Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Generations At Applewood during CMS and state inspections, most recent first.
Failure to complete fall assessments, investigations, and neuro checks for a resident with repeated unwitnessed falls. A resident with COPD, DM2, HF, OA, gait impairment, repeated falls, and high fall risk had multiple unwitnessed falls while trying to sit or get out of bed. Staff documented limited interventions such as Norco, a floor mat, and monitoring, but the record lacked fall risk reassessments after some falls, lacked root cause investigations, and lacked required neuro checks after one fall. The resident later presented to the hospital with right leg pain and deformity, and x-ray showed an acute comminuted distal femur fx.
A resident with multiple chronic conditions suffered an unwitnessed fall and developed severe right knee pain that was not relieved by Norco. Staff documented ongoing moaning, severe pain scores, hospice involvement, and later morphine and Ativan use, but the resident continued to have extreme pain and was ultimately transferred to the hospital, where an acute distal femur fracture was found.
A CNA and an RN were responsible for 30 residents on one unit overnight after a CNA call-off, but the CNA left the facility during the shift and did not perform resident checks, changes, or incontinence care for hours. Surveyors observed video showing the CNA leaving and returning multiple times, and interviews confirmed residents were not turned/repositioned or changed every 2 hours as required. One resident was found visibly soiled and wet when morning staff arrived, and the DON acknowledged that incontinence care and turning/repositioning should be provided every 2 hours and as needed.
Failure to Provide Required ADL and Incontinence Care: Staff failed to provide timely incontinence care and turning/repositioning for totally dependent residents who required 2-person assistance. Video and staff interviews showed a CNA leaving the unit during the overnight shift, no checks or changes being done for hours, and a resident later found visibly soiled and wet. The DON acknowledged that residents should receive incontinence care and turning/repositioning every 2 hours and as needed.
A resident had multiple falls, but the restorative nurse could not show that the falls were fully investigated or that the care plan was reviewed and revised after each event as required. Staff could not clearly identify the interventions in place after the falls, and documentation did not show a root cause analysis after each fall. The resident later required hospital transfer and was diagnosed with a right femur fracture.
The facility failed to keep call lights accessible to several residents, contrary to its policy requiring functioning call lights to be within residents’ reach. One resident returning from dialysis was left in a reclining chair and had to shout for help because the call light cord was wedged behind the bed and a floor mat. Other residents lying in bed or seated in wheelchairs either had call light cords dangling from a wheelchair or positioned behind a wheelchair, and each reported not knowing where the call light was. In each case, the call light was not within easy reach of the resident.
A high fall-risk resident with impaired balance, intermittent confusion, and a history of recent falls was found on the floor near the bathroom after sliding while walking in regular socks instead of non-skid socks. The resident’s care plans documented the need for supervised transfers and fall prevention interventions, yet the resident was unsupervised for several hours and not using appropriate footwear. Staff reported the resident was not able to walk and typically self-transferred to a wheelchair and then to the toilet, but the positioning of the wheelchair and bedside table, along with lack of supervision and non-adherence to universal fall precautions outlined in the facility’s fall prevention policy, contributed to the fall and resulting leg injury.
A resident’s assigned call light was found wedged behind the head of the bed between the wall and a folded floor mat, leaving it inaccessible while the resident sat in a reclining chair needing assistance. When the DON provided the resident with this call light and asked the resident to press the button, the hallway light above the door did not activate on two attempts. When the resident was given the call light from the other bed in the room, that call light functioned properly and activated the hallway light. Facility policy required that a functioning call light be placed where it is accessible to the resident, but this was not done for this resident.
Two residents at risk for pressure injury developed multiple facility-acquired pressure ulcers, including a Stage 4 heel ulcer and unstageable coccyx/sacral and ischial wounds, after staff failed to consistently identify, document, and report early skin changes. One resident developed a new rear thigh pressure ulcer that was measured but not staged or fully described, and no physician treatment order or treatment documentation was found for this wound during the stay. For the other resident, staff reported performing weekly head-to-toe skin assessments and CNA skin checks during care, but there were no shower sheets or assessment records showing early skin alterations before the advanced pressure injuries were discovered. The DON acknowledged lapses in reporting by CNAs, and the wound care coordinator confirmed the absence of prior skin alteration documentation, while facility policies required daily/weekly skin checks, Braden risk assessments, prompt wound staging and description, and physician-ordered treatments for all pressure ulcers.
A resident with Multiple Sclerosis and muscle wasting, who was alert and able to communicate needs, fell inside a facility transport vehicle when the CNA driver braked, resulting in a right intertrochanteric femur fracture. The CNA reported that the wheelchair was locked and a seatbelt applied, and that the resident slid to the floor and initially denied pain before being assisted back into the wheelchair and taken to her room. The resident later reported that the wheelchair had not been strapped or properly secured, no seatbelt was used, and that both she and the wheelchair moved and tipped during the abrupt stop, with the chair striking her head. After arrival back at the facility, the CNA transferred the resident to bed despite her complaint of right leg pain, and only then was an RN notified and an assessment performed, which revealed right leg shortening, external rotation, and swelling. This sequence of events shows a failure to ensure proper securement during transport and to follow the facility’s fall management guideline requiring assessment before moving a resident after a fall.
