene. These actions were inconsistent with both facility policy and standard infection control practices for contact isolation. Additionally, a visitor entered the resident's room without being provided or instructed to wear appropriate PPE, such as gown and gloves, and reported not being educated about isolation precautions during previous visits. The facility did not have a policy available for contact isolation setup and used regular trash cans and unit hampers for disposal of soiled items from isolation rooms, contrary to best practices. These failures were confirmed through interviews with staff, including the DON and Infection Preventionist, who acknowledged the lack of proper isolation supplies and visitor education.
Failure to Follow Incontinence Care Policy
Penalty
Summary
The facility failed to adhere to its incontinence care policy by not checking a resident for incontinence at least every two hours. This deficiency affected a resident who was cognitively intact and always incontinent, as documented in their minimal data set. The resident was found soaked in urine, with a saturated adult brief, wet bed sheets, and a mattress, indicating that they had not been checked for incontinence for at least four hours. The CNA on duty admitted to checking the resident between 7:00 am and 8:30 am but did not change them, despite the resident's request for assistance. The resident reported screaming for help throughout the night and stated that they were last changed around 1 or 2 am and again at 7:15 am by the night shift CNA. The resident expressed a need to be changed every hour, but staff reportedly told them to wait until every two hours. The Director of Nursing confirmed that residents should be changed every two hours and as needed, including upon request. The facility's incontinence care policy requires residents to be checked approximately every two hours and provided with perineal and genital care after each episode.
Breach of Resident's Financial Confidentiality
Penalty
Summary
The facility failed to ensure the confidentiality of a resident's financial records, specifically for a male resident with multiple diagnoses including Parkinson's disease, CHF, ESRD, COPD, dementia, delirium, and depression. The resident is his own decision maker, but a family member acts as a substitute decision maker. The Business Office Manager, responsible for handling residents' financial accounts, mistakenly sent an email containing the resident's bank statements to an incorrect external recipient. This breach of confidentiality was discovered during a review of the Business Office Manager's emails, following a situation where the family member had to provide bank statements to prove a payment was made to the facility. The resident's admission packet and contract explicitly state the right to confidentiality of financial records, which was violated in this instance.
Improper Antiviral Dosing for Residents with Renal Impairment
Penalty
Summary
The facility failed to ensure that two residents, who were undergoing treatment for viral infections, received the correct dosage of antiviral medication, Valtrex. Resident R2, who was diagnosed with shingles, was prescribed a standard dose of Valtrex without adjusting for his renal impairment due to end-stage renal disease and dependence on dialysis. This oversight led to R2 receiving a higher dose than he could tolerate, resulting in hospitalization for altered mental status and toxic encephalopathy related to acyclovir toxicity. The Nurse Practitioner acknowledged the error, noting that the dose should have been adjusted based on R2's creatinine clearance. Similarly, Resident R4, also with end-stage renal disease and on dialysis, was prescribed the same standard dose of Valtrex without renal adjustment. R4 experienced confusion and hallucinations, which were attributed to the improper dosing of Valtrex. The Director of Nursing confirmed that the dosing was incorrect and that it is the provider's responsibility to order the proper dosage. The facility's policy mandates the safe and effective administration of medications, which was not adhered to in these cases.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to adhere to its fall prevention program, resulting in a resident sustaining a right knee fracture. The resident, who has a history of multiple falls and significant medical conditions including spinal stenosis and hypertensive heart disease, experienced a fall that led to an emergency room visit. The resident's care plan included specific interventions to prevent falls, such as keeping the bed in the lowest position, ensuring call lights were within reach, and using floor mats. However, these interventions were not properly implemented, as observed by the surveyor. During the surveyor's visit, the resident's room was found to be inadequately lit, with the call light out of reach and one of the floor mats improperly positioned. The bedside table was placed on a fall mat, posing an additional hazard. The resident reported a fall following an altercation with a staff member during a transfer, although the exact circumstances of the fall were unclear. The resident's care plan was not followed, as evidenced by the lack of visual prompts and the improper placement of safety equipment. Interviews with staff revealed inconsistencies in the assessment and documentation of the resident's condition. The night nurse failed to document an assessment of the resident's knee after the resident requested an ice pack for pain. The assistant director of nursing confirmed that the nurse likely did not assess the knee, and the facility's investigation into the incident was inconclusive. The facility's fall prevention policy mandates that personal items be kept within reach and that residents requiring assistance not be left alone, both of which were not adhered to in this case.
