Foster Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 2840 West Foster Avenue, Chicago, Illinois 60625
- CMS Provider Number
- 146167
- Inspections on file
- 31
- Latest survey
- December 26, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Foster Health & Rehab Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions and intact cognition was verbally abused by an escort during a clinic visit, as witnessed by two clinic staff. The facility failed to provide required abuse prevention training to the escort, did not report the abuse allegation to IDPH within the mandated timeframe, and did not follow its own abuse prevention policy, resulting in a failure to protect the resident's rights.
A resident with significant mobility and medical needs was placed in a wheelchair that was too small and unstable for transport, resulting in a fall and prolonged distress. The facility did not follow its own incident reporting and investigation policy, failed to document the event, and did not reassess the resident or ensure proper wheelchair fit, as confirmed by staff interviews and record review.
A resident with cerebral palsy and other neurological conditions began experiencing new, severe spastic movements, representing a change from baseline. Despite this, the care plan was not updated to include new interventions or address the exacerbation until it was identified during survey review.
A resident with visual impairment experienced repeated hair-pulling by another resident, leading to feelings of fear and unsafety. Despite documentation of these incidents, the facility staff failed to report them promptly and did not implement adequate measures to prevent further abuse. The care plans lacked interventions to address the aggressive behavior, and the facility's abuse policy was not effectively enforced.
A resident with visual impairment reported repeated hair-pulling by another resident, which was not immediately reported or investigated by the facility staff as required by their abuse policy. Despite documentation of the incidents, the facility administrator and a registered nurse failed to report the abuse to the Department of Public Health within the mandated timeframe, highlighting a deficiency in the facility's adherence to its abuse policy.
A resident with visual impairment reported repeated hair-pulling incidents by another resident, leading to feelings of unsafety. Despite the facility's abuse policy requiring immediate reporting and investigation, staff failed to report and investigate the incidents promptly. The facility lacked a designated abuse coordinator during weekends, contributing to the delay in addressing the issue.
A resident with visual impairment and mental health diagnoses experienced repeated aggression from another resident, including hair-pulling and room intrusion, causing fear and distress. Despite documentation of these incidents, the facility failed to update care plans or implement safety measures, violating their Behavioral Assessment policy. The administration acknowledged the issue but did not take timely action to protect the affected resident.
The facility failed to properly label, date, and store food items, adhere to FIFO guidelines, and ensure kitchen staff wore appropriate hair coverings. Several opened food items lacked proper labeling, and dry storage items were not organized according to FIFO. The dietary manager acknowledged these lapses, and the registered dietitian highlighted the risk of serving expired food. Additionally, a cook was observed without a beard protector, violating the facility's policy on hair coverings.
The facility failed to implement proper infection control measures, including the absence of Enhanced Barrier Precautions signage for two residents with wounds, lack of annual review of infection control policies, and inadequate measures to prevent Legionella growth. Additionally, improper linen handling was observed, with staff failing to follow hand hygiene protocols, potentially leading to the spread of bacteria.
The facility failed to complete comprehensive MDS assessments within regulatory timeframes for 13 residents. An LPN acknowledged the failure to adhere to RAI guidelines, which require timely completion of admission and annual MDS assessments. This systemic issue in the assessment process could impact resident care quality.
The facility failed to complete MDS assessments within the required timeframes, potentially affecting 13 residents. The MDS/Care Plan coordinator, an LPN, acknowledged the late completion of assessments, citing personal illness as a contributing factor. This deficiency involved not adhering to CMS RAI guidelines, which require quarterly MDS assessments to be completed no later than 14 days after the ARD.
The facility did not ensure that MDS assessments for seven residents were certified by an RN, as required. Instead, an LPN signed off on these assessments, which are essential for evaluating residents' ADLs, cognitive function, and other health indicators.
The facility failed to develop comprehensive care plans for residents, missing crucial details such as code status and medication use. Several residents, including those with severe cognitive impairment and on psychotropic medications, lacked care plans addressing their needs. Additionally, a resident reported not receiving anticonvulsant medication, with no care plan in place for its use. This deficiency violates the facility's policy requiring person-centered care plans developed by the interdisciplinary team.
The facility failed to secure the emergency crash cart, leaving it unlocked and accessible in a hallway. The cart contained IV kits, needles, and other medical supplies, posing a safety risk to 19 ambulatory residents. The DON acknowledged the lack of a functional lock and the ongoing process to obtain a new one, while the facility's policy requires the cart to be locked at all times.
The facility failed to conduct monthly medication regimen reviews for residents on psychotropic medications. The DON confirmed that MRRs should be done monthly by a pharmacist, but no documentation was available for several residents. This included a resident with multiple diagnoses on medications like Fluoxetine and Valproic Acid. The facility's policy on psychotropic drugs was not followed, and the policy itself was not provided when requested.