The facility did not report allegations of abuse, neglect, or injuries of unknown origin to the State Survey Agency within the required two-hour timeframe for several residents. Incidents included family and staff reports of bruising, rough care by CNAs, inappropriate touching by a staff member, and a medication error. Although internal investigations were initiated, the mandated reporting deadlines were not met, contrary to the facility's abuse prevention policy.
Four residents identified as at risk for abuse did not have person-centered care plans developed or implemented, despite completed abuse risk assessments indicating care planning was required. Staff interviews revealed confusion over responsibility for initiating these care plans, and documentation was not present in the residents' medical records.
Three residents with pressure ulcers or high risk for skin breakdown did not receive appropriate prevention or treatment interventions. One resident developed a stage 4 knee ulcer without timely treatment or care plan updates, another was on an air mattress set incorrectly for their weight, and a third did not receive a recommended low air loss mattress. Staff interviews and documentation revealed gaps in following pressure ulcer prevention protocols.
A resident admitted on escitalopram for major depressive disorder did not have a documented attempt at gradual dose reduction (GDR) or a clinical contraindication for not attempting GDR, as required by facility policy. The DON confirmed the absence of GDR documentation in the medical record, despite policies mandating GDR attempts for residents on psychotropic medications.
A resident with urinary retention and an indwelling catheter did not have a care plan addressing catheter care, despite observations confirming catheter use and facility policy requiring comprehensive care planning. The ADON confirmed the absence of documentation or interventions related to the catheter.
A resident with hemiplegia and urinary incontinence did not receive timely incontinence care, resulting in prolonged exposure to wet and soiled bedding. The resident reported not being changed since early morning, and staff confirmed delays due to lack of assistance and busy schedules. The DON acknowledged the absence of a formal incontinence policy and stated that care should be provided every two hours or as needed.
A dependent, severely cognitively impaired resident with multiple complex medical conditions developed a large stool ball and was hospitalized for fecal impaction. Facility staff did not consistently monitor or document bowel movements or symptoms of impaction, despite the resident's inability to communicate and a care plan requiring such monitoring. Changes in the resident's condition were noted, but assessment and documentation were lacking.
The facility did not follow physician orders for urinary catheter care for two residents with indwelling catheters. One resident had multiple missed or undocumented catheter care shifts despite an order for care every shift, and also experienced recurrent UTIs with multidrug-resistant organisms. Another resident had a Foley catheter in place but lacked any physician orders for catheter care, size, or changes. Facility policy requires such orders and their implementation, but these were not met.
A resident who sustained a left femur fracture during a transfer did not receive timely follow-up with an orthopedic surgeon due to the facility's failure to arrange appointments, address insurance barriers, and document communication or transportation to appointments.
A resident with a physician order for double meat at lunch was served only one piece of meat, despite both the order sheet and diet card specifying the need for a double portion. The resident, who was alert and oriented, confirmed the discrepancy, and the dietary manager acknowledged that the therapeutic diet order was not followed.
A resident who suffered a left femur fracture during a transfer did not receive the ordered OT and PT services to address pain, mobility, and ADL limitations. Although therapy evaluations and plans of care were completed, no skilled therapy was provided due to issues with insurance authorization, and no further attempts were documented after an insurance change.
A resident was found with a soiled, discolored, and lifting midline IV dressing that had not been changed within the facility's required 5-7 day interval. Staff interviews revealed uncertainty about responsibility and policy adherence, and the dressing was not dated. The facility's policy requires dressings to be changed at specific intervals or when soiled, but this was not followed.
A resident with multiple risk factors for pressure ulcers did not receive timely or documented pressure ulcer prevention and care interventions, including delays in providing a low air loss mattress, missed and undocumented dressing changes, and incomplete daily skin assessments. The sacral wound was not properly identified or documented upon return from the hospital, and the wound progressed to a stage 4 ulcer with infection due to these lapses.
The facility did not follow its controlled substance policy, resulting in multiple instances where hydrocodone doses were signed out for two residents but not documented as administered on the MAR. Despite physician orders for as-needed pain management, the required documentation was missing, and one resident reported not requesting the medication as frequently as recorded. The DON confirmed that controlled substances should be documented after administration, highlighting a lapse in accurate recordkeeping.
A resident with significant weakness and mobility issues fell from bed during incontinence care when a CNA turned away, leaving the resident near the edge. The resident required partial to moderate assistance and was identified as a fall risk, but was not adequately supervised or positioned safely, leading to the fall.
A resident developed a stage 4 pressure ulcer on the sacrum due to the facility's failure to provide adequate care and prevention. Despite having a history of pressure ulcers and orders for weekly skin assessments, the resident's condition worsened without timely intervention. Observations showed the resident was left unchanged and without proper wound dressing, and there was a lack of communication and follow-up by the wound care team, leading to hospitalization for infection treatment and surgical debridement.
