Elmhurst Extended Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Elmhurst, Illinois.
- Location
- 200 East Lake Street, Elmhurst, Illinois 60126
- CMS Provider Number
- 145111
- Inspections on file
- 23
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Elmhurst Extended Care Center during CMS and state inspections, most recent first.
The facility failed to provide adequate hygiene and grooming assistance to several dependent residents. One resident with significant physical impairments was repeatedly observed with long, dirty fingernails, crusted eyes, and overgrown facial hair and expressed a desire for nail and beard care. Another resident with Parkinson’s disease was seen on multiple occasions in the dining room wearing the same dirty, stained clothing, with long dirty fingernails and unkempt facial hair, and reported being unable to perform his own grooming. A cognitively impaired resident requiring maximum ADL assistance was observed for hours in soiled pants and with overgrown facial hair. A resident with dementia and malnutrition was repeatedly seen in bed with extremely oily hair and heavy dandruff flakes on his shirt; a CNA reported not seeing this resident showered in three months, while an LPN stated the resident often refused showers, and bathing documentation was largely incomplete despite a care plan indicating the need for assistance. The DON stated staff are expected to provide grooming, nail care, facial hair care, and clean clothing, and to individualize and document care for bathing and grooming refusals.
A resident with dementia, depression, anxiety, anorexia, and protein-calorie malnutrition repeatedly refused bathing and meals, yet the facility failed to include individualized interventions for these refusals in the care plan. Over several observations, the resident was noted to have extremely oily hair and heavy dandruff, with CNAs and an LPN reporting consistent shower refusals and bathing documentation showing mostly missing entries and only two recorded refusals. The resident frequently left meals untouched, with CNAs removing trays after minimal intake without offering alternatives or providing cueing or prompting, despite documented underweight status, high malnutrition risk, and increased nutritional needs. Facility leadership and policies stated that refusals of bathing, grooming, and meals should be addressed with personalized, resident-specific care plan interventions, but such interventions were absent for this resident.
The facility did not provide required written documentation, including bed hold notices and involuntary discharge notifications, to residents or their representatives during transfers or discharges. Multiple staff members, including the DON, LPNs, and RNs, indicated confusion about who was responsible for issuing these documents, resulting in residents and families not receiving information about their rights or the facility's policies.
A resident with a history of hip issues experienced a change in condition after a shower transfer, resulting in a hip dislocation. The CNA did not immediately notify the nurse, leading to a delay in care. The resident was eventually sent to the hospital after the oncoming nurse discovered the issue. The facility's policy requires notification of changes, but lacks specific time frames.
A resident developed unstageable pressure injuries on both heels due to the facility's failure to identify and manage the wounds. Despite orders for heel protectors, they were not consistently used, and necessary wound assessments and interventions were delayed. The resident's care plan lacked documentation of pressure injuries and interventions, contrary to the facility's policy.
A resident with severe cognitive impairment and multiple diagnoses experienced a 5.87% weight loss in one week, which was not promptly addressed by the facility. The resident's physician and dietician were not notified in a timely manner, and the care plan lacked interventions for the weight loss. The dietician was informed 10 days to 2 weeks later and ordered supplements, but the resident initially refused them. The facility's policy for communication between the nurse and dietician was not followed.
The facility failed to store kitchen utensils properly and ensure appropriate glove use, risking cross-contamination for all 33 residents. A cook was observed not changing gloves between tasks and handling utensils stored haphazardly, which was confirmed by staff as not meeting infection control standards. The administrator admitted there was no specific policy for utensil storage and cross-contamination prevention.
The facility lacked policies for enhanced barrier precautions and legionella management, affecting infection control. Residents with medical devices like gastrostomy tubes and urinary catheters were not under proper precautions, and staff were observed without PPE. The facility's water treatment policy did not address legionella, potentially impacting all residents.
The facility failed to maintain the kitchen freezer in a safe condition, affecting all 33 residents. The freezer and refrigerator door handles were broken, preventing proper sealing, and there was significant ice buildup inside the freezer. The maintenance staff and administrator were unaware of these issues, and the facility's Equipment and Maintenance policy was not followed.
Two residents were not treated with dignity in a LTC facility. One resident, with severe cognitive impairment, was placed over a trash can during incontinence care instead of being toileted properly. Another resident, also with severe cognitive impairment, had his meal tray withheld, causing him to express hunger and thirst. The DON acknowledged these actions as dignity concerns.