The facility failed to label multi-dose inhalers with opened dates for four residents and stored expired Famotidine in the medication cart. The inhalers, including Breo, Incruse, Advair, and Fluticasone Furoate, lacked opened dates, violating the facility's medication storage policy. Additionally, expired Famotidine was found in the cart, contrary to the policy requiring disposal by expiration.
The facility failed to provide therapeutic diets as prescribed by physicians for several residents, leading to discrepancies between prescribed and served diets. A resident on a No Concentrated Sweets diet received a mechanical soft diet, while another on a renal diet was served regular meals. Additionally, there were inconsistencies in liquid consistencies served to residents requiring specific textures. These issues arose from poor communication and documentation between nursing and dietary departments.
A resident with multiple health issues and a high fall risk was found without a call light within reach, despite facility policies and care plans requiring it. The call light was on the roommate's side, with a string too short to reach the resident. Staff confirmed the deficiency, highlighting the importance of call light accessibility for resident safety.
A facility failed to accurately document a resident's advance directives, leading to a discrepancy between the resident's POLST form indicating DNR status and facility records showing FULL CODE. The resident, with severely impaired cognition, had no care plan for advance directives, and the POLST form was missing from the nursing station binder. Staff interviews revealed the importance of consistent documentation to respect resident preferences, highlighting a lapse in maintaining accurate records.
The facility failed to conduct required Level 2 PASARR screenings for two residents with mental and intellectual disabilities. One resident, admitted with bipolar disorder, lacked documentation for a Level 2 PASARR evaluation, while another resident's record showed no PASARR documentation despite multiple diagnoses. The facility relied on hospital staff for PASARR checks, contrary to their policy requiring screenings prior to admission.
The facility experienced a 14.29% medication error rate due to several incidents involving three residents. A nurse was unable to administer prescribed insulin to a resident due to its unavailability. Another resident did not receive a prescribed nasal spray, and a third resident missed a dose of anticonvulsant medication and received an incorrect dose of Aspirin. The DON emphasized adherence to the 6 Rs of medication administration and physician orders.
Two residents in an LTC facility experienced significant medication errors due to unavailable medications. A resident with diabetes did not receive their prescribed insulin, and another resident with a history of seizures did not receive their anticonvulsant medication for four days. The facility's Director of Nursing acknowledged the importance of administering medications as per physician orders.
The facility failed to provide menu variety for residents on pureed diets, as kitchen staff did not follow recipes or production sheets, leading to repeated meals of mashed potatoes and applesauce. The dietary manager and cooks admitted to not pureeing certain foods, resulting in a lack of variety. The registered dietitian confirmed that the menus were designed for nutritional adequacy and variety, which was not achieved for residents with specific medical conditions requiring pureed diets.
A resident's personal refrigerator contained unlabeled and spoiled food items, including turkey bologna with a sour smell and discolored hotdogs. The resident, who has multiple medical conditions, was unaware of the need to label and date food items. The Dietary Manager and Registered Dietitian acknowledged the importance of labeling to prevent consumption of expired items, as per facility policy.
A resident with moderate cognitive impairment was physically assaulted by another resident during a meal in the dining room. The aggressive resident, who also had cognitive impairments and a history of behavioral issues, threw milk at the other resident's head after being told not to take food from another's tray. Staff intervened promptly, separating the residents and conducting an assessment, with no visible injuries noted.
A resident with severe cognitive impairment alleged ongoing physical abuse by staff, which was not investigated or reported by the facility. The DON dismissed the claims due to the resident's dementia, and the Administrator was unaware of the allegations until later. The facility's incident reports lacked documentation of the abuse allegation, violating their Abuse Prevention Program.
Failure to Protect Resident from Verbal Abuse and Report Allegation
Penalty
Summary
A facility failed to protect a resident from verbal abuse by a staff member, did not provide required abuse prevention training to the alleged perpetrator, and did not report an allegation of abuse to the Illinois Department of Public Health (IDPH) within the required timeframe. The incident involved a resident with multiple diagnoses, including hyperlipidemia, type 2 diabetes, repeated falls, anxiety disorder, dysphagia, major depressive disorder, spinal stenosis, pain, fibromyalgia, morbid obesity, and generalized anxiety disorder. The resident was cognitively intact, as indicated by a BIMS score of 15, and had a care plan specifying the need for a safe environment and protection from mistreatment. During a medical clinic visit, the resident's escort was reported by two clinic staff members to have verbally abused the resident by telling him to "shut the f_ _k up" after a brief exchange regarding appointment wait times. The resident became quiet and appeared sad following the incident. The clinic manager reported the incident to the facility, but the office manager and administrator did not believe the allegation and did not report it to IDPH as required by facility policy. The administrator later acknowledged not being aware of the abuse allegation at the time and admitted that the escort's abuse training documentation could not be located. Interviews revealed that the escort did not recall receiving abuse training and was unaware of the abuse coordinator. Facility policy required immediate reporting of abuse allegations and documentation of abuse prevention training for all employees. The lack of timely reporting, failure to provide or document abuse training, and the staff's disbelief of the allegation contributed to the facility's failure to protect the resident's rights and comply with abuse prevention protocols.