Two residents under enhanced barrier precautions were affected by staff's failure to use proper PPE and adhere to hand hygiene protocols. A resident received wound care without staff wearing gowns or performing hand hygiene between glove changes, while another resident received incontinence care without staff wearing gowns. The facility's policies on hand hygiene and enhanced barrier precautions were not followed.
A facility failed to provide adequate hygiene care for a dependent resident with severe cognitive impairment. The resident was found with long, jagged fingernails and actively bleeding scratch marks, indicating a lack of proper grooming. A CNA noted that nails are cut during scheduled showers, but the resident's tendency to scratch herself led to frequent changes of her sheets. The facility's policy requires necessary services to maintain good grooming and hygiene for residents unable to perform activities of daily living independently.
Two residents in a LTC facility did not receive prescribed medications and topical treatments due to unavailability. One resident with severe cognitive impairment and skin conditions missed multiple applications of creams, while another resident with multiple diagnoses missed doses of oral and topical medications. The facility's failure to reorder and ensure medication availability led to these deficiencies.
A resident with severe cognitive impairment and multiple medical conditions received inadequate incontinence care from two CNAs, who failed to spread the resident's legs for proper cleaning, reused the same washcloth, and did not change gloves or perform hand hygiene. The DON expected staff to follow proper procedures to prevent infection, as outlined in the facility's policy.
A resident with significant medical conditions, including a right above-knee amputation, was improperly transferred without a mechanical lift, resulting in a fracture. Despite the resident's request for the lift, a CNA proceeded with a manual transfer, assisted by another CNA unfamiliar with the resident's needs. The facility's policy requiring mechanical lifts for such transfers was not followed, leading to the resident's injury.
The facility failed to provide necessary admissions paperwork, including notice of rights and responsibilities, to three residents upon admission. The admissions packets lacked signatures and dates verifying receipt and agreement. The Admissions Director did not document all attempts to complete the packets, and in some cases, packets were not returned or signed by family members. The facility's policy requires that residents receive an admission agreement at the time of admission, but this was not consistently followed.
The facility failed to implement effective fall prevention measures for three residents, leading to multiple falls and one resident being hospitalized with a femoral fracture. Despite being identified as high fall risks, necessary interventions such as bilateral floor mats and low bed positions were inconsistently applied, contrary to the residents' care plans and the facility's fall prevention policy.
A resident with chronic health conditions did not receive anti-embolism stockings as ordered by the physician, leading to observed swelling in the lower extremities. The RN admitted difficulty in applying the stockings due to the resident's mobility, and the DON acknowledged the need to follow physician orders. The facility's policy on elastic stockings was not adhered to.
A resident with a history of CVA and limited range of motion was not provided with a prescribed hand splint and sling, as per physician orders and care plan interventions. The resident was observed without the splint, and the restorative nurse was unaware of the order, indicating a failure to follow the facility's policy on restorative programming and splint assistance.
The facility failed to serve coffee at a safe temperature, leading to a resident sustaining burns. Another resident rolled out of bed during a linen change due to inadequate supervision, resulting in multiple injuries. Additionally, the facility did not develop adequate fall prevention interventions for a resident with a history of falls and severe cognitive deficits.
The facility failed to provide adequate feeding assistance for two residents with visual deficits, leading to significant unplanned weight loss. One resident lost 8.99% of her weight in one month, while another lost 10.6% over four months. Despite care plans indicating the need for feeding assistance, staff did not regularly provide the necessary support.
The facility failed to follow their hot beverage policy by serving coffee at 145 degrees Fahrenheit and not logging temperatures, resulting in a resident with multiple sclerosis and Alzheimer's disease suffering full-thickness burns after spilling hot coffee on her lap.
The facility failed to notify the family and hospice in a timely manner of a fall incident involving a resident with Dementia and other conditions. The resident was found on the floor in a praying position, and the facility's policy mandates notification of any change in the resident's condition or status.
The facility failed to follow their abuse policy by not investigating or determining how a resident's injury of unknown origin occurred. A resident was found with a bruise on her hand, and despite the policy requiring immediate reporting and investigation, no action was taken.
The facility failed to supervise an impulsive, confused resident with an unsteady gait, resulting in the resident getting into bed with another resident, causing distress. Despite known aggressive behaviors and the need for constant observation, the resident was not adequately monitored, leading to the incident.