Two residents with cognitive impairments were restrained by having their wheelchair wheels locked, preventing independent movement. Staff members, including a CNA and an LPN, locked the wheels to keep the residents in one place, despite their attempts to move. The DON confirmed this action as a restraint, which is against facility policy unless medically necessary.
A resident with Alzheimer's and dementia was left in a saturated incontinence brief for an extended period, as observed by a surveyor. The CNA admitted the resident had not been checked since the morning, contrary to the facility's policy requiring checks every two hours. The DON emphasized the importance of regular checks to prevent infections.
The facility failed to ensure safe transfers for a resident with severe cognitive and lower extremity impairments by not using a gait belt, leading to potential injury. Additionally, a resident with dysphagia was left unsupervised during meals, despite being on aspiration precautions, which violated facility policy.
A facility failed to label oxygen tubing for a resident with chronic respiratory conditions, as required by policy. The resident's oxygen tubing and humidifier were observed without labels on two occasions, and the MAR did not document the change schedule. The DON and an RN confirmed the policy of weekly changes and labeling, but the care plan lacked specific interventions for tubing changes.
A resident with severe cognitive impairment and multiple diagnoses was inappropriately administered Seroquel on a PRN basis for behaviors such as resistance to assistance and refusal to follow commands. The facility failed to document the use of non-pharmacological interventions prior to administering the medication, and the Director of Nursing confirmed that the medication was used for staff convenience, contrary to the facility's policy.
A facility failed to properly store a Pneumovax 23 vaccine for a resident, as it was found unrefrigerated in a medication cart. The vaccine, received on a previous date, was supposed to be refrigerated but was instead stored in a bag labeled 'Refrigerate.' An RN confirmed the vaccine was no longer viable, and the DON explained it was kept in the cart while the resident was out for surgery. The facility's policy requires medications to be stored according to manufacturer recommendations.
A resident with a DNR order was found unresponsive, and the facility staff initiated CPR, failing to honor the resident's end-of-life wishes. The staff was unsure of the resident's code status, and CPR was performed until the DNR status was confirmed. The facility's policy on maintaining and referring to advance directives was not followed.
A resident with hydrocephalus and dementia fell from a wheelchair, but the incident was not properly documented or assessed by the LPN. The facility's fall management protocols, which require immediate assessment, documentation, and notification, were not followed.
The facility failed to safely position a resident during care, resulting in a fall and injuries, and did not properly document or communicate another resident's transfer status, leading to unsafe conditions. The lack of policies on bed mobility and positioning contributed to these deficiencies.
A resident with multiple health issues was transferred to the hospital after a fall, but the facility failed to notify the resident's physician and family. The DON confirmed that the assigned Agency RN did not document the incident or notify the necessary parties, contrary to facility policy. The physician was unaware of the fall and hospital transfer, and the family expressed concerns about the lack of notification and medical attention.
A resident with severe cognitive impairment and multiple medical conditions was found with significant bruising, which was not reported to the State Survey Agency as required by the facility's policy. The DON and staff were aware of the bruises, but the injury was not communicated to the abuse coordinator or reported, leading to a deficiency.
A resident was not readmitted to the facility after hospitalization, despite the facility's bed-hold policy allowing for such a return. The resident's daughter took her to the hospital due to unresolved symptoms, and the facility later refused readmission, citing the resident's complexity and the daughter's complaints. The facility failed to notify the attending physician and did not adhere to their own policies regarding family concerns and Medicaid residents' rights.
A resident with dementia was sexually abused by another resident with a known history of inappropriate sexual behavior and wandering. The facility failed to implement a care plan or take adequate action despite staff reports of the resident's behavior, leading to an immediate jeopardy situation.
A facility failed to thoroughly investigate an abuse allegation involving two residents in the Dementia unit. Despite video evidence provided by a resident's family, the administrator did not review the footage or notify necessary authorities. The accused resident had a history of inappropriate behavior, but the facility lacked a care plan to address these issues. Staff reports of inappropriate behavior were not adequately documented or addressed, leading to a deficiency in handling the abuse allegation.