Failure to Assess Wheelchair Sizing and Follow Incident Reporting Policy
Penalty
Summary
A resident with multiple complex medical conditions, including morbid obesity, repeated falls, and non-ambulatory status, was not properly assessed for appropriate wheelchair sizing. The resident was transferred to a smaller, unstable wheelchair to accommodate transportation van limitations, despite the resident's usual need for a larger, more supportive wheelchair. The smaller wheelchair was reported to be broken and unable to safely support the resident, resulting in the resident falling and remaining on the floor of the van for an extended period. Multiple staff interviews confirmed that the wheelchair used was not suitable for the resident's size and needs, and that the resident expressed discomfort and dissatisfaction with the substitute wheelchair. The facility failed to follow its own Accident Incident/Fall Reporting Policy after the incident. There was no immediate assessment documented upon the resident's return, no incident report completed, and no evidence of a thorough investigation or root cause analysis as required by policy. The Director of Nursing acknowledged that risk management procedures were not followed, and that the incident was not properly documented or communicated to the necessary parties, including the resident's physician and family. Additionally, there was no documentation of a 72-hour post-incident assessment or neuro-checks as outlined in facility policy. Staff interviews revealed a lack of clear procedures for wheelchair assessment and documentation. The restorative nurse stated that while residents are measured for wheelchair suitability, there is no formal documentation of wheelchair size or reassessment following incidents. The absence of a documented process for ensuring proper wheelchair fit contributed to the use of an inappropriate wheelchair, which directly led to the resident's fall and subsequent complications during transport.
Failure to Update Care Plan Following Exacerbation of Neurological Symptoms
Penalty
Summary
The facility failed to update the care plan for a resident experiencing an exacerbation of neurological symptoms. The resident, who had a history of cerebral palsy, metabolic encephalopathy, and reduced mobility, began exhibiting new and severe spastic movements of the upper and lower extremities. These symptoms represented a significant change from the resident's baseline condition, as confirmed by the Director of Nursing, who noted that the resident had not previously displayed such jerking movements. Despite the onset of these new symptoms and the implementation of 1:1 supervision, the resident's care plan was not promptly revised to address the change in condition or to include new interventions specific to the exacerbation. Record review showed that the resident's care plan, initially created to address musculoskeletal alterations related to cerebral palsy, had not been updated with new interventions until the day of the survey. The facility's policy requires that care plans be revised as information about the resident and their condition changes, and that all identified problem areas be incorporated into the care plan. However, the care plan for this resident did not reflect the recent changes in neurological status or the need for additional interventions until after the deficiency was identified by surveyors.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from mental and physical abuse, as evidenced by repeated incidents involving another resident. The affected resident, who has visual impairment and intact cognition, reported multiple instances of hair-pulling by another resident, which caused her to feel unsafe and fearful. Despite the resident's complaints and the documentation of these incidents in behavioral notes, the facility did not take adequate measures to prevent further abuse or address the resident's concerns. The facility's staff, including the administrator and registered nurse, were aware of the incidents but failed to report them in a timely manner as required by the facility's abuse policy. The registered nurse documented the incidents but did not inform her supervisor, and the administrator only became aware of the situation after being informed by the resident. The facility lacked a designated abuse coordinator during weekends, which contributed to the delay in addressing the abuse. Additionally, the care plans for both residents involved did not address the aggressive behavior or provide interventions to prevent further abuse. The Director of Social Services did not document the incidents in the psychosocial notes and failed to recognize the resident's expressed feelings of unsafety. The facility's abuse policy emphasizes the importance of preventing mistreatment and ensuring resident security, but these measures were not effectively implemented in this case.