Delayed Response to Resident's Change in Condition
Penalty
Summary
The facility failed to promptly notify a resident's primary care physician and send the resident to the hospital when a significant change in condition occurred. The resident, a male with a complex medical history including acute and chronic respiratory failure, tracheostomy, and cerebral palsy, experienced an elevated heart rate that persisted for over 15 hours. Despite multiple interventions, including medication administration and placement on a ventilator, the resident's condition did not improve, and the primary care physician was not notified until late in the day. Throughout the day, various staff members, including registered nurses, respiratory therapists, and nurse practitioners, were involved in monitoring and attempting to manage the resident's condition. However, there was a lack of timely communication and coordination among the staff, leading to delays in critical decision-making. The resident's elevated heart rate and respiratory distress were not adequately addressed, and the necessary escalation to emergency services was not made until prompted by the resident's family member. The report highlights the breakdown in communication and decision-making processes within the facility, which contributed to the delay in providing the resident with the necessary higher level of care. The failure to act promptly and notify the appropriate medical personnel resulted in the resident's condition worsening and ultimately led to their death.
Failure to Notify PCP of Resident's Condition Changes
Penalty
Summary
The facility failed to notify and inform a resident's primary care physician (PCP) of the onset of an elevated heart rate and other significant changes in the resident's condition in a timely manner. The resident, a male with a complex medical history including acute and chronic respiratory failure, tracheostomy, and cerebral palsy, experienced a significant increase in heart rate starting at 12:46 AM. Despite this, the PCP was not notified until 3:23 PM, approximately 14 hours later, after the resident's condition had further deteriorated. Throughout the day, the resident's heart rate remained elevated, and additional symptoms of respiratory distress were observed. The facility's staff, including a respiratory therapist and a pulmonary nurse practitioner, intervened by placing the resident on a ventilator and ordering a chest x-ray and antibiotics. However, these actions were taken without direct communication with the PCP, who was only informed after all respiratory and cardiac interventions had been exhausted. The report highlights a breakdown in communication and protocol adherence, as the facility's guidelines require prompt notification of critical laboratory values and changes in a resident's condition. The failure to notify the PCP in a timely manner, despite the presence of elevated white blood cell counts and other indicators of potential infection, contributed to a delay in providing the resident with the necessary higher level of care.
Improper Disposal of PPE for Resident on Contact Isolation
Penalty
Summary
The facility failed to follow proper infection control practices for a resident on contact isolation due to influenza. An LPN was observed exiting the resident's room wearing a gown and gloves, then walking down the hall with the potentially infectious PPE still on. The LPN eventually doffed the PPE in the hallway and placed it on top of the isolation cart before transporting it to the nurse's station and disposing of it in a garbage bin there. The LPN admitted to not checking for a garbage bin inside the resident's room and stated he did not think it mattered where the PPE was disposed of. The Director of Nursing confirmed that staff should remove PPE before leaving a resident's room to prevent the spread of infection. The facility's policy also states that gloves and gowns should be removed before exiting the resident's room. The surveyor observed that the resident's room had garbage bins available for proper disposal of PPE. This failure to follow infection control protocols has the potential to affect 16 residents residing on the same wing.