Failure to complete fall assessments, investigations, and neuro checks for a resident with repeated unwitnessed falls
Penalty
Summary
The facility failed to follow its fall policy for a resident with a documented high fall risk and repeated unwitnessed falls. The resident was admitted with chronic obstructive pulmonary disease, type II diabetes, heart failure, osteoarthritis of the knee, repeated falls, gait abnormalities, lung cancer, and weakness. Her fall risk evaluation documented that she was high risk for falls, with scores of 13, 16, and 23 on different assessments. The record shows multiple unwitnessed falls, including falls on 2/23/26, 3/8/26, 3/20/26, and 3/28/26. After the fall on 2/23/26, the resident reported she was trying to get into her chair when her ankles gave out and she fell forward. She refused hospital transfer, hospice was contacted, and she was given Norco and repositioned. There was no documentation of a fall risk assessment, new fall intervention, or fall investigation with root cause after this fall. After the fall on 3/8/26, the resident was found sitting on the floor beside her bed, alert and oriented x3, and stated she did not know what happened. She was assisted up by mechanical lift, assessed for injury, and monitored, but there was no documentation of a fall risk assessment, new intervention after she refused a larger floor mat, or fall investigation with root cause. After the fall on 3/20/26, the resident was found sitting on the floor mat beside her bed and was alert and oriented x3. Staff documented that neurological checks were initiated and monitoring increased, but the neurological assessment record did not document responses for several time points, and there was no documentation of a fall investigation with root cause. After the fall on 3/28/26, the resident was found lying on the floor mat adjacent to her bed, moaning, with no footwear and no clothing on. She complained of right knee pain and received Norco. There were no neurological checks documented after this fall, and there was no fall investigation with root cause. The hospital later documented that the resident had a fall two days earlier that had not yet been evaluated and that she had pain and deformity to the right lower extremity; x-ray showed an acute comminuted fracture of the distal femoral metaphysis with posterior displacement and angulation.
Failure to Provide Effective Pain Management After Unwitnessed Fall
Penalty
Summary
The facility failed to provide effective pain management for a resident with multiple chronic conditions, including COPD, type II diabetes, heart failure, osteoarthritis of the knee, repeated falls, gait abnormalities, lung cancer, and weakness, after an unwitnessed fall in the resident’s room. After the fall, staff found the resident lying on the floor mat beside the bed, moaning, and complaining of right knee pain. The resident was returned to bed, assessed, and given Norco for pain, with documentation that range of motion was performed and fall precautions were in place. Following the initial dose of Norco, the resident continued to moan loudly and reported severe right knee pain that was not relieved by the medication. Nursing documentation states the resident declined hospital transfer at that time, and hospice was contacted for reassessment and possible additional pain management or transfer to a higher level of care. Hospice documented severe, constant right knee pain with pain scores up to 9/10, noted that Norco was not helping, and ordered morphine and Ativan stat, with a comfort kit also ordered stat. Facility documentation later showed morphine was administered, but the resident continued to have severe pain, moaning, and restlessness over the next day. The resident’s condition continued to worsen, with notes describing lethargy, minimal responsiveness, nonverbal moaning, and right knee tenderness during care and turning. The NP documented that the resident had been moaning in a lot of pain over the weekend even with Norco, that morphine had been given because Norco was not strong enough, and that hospice had approved an x-ray. The resident was later transferred to the hospital per family request, where imaging showed an acute comminuted fracture of the distal femoral metaphysis with posterior displacement and angulation. The facility’s pain policy required screening, assessment, individualized pain management, reassessment after treatment, and notification of the provider when pain medications were ineffective, but the record shows the resident remained in severe pain after the fall before hospital transfer.
Failure to Provide Required ADL and Incontinence Care
Penalty
Summary
The facility failed to follow its abuse prevention policy by not providing necessary personal care and assistance with ADLs, including incontinence care and turning/repositioning, for residents on one nursing unit. Surveyors observed and reviewed video surveillance from 5/2/26 to 5/3/26 showing a CNA entering the facility late, leaving during the night, returning, and leaving again. The CNA stated she was scheduled for a double shift, that only she and one nurse were present on the unit during the overnight shift because of a CNA call-off, and that she did not perform checks or changes on any resident during the entire overnight shift. She also stated she did not provide incontinence care to residents needing two-person assistance and waited until 7:00 AM to provide care for one resident who was severely contracted. Interviews with other CNAs and the DON confirmed that residents should receive incontinence care and turning/repositioning every two hours and as needed. A day-shift CNA stated that when she arrived, the overnight CNA was providing care to the resident with assistance from another CNA. Another CNA stated that the resident was visibly soiled and wet at the start of the morning shift. The overnight nurse aide also stated she took breaks outside in her vehicle, sometimes fell asleep, and sometimes left the facility to check on her mother. The overnight nurse stated she was unaware the CNA left the facility during the shift and said she answered call lights but did not provide incontinence care, telling residents they would be changed when the assigned CNA returned. Record review showed 30 residents were on the unit during the overnight shift, with two CNAs scheduled but one calling off. The facility assessment stated its typical staffing pattern required 28 CNAs for an average census of 121 residents. The facility’s policies stated that residents unable to perform ADLs independently must receive necessary services for hygiene and personal care, and that residents who cannot assist themselves may be turned every two hours and/or as often as needed. The cited failure affected all 30 residents on the unit during the shift in question.