Failure to Report and Investigate Resident Abuse
Penalty
Summary
The facility failed to adhere to its abuse policy by not reporting incidents or allegations of abuse involving a resident, R1, who experienced repeated hair-pulling by another resident, R2. R1, who is visually impaired and has intact cognition, reported feeling unsafe due to R2's actions, which included multiple instances of hair-pulling and unauthorized entry into R1's room. Despite R1's complaints and the documentation of these incidents in behavioral notes, the facility did not take immediate action to report or investigate the abuse as required by their policy. On December 15, 2024, R1 reported to the facility's administrator, V1, that R2 had pulled her hair again, an incident that was also documented by a registered nurse, V6. However, V6 failed to report the incident to her supervisor, citing forgetfulness, and V1 did not report the incident to the Department of Public Health within the required timeframe. The facility's abuse policy mandates immediate reporting of such incidents, but this protocol was not followed, leading to a delay in addressing the abuse. R2, who has a history of restlessness, agitation, and cognitive impairment, was observed to require constant redirection by staff. Despite this, the facility did not have a designated abuse coordinator during weekends, and V1 only became aware of the incident after R1 personally informed her. The lack of immediate reporting and investigation of the abuse incidents involving R1 and R2 highlights a significant deficiency in the facility's adherence to its abuse policy.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to adhere to its abuse policy by not investigating incidents and allegations of abuse involving a resident, R1, who experienced hair-pulling by another resident, R2. R1, who has visual impairment and other medical conditions, reported feeling unsafe due to repeated incidents of hair-pulling by R2. Despite R1's intact cognition, as indicated by a BIMS score of 15, the facility did not take timely action to address her concerns. R1 expressed fear for her safety, especially after R2 entered her room uninvited, and mentioned that other residents had also experienced aggression from R2. The facility's staff, including V6, a Registered Nurse, and V1, the Administrator, failed to report and investigate the incidents promptly. V6 documented the incident but did not report it to her supervisor, citing forgetfulness. V1, upon learning of the incident from R1, did not file a reportable incident due to the delay in reporting, despite acknowledging that the incident constituted abuse. The facility lacked a designated abuse coordinator during weekends, which contributed to the delay in addressing the incident. The facility's abuse policy mandates immediate reporting and investigation of abuse allegations, with a final investigation to be completed within five working days. However, the facility did not follow these procedures, as evidenced by the lack of immediate reporting and investigation of the incidents involving R1 and R2. The policy also requires the appointment of an investigator and a thorough review of documentation, which was not conducted in this case.
Failure to Address Aggressive Behavior in LTC Facility
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, identified as R1, who expressed fear and anguish due to repeated aggressive behavior from another resident, R2. R1, who has a diagnosis of visual impairment, anoxic brain damage, bipolar disorder, and depression, reported multiple incidents where R2 pulled her hair and entered her room uninvited, causing her to feel unsafe. Despite R1's intact cognition, as indicated by a BIMS score of 15, the facility did not address these incidents in R1's care plan or provide adequate interventions to prevent further occurrences. R2, who has a diagnosis of restlessness, agitation, schizophrenia, bipolar disorder, and major depressive disorder, exhibited physically aggressive behavior towards R1 and other residents, R3 and R4. R2's behavior was documented in behavioral notes, yet the facility staff, including the Director of Social Services, failed to incorporate these incidents into the care plans of the affected residents. The facility's policy on Behavioral Assessment, Intervention, and Monitoring was not followed, as the interdisciplinary team did not evaluate the severity of R2's behavior or implement safety strategies to protect R1 and others from harm. The facility's administration, including the Administrator and Director of Nursing, acknowledged the impact of R2's behavior on R1's mental well-being but did not take timely action to address the situation. The Administrator was unaware of the incidents until informed by surveyors, and the Director of Social Services did not document R1's expressed feelings of unsafety in psychosocial notes. This lack of communication and failure to update care plans contributed to the ongoing risk and distress experienced by R1 and other residents.