Failure to Provide Hygiene and Grooming Assistance for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate hygiene and grooming assistance to multiple residents who required help with activities of daily living (ADLs). One resident with hemiplegia, hemiparesis, and muscle wasting, who was alert and oriented and required extensive to total assistance with ADLs, was repeatedly observed in bed with long, dirty fingernails containing brown/black material underneath, overgrown and unkempt facial hair, and crusty eyes. This resident stated he wanted someone to clip his nails and trim his facial hair. Another alert and oriented resident with Parkinson’s disease and gait abnormalities was observed in the dining room on consecutive days wearing the same dirty, stained clothing, with crumbs on his clothes, long dirty fingernails with dark material underneath, and unkempt overgrown facial hair. He reported that it would be nice if staff would clip his nails and trim his facial hair and later stated he could not perform this grooming himself and needed staff assistance. A CNA confirmed that this resident’s condition had declined and he now required assistance with grooming and hygiene. A third resident with vascular dementia, severe cognitive impairment, and a need for maximum assistance with ADLs was observed in group activities and later in a hallway wearing soiled pants stained with an unidentified substance and with overgrown facial hair/whiskers on the chin, with no change in clothing noted over several hours. A fourth resident with dementia, protein calorie malnutrition, depression, anxiety disorder, and anorexia was observed lying in bed on two separate days with extremely oily hair and a thick layer of white flakes, identified by a CNA as likely dandruff, on the front of his shirt. The CNA reported she had not seen this resident showered during her three months of employment. An LPN stated this resident consistently refused showers, while point-of-care bathing records over nearly a month showed missing documentation for most days and only two refusals, despite a care plan indicating the resident needed supervision or touching assistance for bathing. The DON stated that staff are expected to provide grooming and hygiene, including nail care, facial hair care, and ensuring clean clothing, and that personalized care plan interventions and documentation of refusals should be in place for bathing and grooming, which were not evident in these cases.
Failure to Care Plan for Resident’s Refusal of Personal Care and Meals
Penalty
Summary
Surveyors identified a failure to develop and implement care plan interventions for a male resident with dementia, protein calorie malnutrition, depression, anxiety disorder, and anorexia who was admitted on 10/21/2024 and was known to refuse personal care and meals. On multiple observations in early January 2026, the resident was found lying in bed wearing a gown, with extremely oily hair and a thick layer of white flakes on the front of his shirt, which a CNA identified as likely dandruff. A CNA reported she had not seen the resident shower during her three months of employment, and an LPN stated the resident consistently refused showers. Review of point-of-care bathing documentation from 12/10/2025 to 01/06/2026 showed missing bathing information on most days and only two refusals documented. Despite this pattern, the resident’s current care plan did not include any interventions addressing refusal of bathing or showering. The resident was also observed repeatedly refusing or minimally consuming meals. On one occasion, he did not eat his lunch and stated he might eat later, but his tray was removed with most of the meal untouched, and the CNA did not offer alternative choices, explaining that he was a picky eater with a poor appetite and usually asked if he wanted something different. On another observation, the resident ate only a piece of bread and declined the rest of a full meal; his tray was again removed by a CNA without offering alternative foods or providing cueing or prompting, with the CNA stating he did not eat much and mainly drank fluids. The resident’s nutritional risk assessment documented that he was underweight with increased nutritional needs and would benefit from gradual weight gain, and the dietitian’s notes indicated he was at high risk for malnutrition, averaging 50–75% meal intake with 25% of the time less than 50% intake. Nonetheless, his care plan did not include interventions for refusing meals, despite facility leadership acknowledging that refusals of bathing, grooming, and meals should be care planned with personalized interventions, as required by the facility’s Care Planning Policy.
Failure to Provide Required Written Transfer/Discharge Documentation
Penalty
Summary
The facility failed to provide written documentation of transfer or discharge, including required bed hold notices and involuntary discharge notifications, for four residents who were transferred or discharged from the facility. In each case, the residents or their representatives did not receive the necessary written information regarding their rights, the facility's bed hold policy, or the reasons for non-admittance, as required by facility policy and federal regulations. Staff interviews revealed a lack of clarity regarding responsibility for providing these documents, with nursing staff, the DON, and social services each indicating it was not their role to issue the notices. One resident with multiple diagnoses, including dementia and chronic kidney disease, was transferred to the hospital due to behavioral issues and was not allowed to return to the facility. The resident's family member expressed that she did not want the resident discharged and would have preferred he remain at the facility while awaiting placement elsewhere. Both the DON and CEO confirmed that no involuntary discharge notice, judiciary petition, or bed hold notification was provided, citing lack of awareness or misunderstanding of the requirements. Other residents were transferred to the hospital for medical reasons such as lethargy, wound care, and complications related to chronic conditions. In each instance, staff provided paramedics with medical documents but did not issue written bed hold notices to the residents or their representatives. Staff interviews consistently indicated that the responsibility for providing these notices was unclear, and the facility was unable to produce any documentation showing that the required notifications had been given.