Failure to Provide Required ADL and Incontinence Care
Penalty
Summary
The facility failed to follow its ADL policy and turning/repositioning protocol by not providing incontinence care and repositioning every two hours and as needed for four totally dependent residents, including R1, R10, R12, and R13, who required two staff for all ADL care. The deficiency was identified through interview and record review and involved the potential to affect all 30 residents on one nursing unit. The facility’s ADL policy stated that residents unable to carry out ADLs independently would receive services necessary to maintain good nutrition, grooming, and personal and oral hygiene, and the turning/repositioning protocol stated that residents who cannot assist themselves may be turned every two hours and/or as often as needed. Video surveillance from the night shift on 5/2/26 into 5/3/26 showed V8 CNA arriving at the facility, entering the building, leaving the facility during the shift, returning later, and leaving again before returning. V8 stated she was scheduled for a double shift and that she and V38 RN were the only staff on the side 3 unit overnight because of a CNA call-off. V8 stated she did not do any checks or changes on any resident during the entire 11:00 PM to 7:00 AM shift and did not provide incontinence care to residents requiring two-person assistance, waiting until 7:00 AM to provide incontinent care for R1, who was described as severely contracted and visibly soiled and wet when later seen by V21 CNA. V14 CNA and V21 CNA both stated that ADL and incontinence care should be provided every two hours and as needed. V38 stated that no incontinence care was provided to any resident during the shift and that residents were told they would be changed when V8 returned.
Failure to Review and Revise Fall Care Plan After Repeated Falls
Penalty
Summary
The facility failed to follow its fall prevention and management policy and failed to review and revise one resident’s care plan after each fall. The resident had multiple falls, and the restorative nurse stated she was responsible for investigating each fall, determining new interventions during the daily morning IDT meeting, and updating the falls care plan after each event. However, when asked about interventions after the resident’s falls, she was unable to identify what was done after the first fall, acknowledged that a larger floor mat was brought in but refused by the resident, and could not verbalize any other intervention that had been implemented. She also stated that after a later fall, a medication review was done because of confusion, and that the nurse practitioner decreased trazodone, but the medication orders reviewed showed trazodone 50 mg had already been discontinued and 25 mg was ordered only as needed. The record also showed an antibiotic was ordered for a UTI, but there was no documentation that a urinalysis was done before the antibiotic was started. The restorative nurse was unable to provide documentation of a root cause analysis after each fall and could not explain what staff she spoke with after each fall, the resident’s predisposing factors, when the resident was last seen, or when pain medication or sedating medication had last been given. The resident was transported to the hospital after the fourth fall and was diagnosed with a right femur fracture. The facility’s fall prevention and management policy required investigation of all circumstances and related outcomes, and required the falls care plan to be reviewed and revised with any fall event.
Failure to Ensure Resident Call Lights Were Accessible
Penalty
Summary
The facility failed to follow its call light policy requiring a functioning call light to be placed where it is accessible to the resident, resulting in multiple residents not having call lights within reach. During observation on 2/13/26 at 9:45 AM, one resident was heard shouting for help from his room and reported being uncomfortable in a reclining chair after returning from dialysis at 5:00 AM and wanting to go back to bed; his call light cord was found by the DON wedged between the wall and a folded floor mat behind the head of the bed, and he stated he could not find it. Later that morning, another resident lying in bed had a call light cord observed dangling on a wheelchair positioned at the side of the bed and stated not knowing where the call light was. A third resident sitting in a wheelchair next to her bed had a call light cord located behind the wheelchair and not within reach, and also stated not knowing where the call light was. A fourth resident sitting in a wheelchair next to her roommate’s bed similarly stated she did not know where her call light cord was, and her call light was observed not to be within reach. These observations and resident interviews showed that four residents did not have accessible call lights as required by the facility’s policy. The deficiency centers on the inaccessibility of call light cords for these residents, as evidenced by their inability to locate or reach the call lights when they needed assistance, and the physical placement of the cords behind furniture or on equipment rather than within the residents’ immediate reach.
Failure to Implement Fall Prevention Measures and Supervision for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to identify, evaluate, and eliminate fall hazards and to provide adequate supervision for a high fall-risk resident. The resident was found lying on his right side on the floor near the bathroom, wearing regular socks instead of non-skid socks. His wheelchair was positioned at the head of the bed with the bedside table in front of it, and he reported that he slid while walking to the bathroom because of the socks he was wearing. A nurse responded to the surveyor’s call for assistance, obtained vital signs, and performed a head-to-toe assessment, identifying an open area on the resident’s right lateral lower leg. Multiple CNAs stated that the resident was not able to walk and that his usual pattern was to self-transfer to his wheelchair, self-propel into the bathroom, and then self-transfer onto the toilet. Record review showed that the resident’s admission fall risk assessment documented a history of falls in the past three months, intermittent confusion, chairbound status, and incontinence. The falls care plan identified the resident as high risk for falls related to gait and balance problems, with interventions including anticipating and meeting his needs. The ADL care plan documented an ADL self-care performance deficit related to impaired balance and specified that transfers required supervision by one staff member to move between surfaces. Despite these identified risks and care plan interventions, the resident was not wearing appropriate non-skid socks and did not receive the supervision required for transfers, as his assigned CNA reported last rounding on him several hours earlier. The facility’s fall prevention and management policy called for universal fall precautions, standardized assessment of fall risk factors, and implementation of a fall risk care plan to address universal precautions and individual risk factors, which were not effectively implemented in this case.