Deficiencies in Food Safety and Staff Hygiene Practices
Penalty
Summary
The facility failed to ensure proper labeling, dating, and storage of food items, as well as adherence to First In, First Out (FIFO) guidelines, and appropriate use of hair coverings by kitchen staff. During an inspection, it was observed that several opened food items in the walk-in refrigerator were not labeled with opened or use-by dates, including barbeque marinade, Italian dressing, honey mustard dressing, soy sauce, mayonnaise, and pickle chips. Additionally, some items in the dry storage room, such as cans of beans and bins of various dry goods, were not labeled with delivery dates or organized according to FIFO guidelines. The dietary manager, V13, acknowledged the importance of labeling and dating to prevent food-borne illnesses but admitted that some items were not labeled because they were used frequently. However, this practice contradicts the facility's policy, which requires all foods to be properly dated and labeled. Furthermore, the facility's registered dietitian, V6, emphasized the risk of serving expired food, which could lead to bacterial overgrowth and potential food-borne illnesses. Additionally, the facility failed to ensure that kitchen staff wore appropriate hair coverings. V15, a cook, was observed in the kitchen without a beard protector, despite having facial hair. V13 confirmed that hair and beard restraints should be worn at all times in the kitchen to prevent contamination. The facility's policy mandates that all kitchen staff wear hair coverings, including beard protectors, to maintain food safety standards.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, as evidenced by several deficiencies observed during the survey. Two residents with active wounds did not have Enhanced Barrier Precautions (EBP) signage posted outside their rooms, which is necessary to alert staff to wear the appropriate Personal Protective Equipment (PPE) before providing care. This oversight was confirmed by both a Registered Nurse and the Director of Nursing/Infection Preventionist, who acknowledged the potential for infection transmission due to the absence of signage. Additionally, the facility did not conduct an annual review of its infection control policy and procedures, as the provided policy was undated, and the last documented review was over a year ago. The facility also failed to implement measures to prevent the growth of Legionella and other waterborne pathogens, with the last check for Legionella being conducted over a year prior. The Maintenance Director was unable to provide documentation of current measures in place. Furthermore, improper handling of linen was observed, with a Laundry/Housekeeping Aide handling clean gowns with contaminated hands and wearing dirty gloves in the hallway, which could lead to the spread of bacteria. The facility's policies on hand hygiene and linen handling were not adhered to, as confirmed by the Director of Nursing/Infection Preventionist.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the regulatory timeframes for 13 out of 26 residents reviewed. These assessments are crucial for evaluating the needs and care plans of residents. The deficiencies were identified through interviews and record reviews, revealing that the assessments were not completed within the required timeframes as specified by the Centers for Medicare & Medicaid Services (CMS) Resident Assessment Instrument (RAI) process. For instance, one resident's annual MDS assessment was completed over a month late, while another's admission MDS assessment was completed more than two months after the assessment reference date (ARD). The Licensed Practical Nurse (LPN) MDS/Care Plan Coordinator acknowledged the failure to adhere to the RAI guidelines, which require that admission MDS assessments be completed no later than the 14th calendar day of a resident's admission, and annual MDS assessments be completed within 14 days from the ARD. The report highlights multiple instances where these timeframes were not met, indicating a systemic issue in the facility's assessment process. This failure to complete timely assessments could potentially impact the quality of care provided to the residents.
Failure to Complete MDS Assessments Within Regulatory Timeframes
Penalty
Summary
The facility failed to complete Minimum Data Set (MDS) assessments within the regulatory timeframes as specified by the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) guidelines. This deficiency potentially affected 13 out of 26 residents reviewed for resident assessment. The MDS assessments are crucial for determining residents' activities of daily living, cognitive function, urinary/bowel function, current diagnosis, medication use, skilled therapy, and any falls. The RAI guidelines require that quarterly MDS assessments be completed no later than 14 days after the Assessment Reference Date (ARD). However, the facility did not adhere to these guidelines, resulting in late completion dates for several residents' assessments. During the survey, it was found that the MDS/Care Plan coordinator, an LPN, acknowledged the late completion of MDS assessments. For instance, one resident's quarterly MDS ARD was on July 24, 2024, but the assessment was completed on September 19, 2024, which should have been completed by August 7, 2024. Another resident's quarterly MDS ARD was on August 21, 2024, but the assessment was completed on September 30, 2024, which should have been completed by September 4, 2024. The LPN attributed the delays to personal illness, which may have contributed to not locking the assessments within the required timeframe. This failure to complete assessments on time could potentially affect the care provided to the residents.
Failure to Ensure RN Certification of MDS Assessments
Penalty
Summary
The facility failed to ensure that each Minimum Data Set (MDS) assessment was certified as complete by a registered nurse (RN) for seven residents out of 26 reviewed. The assessments for these residents were instead signed by an LPN, identified as V17, who has been working in the facility for two years as the MDS/Care Plan coordinator. The MDS assessments are crucial for determining residents' activities of daily living, cognitive function, urinary/bowel function, current diagnosis, medication use, skilled therapy, and any falls. The State Operations Manual requires that each resident's assessment be coordinated by and certified as complete by an RN, which was not adhered to in these cases.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for residents, which is a violation of their policy. This deficiency was identified during interviews and record reviews, where it was found that care plans were missing for several residents regarding their code status and medication use. For instance, one resident with severe cognitive impairment had no care plan addressing their full code status, while another resident with intact cognition had no care plan for their DNR status. Additionally, a resident with intact cognition and multiple diagnoses, including heart disease and diabetes, also lacked a care plan for their full code status. Another resident with moderate cognitive impairment and on psychotropic medications had no care plan for their medication use or code status. Furthermore, a resident with a history of seizures and anoxic brain damage reported not receiving their anticonvulsant medication for four days, and it was confirmed that there was no care plan addressing their anticonvulsant medication use. The facility's policy mandates that care plans should be developed by the interdisciplinary team in conjunction with the resident and their family, and should include measurable objectives and timetables to meet the resident's needs. However, the facility failed to adhere to this policy, as evidenced by the lack of care plans for the residents reviewed.