Failure to Notify Nurse of Resident's Change in Condition
Penalty
Summary
The facility staff failed to immediately notify the nurse when a resident experienced a change in condition and could no longer stand or bear weight on her leg after a transfer. This delay in care and treatment resulted in a hip dislocation for the resident. The incident occurred when the resident was being transferred after a shower, and the CNA did not inform the nurse of the resident's inability to stand, assuming it was a common complaint from residents who did not want to stand. The resident, who had a history of left femur fracture, joint replacement surgery, and dislocation of the left hip prosthesis, among other conditions, was in pain and had a misaligned leg after the incident. The CNA did not report the change in condition to the oncoming nurse, who later discovered the issue while passing medication. The nurse then assessed the resident, noted the misalignment and swelling, and contacted the physician for further instructions. The resident was eventually sent to the hospital after a delay in obtaining an X-ray. The facility's policy on patient change of condition requires the charge nurse to notify the attending physician and responsible family member of any sudden changes, but it does not specify time frames for notification. The delay in notifying the nurse and subsequent delay in treatment were acknowledged by the facility's staff, including the Administrator, Nurse Practitioner, and Director of Nursing, who all stated that the CNA should have reported the change in condition immediately.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to identify and manage pressure injuries for a resident, leading to the development of two unstageable pressure injuries on the resident's heels. The resident, a female admitted post-surgery for a right distal femur fracture, initially showed no skin lesions upon admission. However, observations revealed that the resident's feet were often left uncovered and in a dependent position, which contributed to the development of pressure injuries. The facility did not conduct timely wound assessments or implement necessary interventions such as offloading to prevent the progression of the pressure injuries. Despite having orders for heel protectors, these were not consistently applied, and the resident's medical records lacked documentation of wound assessments prior to the physician's evaluation. The wound doctor identified the pressure injuries as unstageable due to necrosis, and the facility's records showed a delay in initiating treatment orders for the left heel. The facility's policy required a care plan to be developed for residents with skin integrity issues, but the resident's care plan did not include any mention of pressure injuries or interventions to offload pressure. The Director of Nursing acknowledged that an initial wound assessment should have been conducted by the primary nurse, and the lack of documentation and intervention could lead to complications such as infection or sepsis.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to identify and address a significant weight loss in a resident, resulting in a 5.87% weight loss over one week. The resident, who has severe cognitive impairment and multiple diagnoses including hydrocephalus, hypertension, mood disorder, dementia with behaviors, and major depressive disorder, experienced this weight loss without timely notification to the physician or dietician. The resident's weight log indicated a drop from 167 lbs to 157.2 lbs within a week, yet the facility's records showed no immediate action or notification to relevant healthcare professionals. The care plan for the resident did not include interventions related to the significant weight loss, and the dietician was not informed of the weight loss until 10 days to 2 weeks later. The dietician noted that supplements were ordered once the weight loss was identified, but the resident initially refused them. The Director of Nursing acknowledged the oversight and emphasized the importance of early identification of weight loss to improve the chances of recovery. The facility's policy required communication between the nurse and dietician for residents with weight loss trends, but this protocol was not followed in this case.
Improper Kitchen Utensil Storage and Glove Use
Penalty
Summary
The facility failed to ensure proper storage and handling of kitchen utensils, as well as appropriate glove use, which could lead to cross-contamination affecting all 33 residents. During an observation, a cook was seen checking the temperature of various food items without changing gloves between tasks, including touching kitchen counters and rummaging through a drawer of utensils. The utensils were stored haphazardly, with scoops, ladles, and spatulas facing different directions, which was confirmed by kitchen staff as not adhering to infection control standards. The facility's administrator acknowledged the absence of a specific policy for the storage of kitchen utensils and prevention of cross-contamination. The existing Sanitation and Infection Control policy required kitchen and storage areas to be neat and orderly but did not provide guidance on how utensils should be stored to prevent cross-contamination. This lack of policy and improper handling practices were identified as deficiencies during the survey.