Inaccessible and Nonfunctional Call Light for a Resident
Penalty
Summary
A deficiency occurred when the facility failed to maintain a resident’s bathroom and bedside call light system in good working condition and accessible to the resident. During observation, the resident was seated in a reclining chair next to the bed closest to the door, and the call light cord for that bed was found between the wall and a folded floor mat behind the head of the bed, out of the resident’s reach. When asked if he could use the call light for assistance, the resident stated he could not find it. The DON was called to the room and located the call light cord behind the head of the bed, then handed the call light button to the resident. When the resident pressed the call light button, the hallway light above the door did not activate, and a second attempt also failed. The resident was then given the call light cord from the other bed in the room, and pressing that button successfully activated the hallway light. The facility’s call light policy, reviewed 06/2024, states that a functioning call light will be placed where it is accessible to the resident, but in this instance the resident’s assigned call light was both inaccessible and nonfunctional.
Failure to Prevent and Treat Facility-Acquired Pressure Injuries in At-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to prevent facility-acquired pressure injuries in residents at risk and to initiate appropriate wound treatment once new pressure ulcers were identified. One resident was admitted with multiple wounds and was assessed as being at moderate risk for pressure ulcers using the Braden Scale, with a score of 13. During the stay, this resident developed a new pressure ulcer on the rear left thigh that was documented with measurements but without staging or descriptive details of the wound. The wound nurse later confirmed that the documentation lacked staging and other required descriptors and, based on a photograph, would have staged the wound as unstageable. For this same resident, review of the Treatment Administration Record and Physician Order Sheet with the wound nurse showed that there was no treatment order for the newly acquired rear left thigh pressure ulcer from the date it was first documented until the resident’s discharge. The wound nurse confirmed the absence of any treatment order, and the wound physician stated that it is important to have treatment for a wound as soon as it is identified, although he suggested that lack of an order did not necessarily mean no treatment was given. The facility’s own policies require that residents with pressure ulcers have a physician’s order for treatment, that wounds be described and documented weekly, and that licensed nurses document treatment on the Treatment Administration Record. A second resident, admitted with intact skin and assessed as at risk for pressure injury with Braden scores of 17 on two separate assessments, developed three facility-acquired pressure injuries: a right heel wound initially documented as a diabetic ulcer and later classified as a Stage 4 pressure injury, an unstageable coccyx/sacrum pressure injury, and an unstageable rear left thigh (ischial) pressure injury described as a deep tissue injury. The wound care coordinator stated that CNAs are expected to check skin during care and report changes to nurses, who then refer to the wound care team, but confirmed there was no documentation of skin alterations prior to the identification of these pressure injuries. The wound physician’s notes documented the right heel as a Stage 4 pressure injury with nonviable tissue and necrosis, and the sacrum and left ischium wounds as unstageable due to necrosis or deep tissue injury. Nursing staff reported that weekly head-to-toe skin assessments are performed, often during bathing or changing, and that any redness or skin changes should be promptly reported and documented for the wound care team to provide treatment orders. However, documentation review revealed no shower sheets or assessment records indicating that the second resident’s skin was assessed during showers or care before the wounds were discovered. The DON acknowledged a lapse in reporting skin conditions, stating that CNAs may have assumed nurses were already aware of the wounds and did not notify the wound care team, and agreed that a Stage 4 pressure ulcer could not develop overnight and that earlier signs should have been reported. Facility policies require daily skin checks, weekly documented skin checks, timely risk assessments, individualized care plans, and immediate treatment orders and wound descriptions for residents with pressure ulcers, but these processes were not followed for the residents involved, leading to the development and progression of multiple facility-acquired pressure injuries without timely identification and treatment. The record for the second resident also showed that the right heel pressure injury became infected, with a wound culture positive for ESBL and subsequent IV antibiotic treatments ordered and administered for the infected heel wound. Despite nurse interviews describing routine and thorough skin assessments and prompt reporting expectations, there was no supporting documentation of early skin changes or interventions prior to the development of the Stage 4 and unstageable pressure injuries. The facility’s documented failures included not preventing facility-acquired pressure injuries in residents identified as at risk, not staging and fully describing a newly acquired pressure ulcer, not obtaining or documenting physician treatment orders for a new pressure ulcer, and not documenting or acting on early skin alterations as required by the facility’s pressure ulcer prevention and treatment policies.