Unlocked Crash Cart Poses Safety Hazard
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the security of emergency supplies in the crash cart, which was observed to be unlocked and accessible in the hallway near the front lobby and nurses' station. The unlocked crash cart contained items such as intravenous (IV) line kits, needles of various sizes, oxygen tubing, and IV fluid bags. This oversight was identified during an observation on the morning of October 8, 2024. Interviews with two registered nurses revealed that the night shift nurse is responsible for checking the crash cart, and both nurses acknowledged that the cart should be locked but were unaware of how long it had been unlocked. They also recognized the potential safety risk if residents accessed the needles. The Director of Nursing (DON) confirmed that the crash cart should be locked when not in use, but admitted that the facility currently lacks a functional lock for it. The DON mentioned that a temporary lock was attempted but failed, and the Assistant Administrator is in the process of ordering a new lock. The facility's policy mandates that the crash cart be locked at all times to ensure supplies are available during emergencies and checked daily to verify the lock's integrity. The deficiency potentially affects 19 ambulatory residents who could access the cart's contents, posing a safety hazard.
Failure to Conduct Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to perform monthly medication regimen reviews (MRR) for four residents who were on psychotropic medications. The Director of Nursing (DON) acknowledged that the MRR should be conducted monthly by a licensed pharmacist to assess the effectiveness, adverse reactions, and safety of the medications. However, the facility was unable to provide any MRR documentation for the residents in question, including one resident with multiple diagnoses such as Bipolar disorder, Major depressive disorder, and Anoxic brain damage. This resident was on medications like Fluoxetine and Valproic Acid, yet the only MRR available was dated several months prior. The surveyor's review of the electronic health records for the other residents revealed that no MRRs were documented for their psychotropic medications, despite active orders for drugs like Alprazolam, Haloperidol, and Paroxetine. The facility's policy on psychotropic drugs, which mandates medication reviews upon admission, was not adhered to, and the facility could not provide the policy when requested. The DON, who started working at the facility recently, confirmed the importance of MRRs for ensuring medication safety and effectiveness but admitted that the reviews had not been conducted as required.
Medication Labeling and Expiration Management Deficiency
Penalty
Summary
The facility failed to properly label and manage medications, specifically multi-dose inhalers and expired medications, for four residents. During an inspection of the medication cart, it was observed that inhalers for four residents were not labeled with the date they were opened. These inhalers included Breo, Incruse, Advair, and Fluticasone Furoate, each of which has specific discard timelines after opening to ensure medication potency and safety. The absence of opened dates on these inhalers indicates a failure to adhere to the facility's policy on medication storage and labeling, which requires such information to be documented. Additionally, the inspection revealed a bottle of house stock Famotidine with an expiration date that had already passed, yet it was still stored in the medication cart. The Director of Nursing confirmed that all medications, including over-the-counter ones, should be discarded by their expiration date and should not be stored or administered past this date. This oversight in medication management and labeling practices highlights a deficiency in the facility's adherence to its own policies and accepted professional principles for medication handling.
Failure to Provide Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to provide therapeutic diets as prescribed by the physician for five residents, leading to discrepancies between the prescribed diets and what was actually served. For instance, Resident R10 was prescribed a No Concentrated Sweets (NCS) diet with pureed texture and thin liquids, but was observed receiving a mechanical soft diet with solid food items. The Dietary Manager, V13, admitted to receiving verbal changes from nursing staff without proper documentation, leading to incorrect diet cards being used. Resident R25, who was supposed to be on a renal diet due to a history of dialysis, was served a regular diet without dietary restrictions. The kitchen staff continued to serve meals based on outdated meal tickets, despite verbal communication that the renal diet was discontinued. However, the Registered Dietitian, V6, emphasized that diet orders should be followed as prescribed by the physician, and any changes should be documented and communicated properly. Additionally, Resident R5, who required nectar thickened liquids, was served thin liquids, while Resident R15, who required thin liquids, was served thickened liquids. These inconsistencies were due to a lack of communication and documentation between the nursing and dietary departments. The facility's policies on diet orders and tray pass were not adhered to, resulting in potential risks to the residents' health and safety.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for a resident, identified as R12, who was part of a sample of 14 residents reviewed for call light accessibility. On multiple occasions, R12 was observed lying in bed without the call light within reach, despite a yellow sign above the bed indicating fall precautions, which included having the call light accessible. The call light was found on the roommate's side of the privacy curtain, with a string too short to reach R12's side. Both a Certified Nursing Assistant (V12) and a Registered Nurse (V5) confirmed the call light was out of reach and acknowledged the need for it to be accessible for the resident's safety. R12 has several diagnoses, including Chronic Obstructive Pulmonary Disease, Hyperlipidemia, Alcohol Abuse, Gastro-Esophageal Reflux Disease, Unspecified Psychosis, Major Depressive Disorder, and Conversional Disorder with Seizures or Convulsions. The resident's Minimum Data Set (MDS) indicated severely impaired cognition and a high fall risk. The care plan for R12 included ensuring the call light was within reach due to the risk of falls related to gait and balance problems. The facility's policies on call lights and fall prevention also emphasized the importance of having the call light accessible to residents at all times.