Lack of Infection Control Policies in LTC Facility
Penalty
Summary
The facility failed to implement an infection prevention and control program, specifically lacking policies and procedures for enhanced barrier precautions and a water management plan for legionella. During the survey, it was observed that the facility did not have signs indicating enhanced barrier precautions on the doors of residents with specific medical conditions such as gastrostomy tubes, urinary catheters, and neutropenia. Staff were seen entering and exiting these rooms without wearing personal protective equipment (PPE), and there was no PPE available near the rooms. The Director of Nursing admitted to being unaware of enhanced barrier precautions until the day before the survey, and the facility lacked a protocol for these precautions. Additionally, the facility did not have a legionella policy or water management plan, despite having a water treatment system in place. The Administrator and Director of Nursing confirmed the absence of a legionella-specific policy, which could potentially affect all 33 residents in the facility. The facility's existing water treatment policy did not address legionella, focusing instead on the processes of water purification through reverse osmosis and other methods.
Failure to Maintain Kitchen Freezer in Safe Condition
Penalty
Summary
The facility failed to maintain the kitchen freezer in a safe operating condition, affecting all 33 residents. During an inspection, it was observed that the walk-in refrigerator and freezer door handles were broken and did not latch properly, preventing the doors from sealing tightly. This issue was noted by the kitchen staff, who were unsure when the handles broke, possibly over the weekend when maintenance was unavailable. Additionally, a panel of the plastic curtain at the freezer entrance was missing, and there was significant ice buildup inside the freezer, including a large icicle hanging from the ceiling. The thermometer inside the freezer was missing, and the cook recorded temperatures from an external thermometer. The kitchen staff were unaware of the missing thermometer and the reason for the freezer intermittently shutting off. The maintenance staff, who had only been employed for a month, were unaware of the maintenance logs and had not been informed of the freezer's issues until the day before the inspection. The administrator also claimed to be unaware of the freezer problems, including the broken handles and ice buildup. The facility's Equipment and Maintenance policy requires the food service director to instruct dietary employees on equipment use and care, order repairs, and maintain records, but these procedures were not followed, leading to the deficiency.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to treat two residents with dignity, as observed in two separate incidents. The first incident involved a resident with severe cognitive impairment and multiple diagnoses, including dementia and bipolar disorder. During incontinence care, two CNAs placed a trash can under the resident while she was in a standing mechanical lift, instead of providing proper toileting assistance. This action was acknowledged by one of the CNAs as a dignity concern, and the Director of Nursing confirmed that such practice was unacceptable and degrading. The second incident involved another resident with severe cognitive impairment and diagnoses such as dementia and dysphagia. The resident's meal tray was initially placed out of reach, and when he attempted to drink water, a staff member removed it and delayed his meal, stating it was easier to feed him later. The resident expressed hunger and thirst, even attempting to drink from a paper towel roll. The Director of Nursing stated that residents should be encouraged to be as independent as possible and that the delay in providing the meal was a dignity concern.
Failure to Ensure Residents are Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that two residents, identified as R27 and R26, were free from physical restraints. R27, who has severe cognitive impairment and is a fall risk, was repeatedly observed with his wheelchair wheels locked by staff members, preventing him from moving independently. Despite R27's attempts to move his wheelchair, staff members, including a CNA and an LPN, locked his wheels to keep him in one place, citing his unpredictable behavior and the need to monitor him. This action was taken without considering R27's inability to comprehend or unlock the wheelchair himself, effectively restraining him. Similarly, R26, who has mild cognitive impairment and was unable to be interviewed due to cognitive issues, was also observed with his wheelchair wheels locked, restricting his movement. R26 attempted to move his wheelchair multiple times but was unable to do so due to the locked wheels. Staff members acknowledged that R26's wheels were locked to prevent him from moving around the unit, despite his expressed desire to move. The Director of Nursing confirmed that holding residents in a position where they cannot move independently constitutes a restraint, which is against the facility's policy unless required for medical treatment.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to a resident diagnosed with Alzheimer's disease, lack of coordination, altered mental status, dementia with behaviors, and cognitive communication deficit. The resident was noted to be always incontinent of bladder according to the facility assessment. During an observation, a surveyor found the resident's pants appeared wet, and upon further inspection, it was discovered that the resident's incontinence brief was saturated with urine, and the wheelchair seat was also wet. The Certified Nursing Assistant (CNA) responsible for the resident admitted that the resident had been toileted earlier in the morning but had not been checked since then, resulting in the resident sitting in urine for an extended period. The Director of Nursing (DON) stated that all residents should be checked and changed every two hours and as needed, especially those who cannot communicate their needs, like the resident in question. The facility's policy on incontinence and catheter management requires that residents who are incontinent receive appropriate treatment and services to prevent urinary tract infections and restore normal bladder function. The failure to adhere to this policy and the lack of timely incontinence care for the resident increased the risk of infection, as noted by the DON.