Improper Weight Settings on Low Air Loss Mattresses
Penalty
Summary
The facility failed to ensure that low air loss mattresses were set at appropriate weight settings for five residents, leading to potential risks for pressure ulcers. Observations revealed that the weight settings on the mattresses for these residents were significantly higher than their actual weights. For instance, one resident's mattress was set for 230 pounds while their actual weight was 110.4 pounds, and another resident's mattress was set for 350 pounds while their actual weight was 160.2 pounds. The Director of Nursing (DON) acknowledged that the weight settings were incorrect and that improper settings could worsen pressure ulcers. The residents involved had various severe medical conditions, including sepsis, chronic respiratory failure, and stage 4 pressure ulcers. The Minimum Data Set (MDS) for these residents did not consistently document their cognitive status or pressure ulcer risk, further complicating their care. The Wound Care Coordinator confirmed that incorrect weight settings on low air loss mattresses increase the risk for pressure injuries. Despite orders to check the mattress settings every shift, the facility did not ensure compliance, leading to this deficiency.
Medication Administration and Storage Deficiencies
Penalty
Summary
The facility failed to follow its medication administration policy by not locking the medication cart when out of sight of the medication nurse, leaving medications on top of the medication cart unattended, and leaving medications at a resident's bedside. During an observation, a registered nurse prepared medications for a resident and left the medication cart unlocked and unattended in the hallway. The nurse also left two medications on top of the cart while administering other medications to the resident. The nurse acknowledged that this was against facility policy and posed a safety risk to residents who might access the medications and consume them inappropriately. In another instance, an agency LPN left five pills in an unlabeled medication cup on top of an unattended medication cart. The LPN admitted awareness of the potential risk that someone could take the medications and have a harmful reaction. The facility's policy mandates that medication carts must be locked when not attended by authorized personnel to prevent unauthorized access and ensure resident safety. Additionally, a resident was observed with a medicine cup containing four white tablets on their over-the-bed table. The resident stated that the nurse had left the pills there earlier, and they were unsure of what the pills were, so they did not take them. The LPN confirmed that she had left the medications at the bedside, which is against facility policy due to safety concerns. The Director of Nursing reiterated that leaving medications at a resident's bedside is unacceptable as it poses a risk of other residents or visitors taking the medication or the intended resident not consuming it as prescribed.
Failure to Feed Residents Dignifiedly and Provide Adequate Feeding Assistance
Penalty
Summary
The facility failed to feed a resident in a dignified manner and did not provide adequate feeding assistance to another resident with a history of weight loss. In the first instance, a cognitively intact resident was observed being fed by a Certified Nursing Assistant (CNA) who was standing at the resident's bedside, contrary to the facility's policy that requires staff to be seated at eye level with the resident to provide a relaxed and comfortable environment. The CNA acknowledged that they should have been sitting while feeding the resident. In the second instance, a resident with a history of continuous weight loss was observed during lunch. The resident was able to feed herself some apples and drink juice but did not consume the main components of her meal. Despite the resident's history of weight loss, no staff offered additional assistance or encouragement to eat. The Dietary Consultant confirmed that dietary recommendations were made but could not ensure they were carried out, and a CNA stated that staff should observe and sit with the resident to encourage eating, especially given her weight loss history.
Failure to Ensure Proper Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents who were self-administering medications had a self-medication administration evaluation and a care plan in place. Additionally, the facility did not have a physician's order for the self-administration of medications for one of the residents. Specifically, one resident was observed with two Fluticasone Propionate Nasal sprays at their bedside and reported self-administering the nasal spray. This resident's self-medication administration evaluation was completed after the observation, and their care plan was initiated earlier but did not include the necessary physician's order at the time of the surveyor's visit. Another resident was observed with three bottles of supplements on their over-the-bed table. This resident's self-medication administration evaluation was completed on the same day as the observation, and their care plan was initiated earlier but revised later. The physician's orders for the supplements were also dated the same day as the observation. The Director of Nursing confirmed that an assessment, physician's order, and care plan should be completed before a resident is allowed to self-administer medication, which was not adhered to in these cases.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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