Discrepancy in Advance Directives Documentation
Penalty
Summary
The facility failed to accurately document the advance directives code status for a resident, identified as R12, which led to a discrepancy between the resident's documented wishes and the information available to the nursing staff. R12, who has a severely impaired cognition with a BIMS score of 06 out of 15, was admitted with multiple diagnoses including Chronic Obstructive Pulmonary Disease and Major Depressive Disorder. The POLST form signed by R12's surrogate, V10, indicated a Do Not Attempt Resuscitation (DNR) status with selective treatment, while the facility's records, including the face sheet and order summary report, incorrectly documented R12 as FULL CODE. This inconsistency was further compounded by the absence of a care plan for advance directives and/or code status in R12's records. Interviews with facility staff revealed that the code status should be consistent across all documentation to ensure the resident's preferences are respected. However, the Director of Nursing acknowledged the discrepancy and the potential for administering CPR against the resident's wishes due to conflicting information. The POLST form, which should have been accessible in the nursing station's Advance Directives binder, was missing, indicating a lapse in maintaining updated and accurate records. The facility's policy mandates that residents' code status be documented in their electronic health records at admission, but this was not adhered to in R12's case, leading to the deficiency identified by the surveyor.
Failure to Conduct Required PASARR Screenings
Penalty
Summary
The facility failed to adhere to its policies and procedures for the Preadmission Screening and Annual Resident Review (PASARR) process for two residents, R2 and R8, who required a Level 2 PASARR screening for mental disability and intellectual disability. For R2, the Minimum Data Set (MDS) indicated cognitive impairment, and the resident was admitted with a diagnosis of bipolar disorder. However, there was no documentation of a referral to the state-designated authority for a Level 2 PASARR evaluation. The Assistant Administrator, V2, could only provide a Level 1 PASARR screening dated several years prior and confirmed the absence of a Level 2 PASARR for R2. For R8, the admission record showed multiple diagnoses, including bipolar disorder and unspecified dementia, with intact cognition according to the MDS. Despite these conditions, no PASARR documentation was found in R8's health record. V2 stated that the facility relied on the hospital's social worker or discharge planner to check PASARR prior to admission and admitted that the facility did not verify PASARR before admitting residents. Consequently, the facility was unable to provide a PASARR evaluation for R8, which is contrary to their policy requiring screening prior to admission and upon any changes in status.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 14.29% error rate during the survey. This deficiency was observed in the medication administration for three residents. For one resident, a registered nurse was unable to administer the prescribed Fiasp insulin due to its unavailability in the medication cart or convenience box. The nurse documented that the insulin was not administered and was awaiting pharmacy delivery. Another resident did not receive the prescribed Flonase nasal spray during the morning medication pass, as observed by the surveyor. Additionally, a third resident did not receive the ordered dose of Levetiracetam solution, an anticonvulsant medication, because it was unavailable. The resident also received an incorrect dose of Aspirin, receiving 81 mg instead of the ordered 325 mg. The Director of Nursing stated that nurses should follow the 6 Rs of medication administration and adhere to physician orders, as outlined in the facility's Quality Assurance in Medication Administration policy.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors. On one occasion, a registered nurse was unable to administer the prescribed insulin to a resident with Type 2 Diabetes Mellitus due to the unavailability of the medication. The resident's blood glucose level was checked, and it was determined that they required an insulin injection according to the sliding scale order. However, the insulin was not found in the medication cart or convenience box, and the nurse stated that the resident would not receive the insulin until the pharmacy delivered it later that day. In another instance, a registered nurse prepared morning medications for a resident with Anoxic Brain Damage and Cerebral Infarction but was unable to administer the prescribed anticonvulsant medication, Levetiracetam, because it was not available. The resident reported not receiving the medication for four days, which is prescribed for seizure activity. The medication was not signed off on the Medication Administration Record as given, and the nurse confirmed that a follow-up call was made to the pharmacy. The Director of Nursing acknowledged that medications must be administered according to physician orders and highlighted the potential for adverse reactions if high-alert medications like insulin and anticonvulsants are missed.