Failure to Ensure Safe Transfers and Supervision During Mealtimes
Penalty
Summary
The facility failed to ensure the safe transfer of a resident, identified as R16, who has severe cognitive impairment, lower extremity impairment, and requires substantial assistance with transfers. On October 8, 2024, a Certified Nursing Assistant (CNA), V18, attempted to transfer R16 without using a gait belt, which is against the facility's policy. During the transfer, R16 expressed pain and discomfort, yelling that her knee hurt and that she couldn't stand. Despite this, V18 continued to lift R16 under her arms and used his back to support her, which could have resulted in injury to both the resident and the staff member. The Director of Nursing confirmed that a gait belt should have been used to ensure safety during the transfer. Additionally, the facility failed to provide adequate supervision during mealtimes for a resident, identified as R28, who has a diagnosis of dysphagia and is on aspiration precautions. On multiple occasions, R28 was observed alone in his room with his meal tray, without any staff present to monitor him. The facility's policy requires that residents on aspiration precautions be supervised during meals to prevent aspiration. Despite this, R28's care plan did not include any interventions for aspiration precautions, and staff were not familiar with his eating habits. The Director of Nursing acknowledged that R28 should have been observed while eating, especially given his refusal to comply with dietary recommendations and speech therapy referrals.
Failure to Label Oxygen Tubing
Penalty
Summary
The facility failed to label oxygen tubing for a resident, identified as R31, who was receiving oxygen therapy. R31's medical conditions included chronic obstructive pulmonary disease, chronic respiratory failure, and chronic congestive heart failure, with a physician's order for oxygen via nasal cannula if oxygen saturations fell below 90%. On two separate observations, the oxygen tubing and humidifier for R31 were found without labels indicating when they were last changed. The Director of Nursing and a Registered Nurse confirmed that the facility's policy required oxygen tubing and humidifiers to be changed weekly and labeled with the change date. However, the Medication Administration Record for R31 did not document any date or time for changing the oxygen tubing, and the care plan lacked interventions regarding the frequency of tubing changes.
Inappropriate Use of Psychotropic Medication for Resident
Penalty
Summary
The facility failed to ensure that a resident's psychotropic medication was used appropriately to treat a medical condition. The resident, who has diagnoses including hydrocephalus, hypertension, mood disorder, dementia with behaviors, and major depressive disorder, was administered Seroquel 50mg on a PRN basis on multiple occasions. The medication was given on 7/28/24, 7/30/24, and 7/31/24, in response to the resident's resistance to assistance and refusal to follow commands, such as getting out of bed or standing up for toileting. These actions were taken without documented use of non-pharmacological interventions prior to administering the medication. The Director of Nursing acknowledged that antipsychotic medications should only be given when residents are in danger of harming themselves or others, and not for staff convenience. The facility's policy on psychotropic medication clearly states that such medications should not be used for discipline or staff convenience and must be required to treat the resident's symptoms. The administration of Seroquel in this case was deemed inappropriate as it was used for staff convenience without attempting alternative approaches, as evidenced by the lack of documentation of non-pharmacological interventions.
Improper Storage of Pneumovax 23 Vaccine
Penalty
Summary
The facility failed to ensure proper storage of a vaccine for a resident, identified as R87, who was reviewed for medication storage. During an observation on the first floor, west medication cart, a Pneumovax 23 syringe intended for R87 was found in the top drawer. The syringe, which was received on 9/7/24, was supposed to be refrigerated but was instead stored in a medication bottle inside a clear bag labeled 'Refrigerate.' V11, an RN, confirmed that the vaccine was no longer viable as it had not been refrigerated. V2, the DON, explained that R87 was out for surgery, and the medications were kept in the cart in anticipation of the resident's return. The facility's policy on medication storage, dated 1/4/24, mandates that medications and biologicals be stored according to manufacturer or pharmacy recommendations to maintain their integrity and ensure safe administration. R87's physician orders, dated 10/10/24, included the Pneumovax 23 injectable. The resident's face sheet, also dated 10/10/24, listed several diagnoses, including acute kidney failure, atherosclerotic heart disease, atrial fibrillation, type 2 diabetes mellitus, hyperlipidemia, hypertension, chronic kidney disease, coronary artery dissection, heart failure, aortic valve stenosis, and anemia.