Failure to Secure Resident During Transport and Inadequate Post-Fall Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was properly secured while being transported in the facility’s private vehicle and to follow post-fall assessment procedures before moving the resident. The resident had diagnoses including Multiple Sclerosis and muscle wasting and atrophy, was alert and oriented with a BIMS score of 13, and was able to make her needs known. During transport back from a medical appointment, the CNA driver reported that the resident’s wheelchair was locked in place with a seatbelt secured, and that when the CNA applied the brakes at a red light, the resident slid out of the wheelchair onto the floor of the vehicle, landing on her buttocks. The CNA stated the resident denied pain at that time, was assisted back into the wheelchair, and then transported back into the facility. Upon return to the facility, the resident reported right leg pain. The CNA assisted the resident to bed and notified a nurse of the incident and the complaint of pain. The nurse assessed the resident and observed external rotation and shortening of the right lower extremity, as well as swelling from the right hip to the right thigh. The nurse practitioner’s note documented that the resident reported slipping out of her wheelchair and hitting her head, denied headache, but complained of right hip pain, with the right hip appearing shortened and externally rotated and pain elicited with abduction and adduction. Hospital records later indicated the resident sustained a right intertrochanteric femur fracture requiring surgical repair with intramedullary nailing of the right proximal femur. The resident’s account of the incident conflicted with the CNA’s description of safety measures during transport. The resident stated that the CNA abruptly pressed the brake, causing her to fall forward to the vehicle floor, and reported that her wheelchair was not strapped or properly secured and that no seatbelt was applied. She stated she was sure the wheelchair was not secured because as she fell forward, the wheelchair also moved, tipped over, and hit her on the head. The facility’s Clinical Guideline for Falls Management requires that, prior to moving a resident after a fall, staff assess for injury, perform a pain assessment and physical assessment, and activate emergency response as required, particularly for potential head injury. The Director of Nursing stated that the expectation and facility policy for fall incidents is to report the fall and not move the resident without assessment, especially if the resident is complaining of pain. Despite this, after the fall in the vehicle and the resident’s subsequent complaint of pain, the CNA moved and transferred the resident back to bed before a nurse assessment, contributing to the identified deficiency in accident prevention and post-fall response.
Failure to Timely Report Allegations of Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to follow its abuse prevention policy by not notifying the State Survey Agency within the required two-hour timeframe after becoming aware of allegations of abuse, neglect, or injury of unknown origin for six residents. In multiple instances, staff became aware of allegations or observations of potential abuse, such as bruising, rough care, inappropriate touching, and medication errors, but the initial reports to the State Survey Agency were delayed, ranging from over two to more than forty-eight hours after the incidents were known. Documentation and interviews confirmed that staff recognized these events as reportable and initiated internal investigations, but did not meet the mandated reporting timeframe. Specific cases included family members and staff reporting bruising, allegations of rough handling by CNAs, inappropriate contact by a staff member, and a medication error. In each case, the facility's own records and staff interviews confirmed the time the allegation was known and the time the report was sent, showing delays beyond the policy requirement. The facility's abuse prevention policy, revised in October 2022, requires immediate reporting, but not more than two hours after the allegation is known, which was not followed in these cases.
Failure to Develop Abuse Risk Care Plans for At-Risk Residents
Penalty
Summary
The facility failed to develop and implement person-centered care plans for four residents identified as at risk for abuse. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for initiating and updating abuse risk care plans. The social services director stated that social services is responsible for care plans related to behaviors, mood, and cognitive status, but not for abuse risk care plans, and was unaware of who should complete them. The interim DON indicated that nurses are responsible for nursing-related care plans and believed social services should initiate abuse risk care plans, while the social service assistant reported that abuse risk assessments are completed but not followed by specific abuse care plans, with documentation instead placed under other care plan categories. Record review showed that each of the four residents had completed abuse risk assessments indicating they were at risk for abuse or neglect and that care planning was required. The assessments cited reasons such as physical and mental dependence, impaired mobility, lack of safety awareness, non-verbal communication deficits, and cognitive fluctuations. Despite these findings and the explicit notation that care planning was required, none of the residents had an at risk for abuse care plan initiated in their medical records.
Failure to Implement and Document Pressure Ulcer Prevention and Treatment
Penalty
Summary
The facility failed to develop and implement adequate pressure ulcer prevention interventions for three residents with significant risk factors and existing pressure ulcers. For one resident with multiple comorbidities including Alzheimer's Disease, chronic kidney disease, and diabetes, a stage 4 pressure ulcer developed on the left knee while in the facility. Despite documentation of the wound as early as March, there was no treatment ordered or documented for the knee until over a month later, and the care plan did not address the knee ulcer or include specific interventions for the knees. Staff interviews revealed a lack of awareness regarding avoidable/unavoidable risk assessments for pressure ulcers, and documentation of prevention measures was incomplete or missing. Another resident with stage 3 and stage 4 pressure ulcers and functional quadriplegia was found on an air loss mattress set at a weight far above their actual weight, contrary to facility policy and staff training, which requires mattress settings to match the resident's weight for effective pressure ulcer prevention. A third resident, who had a wound doctor’s recommendation and family request for a low air loss mattress, was observed on a regular mattress instead of the prescribed pressure-relieving mattress. Facility policy states that such recommendations must be followed, but this was not done, and the resident did not receive the recommended intervention.
Failure to Attempt Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident receiving a psychotropic medication, specifically escitalopram 10mg daily for major depressive disorder, had a documented attempt at gradual dose reduction (GDR) or a clinical contraindication for not attempting GDR. The resident was admitted on this medication and transferred from another LTC facility, with continued use of the same dosage. Upon review, the DON confirmed there was no documentation in the resident's medical record indicating that a GDR had been attempted for the escitalopram. Facility policy requires that residents on psychotropic drugs receive GDRs and behavioral interventions, with attempts at GDR in two separate quarters within the first year of admission on such medications.