Failure to Provide Menu Variety for Pureed Diets
Penalty
Summary
The facility failed to provide and follow menus and recipes to ensure menu variety for residents on pureed diets. Observations and interviews revealed that the kitchen staff did not have recipes for pureed diet consistencies and did not follow any production sheets or spreadsheets. The cooks relied on their experience to prepare meals, leading to a lack of variety and consistency in the meals provided to residents on pureed diets. For instance, residents on pureed diets consistently received mashed potatoes at every meal instead of the pureed version of the regular menu items. The dietary manager and cooks admitted that the kitchen did not puree certain foods like spaghetti, rice, and cornbread, and instead substituted these with mashed potatoes. This practice resulted in residents on pureed diets receiving the same foods repeatedly, such as mashed potatoes and applesauce, which did not align with the planned menu. The registered dietitian confirmed that the menus were designed to ensure nutritional adequacy and variety, and that the cooks should follow the menus and recipes to prevent residents from receiving the same foods repeatedly. The report highlighted the cases of three residents with various medical conditions, including Parkinson's Disease, Dementia, and Dysphagia, who required mechanically altered, therapeutic diets. These residents were not receiving the intended variety in their meals, as the kitchen staff did not follow the standardized recipes and cycle menu policies. The lack of adherence to these guidelines raised concerns about the nutritional adequacy and variety of the meals provided to residents on pureed diets.
Failure to Label and Discard Spoiled Food in Resident's Refrigerator
Penalty
Summary
The facility failed to properly label and date food items in a resident's personal refrigerator and did not discard spoiled foods, which could potentially affect the resident's health. During an observation, a surveyor found that the refrigerator contained an opened container of turkey bologna with a sour smell, hotdogs with black spots and a green tint, and an opened container of almond milk without any labeling or dating. The resident, who has several medical conditions including Cachexia, Severe Protein-Calorie Malnutrition, and Type II Diabetes Mellitus, stated that they were unaware of the need to label and date food items and could not reach inside the refrigerator due to a lack of hand strength. The Dietary Manager acknowledged the responsibility to check the resident's personal refrigerators daily for temperature and expired foods but stated it was not their responsibility to date the items. The Registered Dietitian emphasized the importance of labeling and dating food items to prevent residents from consuming expired items, which could make them sick. The facility's policy requires food brought from outside to be labeled and dated, and staff are responsible for checking the resident's personal refrigerators daily for proper labeling and temperature recording.
Resident-to-Resident Physical Altercation in Dining Room
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse, resulting in an incident where one resident became physically aggressive towards another. The incident involved a resident with moderate cognitive impairment and diagnoses including unspecified dementia and chronic obstructive pulmonary disease. During a meal in the dining room, this resident was allegedly hit on the head and had milk thrown in their face by another resident, who also had moderate cognitive impairment and a history of restlessness, agitation, and schizophrenia. The incident was witnessed by staff, who intervened and separated the residents, initiating one-on-one monitoring. A head-to-toe assessment was conducted on the affected resident, and no visible injuries were noted. The medical doctor and family were informed of the incident. Interviews with the involved residents and witnesses revealed that the aggressive resident became upset after being told not to take food from another resident's tray, leading to the physical altercation. Staff members, including a certified nursing assistant and the activity director, confirmed the sequence of events and noted that the aggressive resident had a history of taking items from others and displaying aggressive behavior. The facility's administrator, who is also the abuse coordinator, outlined the expected procedures for handling such incidents, including separating the residents and conducting assessments. The facility's abuse prevention policy emphasizes the residents' right to safety and freedom from abuse, neglect, or exploitation.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to investigate and report an allegation of abuse for a resident with severe cognitive impairment. The resident, who has a history of dementia and other medical conditions, alleged that multiple staff members physically abused her over several months. During a visit to an ophthalmologist, the resident reported the abuse to her escort, who then informed the Director of Nursing (DON). However, the DON dismissed the allegations, attributing them to the resident's dementia and confusion, and did not initiate an investigation or report the incident to the appropriate authorities. The facility's Administrator was unaware of the abuse allegation until the day of the surveyor's visit and acknowledged that the incident was not reported to the Illinois Department of Public Health. The facility's incident reports from June to August 2024 did not include any documentation of the resident's abuse allegation. The facility's Abuse Prevention Program requires that any allegation or suspicion of abuse be documented and investigated, but this protocol was not followed in this case.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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