Failure to Honor Resident's DNR Order
Penalty
Summary
The facility failed to honor a resident's Do Not Resuscitate (DNR) order, resulting in improper nursing care. The resident, who had multiple serious health conditions including sepsis, multiple sclerosis, and a stage IV pressure injury, was found unresponsive. Despite having a documented DNR order, the nursing staff initiated cardiopulmonary resuscitation (CPR) and called a code blue. The registered nurse on duty was unsure of the resident's code status and did not document the CPR in the resident's chart. CPR was performed for one to two minutes before the staff realized the resident was a DNR, at which point the nurse checked the electronic medical record to confirm the DNR status. The certified nursing assistant present during the incident confirmed that CPR was continued until paramedics arrived, and the facility did not follow the resident's or her family's wishes. The Director of Nursing, who was not present during the incident, acknowledged the importance of adhering to residents' advanced directives. The facility's policy requires maintaining advance directives in the medical record and referring to them throughout the resident's stay. However, in this case, the policy was not followed, leading to the failure to respect the resident's end-of-life wishes.
Failure to Document and Assess Resident After Fall
Penalty
Summary
The facility failed to ensure proper assessment and documentation following a fall incident involving a resident with hydrocephalus, dementia, and major depressive disorder. The resident, who was at high risk for falls, experienced a fall from his wheelchair, which was witnessed by a CNA. The CNA reported the incident to an LPN, who checked the resident and found no injuries but decided not to document the incident or conduct a full assessment. The Director of Nursing later confirmed that no incident report was filled out, and no neurological checks or assessments were documented in the resident's medical record. The facility's policy on fall management requires immediate assessment, documentation, and notification of relevant parties following a fall. However, these procedures were not followed in this case. The LPN did not complete an incident report or update the resident's medical record with the necessary observations and assessments. Additionally, the resident's doctor and Power of Attorney were not informed, and no post-fall monitoring was conducted, which is contrary to the facility's established protocols.
Deficiencies in Resident Safety and Transfer Procedures
Penalty
Summary
The facility failed to safely position and supervise a resident (R1) during incontinence care, leading to a fall and subsequent injuries. R1, who was cognitively intact but dependent on staff for bed mobility, was left unsupervised by a CNA during care, resulting in a fall from the bed. The CNA then improperly assisted R1 back to bed without a nurse's assessment. R1 sustained multiple rib fractures and other injuries, necessitating hospital transfer. The facility lacked specific policies on bed mobility and positioning, contributing to this incident. Another resident (R2), who was severely cognitively impaired and dependent on staff for transfers, was not properly supported in his wheelchair, leading to unsafe leaning and bruising. R2's transfer status was not documented in the care plan or facility's transfer status list, causing inconsistency in transfer methods. Staff were unsure of R2's transfer requirements, leading to varied assistance levels, contrary to the recommendation for a total mechanical lift with two-person assistance. The facility's failure to document and communicate R2's transfer status and ensure proper wheelchair positioning contributed to the resident's unsafe conditions. The lack of policies regarding bed mobility and positioning further exacerbated these deficiencies, as staff were not guided on how to safely manage residents' mobility and transfer needs.
Failure to Notify Physician and Family After Resident's Fall
Penalty
Summary
The facility failed to notify a resident's physician and representative after the resident experienced a change in condition that required hospitalization following a fall. The resident, who had multiple diagnoses including chronic obstructive pulmonary disease, dementia, and osteoporosis, was transferred to the hospital after her daughter called emergency paramedics due to the resident's complaints of generalized pain. The Director of Nursing (DON) confirmed that the Agency Registered Nurse (RN) assigned to the resident did not document the fall incident or the hospital transfer, nor did they notify the resident's physician and representative. The physician confirmed that he was not informed of the resident's fall and subsequent hospital transfer, expressing that he expects to be notified of such changes in condition to determine the need for further evaluation. The facility's policy mandates that nursing staff notify physicians of acute changes in a resident's condition, including falls. The resident's hospital records indicated that the family was concerned about the lack of notification and medical attention following the fall, prompting them to call 911.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to adhere to its policy for reporting abuse in the case of a resident with an injury of unknown origin. The resident, who was severely cognitively impaired and dependent on staff for assistance with transfers and ADLs, was found to have significant bruising on the right inner arm and right lateral torso, extending across the anterior chest area. The bruises were noted by a CNA and an RN, who reported them to the physician and the Director of Nursing (DON). Despite the absence of any reported falls or incidents, the facility did not report the injury to the State Survey Agency as required by their policy. The resident's daughter was informed of the bruises but did not receive an update on the investigation's findings. The DON acknowledged being aware of the bruises and having conducted an internal assessment, but was unaware of the requirement to report the injury to the State Survey Agency. The facility's administrator, who serves as the abuse coordinator, was also unaware of the injury and confirmed that it was not reported. The facility's policy mandates immediate reporting of such incidents, but this protocol was not followed, resulting in a deficiency.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to readmit a resident after hospitalization, which was a violation of their bed-hold policy. The resident, a female with intact cognition, was initially admitted to the facility and later experienced symptoms of nausea, vomiting, and abdominal pain. Despite these symptoms, the facility did not adequately address the resident's condition, leading her daughter, who held power of attorney, to take her to a hospital against medical advice (AMA). The facility did not provide any documentation or inform the daughter that the resident could not return. The Director of Nursing later informed the daughter over the phone that the resident could not be readmitted due to the complexity of her condition and the daughter's complaints. The facility's records showed a lack of communication with the resident's attending physician regarding the transfer to the hospital. The attending physician stated that they were not contacted and would have supported the transfer if informed. The facility's policy required notifying the physician in cases of family concerns, which was not followed. Additionally, the facility's bed-hold policy allowed Medicaid residents the right to return to the first available bed after a hospital transfer, which was not honored in this case. The facility's failure to adhere to these policies and procedures resulted in the resident not being readmitted after her hospitalization.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident with dementia from sexual abuse by another resident, who also had dementia and a known history of sexual behaviors and wandering into other residents' rooms. This incident occurred when the second resident entered the first resident's room during the night and sexually assaulted her. The first resident was unable to give consent due to her cognitive impairment, and the facility's failure to prevent this interaction resulted in an immediate jeopardy situation. The facility's records and interviews revealed that the second resident had a documented history of wandering and inappropriate sexual behavior, which was known to the staff. Despite this, there was no care plan in place to address these behaviors, and the interventions that were documented were not implemented. Staff members had reported the second resident's inappropriate behavior during personal care and other interactions, but the facility did not take adequate action to address these reports or prevent further incidents. The incident was discovered when the first resident's family, who had installed a camera in her room, observed the second resident entering the room and engaging in inappropriate behavior. The family reported the incident to the facility and the police, leading to an investigation. The facility's policies on abuse prevention and reporting were not effectively implemented, contributing to the failure to protect the resident from abuse.
Removal Plan
- Facility wide abuse in-service. Information included to recognize and report sexual behaviors and that Dementia residents are at high risk for abuse as they are unable to communicate or give consent.
- A skin check was conducted on each resident on Dementia floor by staff, with attention directed specifically at potential areas on bodies, most vulnerable for abuse.
- A three questions survey was conducted with each resident of the Dementia floor, to rule out additional occurrences and responses entered in resident charts with notification of V1 and V2 of any additional findings.
- Abuse prevention questionnaire implemented to be completed by staff upon admission, quarterly and as needed.
- Nightly hallway security implemented. Nursing staff to ensure one person is always sitting in the hallway monitoring resident's movements.
- Continued screening of background checks with denial of potential abusers.
- Families of Dementia residents contacted for wellness checks and no additional concerns or reports of suspected abuse provided by families.
- Quality Assurance to be completed by Director of Nursing.
- Emergency Quality Assurance conducted with Medical Director and interdisciplinary staff to discuss implementation of abatement plan.
Inadequate Investigation of Abuse Allegation in Dementia Unit
Penalty
Summary
The facility failed to conduct a complete and thorough investigation of an allegation of sexual abuse involving two residents in the Dementia unit. The incident was reported by the family of one resident, who claimed that another resident had touched their family member during the night shift. Despite the family providing video evidence of the incident, the facility's administrator did not review the footage and concluded the investigation without corroborating the allegation. The administrator also failed to notify the local State Ombudsman, Adult Protective Services, or the police, relying on the family's report to law enforcement instead. The facility's investigation was inadequate, as it did not include comprehensive interviews or statements from staff who had previously reported inappropriate behavior by the accused resident. The accused resident had a documented history of wandering and inappropriate behavior, yet the facility did not have a care plan addressing these issues. Staff members had reported incidents of inappropriate behavior by the resident, but these reports were not adequately addressed or documented in the investigation. The facility's policies and procedures for preventing and investigating abuse were not followed. The administrator did not notify the necessary authorities as required by the facility's policies. Additionally, the facility failed to implement care plans for residents with behaviors that could lead to conflict or abuse, as outlined in their abuse prevention policy. This lack of adherence to policy and thorough investigation procedures contributed to the deficiency in handling the abuse allegation.
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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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