Failure to Develop and Implement Urinary Catheter Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan for a resident who was admitted with a diagnosis of urinary retention and required an indwelling urinary catheter. During the survey, the resident was observed with a urinary catheter in place on multiple occasions, but a review of the resident's care plan revealed no documentation or interventions related to catheter care. The Assistant Director of Nursing confirmed that there was no care plan addressing the urinary catheter and was unable to explain the omission. Facility policy requires a comprehensive, person-centered care plan with measurable objectives and timeframes, including interventions for areas of potential risk, but this was not followed for the resident in question.
Failure to Provide Timely Incontinence Care
Penalty
Summary
A resident with diagnoses of obesity, hemiplegia, and hemiparesis following a cerebral infarction, who was assessed as cognitively intact and always incontinent, did not receive timely incontinence care. On the day in question, the resident was observed with the call light on, reporting that she was wet and had not received incontinence care since 4:00am. The resident's bed sheets were visibly soiled with urine, and there was a strong odor of urine present. The resident expressed feeling bad about not being provided care. The assigned CNA confirmed that she had not provided incontinence care to the resident until late in her shift, citing the need for assistance and staff being busy as reasons for the delay. Both the CNA and another staff member observed that the resident's brief and bed sheets were saturated with urine. The DON stated that the facility did not have an incontinence policy but expected residents to be checked and changed every two hours or as needed.
Failure to Prevent and Monitor Fecal Impaction in Dependent Resident
Penalty
Summary
The facility failed to prevent a dependent resident from developing a large stool ball, resulting in hospitalization for fecal impaction. The resident had multiple diagnoses, including respiratory failure, tracheostomy status, anemia, seizures, hemiplegia, metabolic encephalopathy, and aphasia, and was identified as severely cognitively impaired and dependent on staff for all care. The resident was also frequently incontinent of bowels. Hospital records indicated the presence of a large stool ball in the rectum with mass effect on the bladder, requiring an enema. Facility staff noted changes in the resident's condition, including copious drainage from a sacral wound, increased pitting edema, decreased alertness, and lack of usual responsiveness. Interviews with facility staff revealed that symptoms of impaction, such as decreased bowel movements, discomfort, pressure, or bloating, were not effectively assessed or documented for this resident, who was unable to communicate. The care plan included monitoring and documenting signs of constipation or fecal impaction, but there was no evidence that this was consistently done. The nurse practitioner confirmed that the facility would not have known about the impaction unless daily tracking of bowel movements was performed, which was not documented in this case.
Failure to Provide and Document Physician-Ordered Catheter Care
Penalty
Summary
The facility failed to follow physician orders for providing urinary catheter care every shift for residents with indwelling catheters, as well as failed to obtain and document a diagnosis in the physician's orders for an indwelling catheter. For one resident with a chronic indwelling catheter, there were multiple documented instances across several months where catheter care was not recorded as provided on various shifts. This resident had a history of urinary tract infections, including infections with multidrug-resistant organisms, and received antibiotic treatments as a result. The treatment administration record showed numerous days and shifts with missing documentation of catheter care, despite an active physician order for care every shift. Another resident was admitted with a Foley catheter in place, but there were no physician orders documented regarding catheter care, catheter size, or catheter changes. Facility staff confirmed that such orders should have been present but were unable to locate them. Facility policies require that all medications and treatments, including catheter care, be ordered by a physician and implemented by staff, but these requirements were not met for the residents reviewed.
Failure to Arrange and Document Follow-Up Orthopedic Care
Penalty
Summary
The facility failed to provide medically-related social services to assist a resident in scheduling and attending follow-up appointments with an orthopedic surgeon after the resident sustained a fractured left femur during a transfer from bed to wheelchair. The resident reported wearing a knee immobilizer since the fall and stated that no follow-up appointment with an orthopedic surgeon was made. Documentation in the medical record indicated attempts to schedule an appointment were hindered by the resident's insurance not being accepted by local orthopedic offices. The facility staff noted efforts to contact the local county Health Systems and to schedule a primary care provider appointment to obtain a referral, but there was no documentation confirming that referrals were sent or that the resident was transported to scheduled appointments. Further, the facility was unable to provide documentation of communication with the resident's insurance provider, attempts to schedule appointments, or records confirming that the resident was seen by an orthopedic surgeon. The lack of documentation and follow-through on arranging necessary medical appointments and transportation resulted in the resident not receiving timely follow-up care after a significant injury.
Failure to Provide Physician-Ordered Double Meat Portion at Lunch
Penalty
Summary
The facility failed to follow a physician's prescribed diet order for a resident who required double portions of meat at lunch. The resident's physician order sheet and diet card both specified a regular texture, thin diet with double meat at lunch. However, during observation at lunchtime, the resident was served only one piece of meat instead of the ordered double portion. The resident, who was alert and oriented, confirmed receiving only one piece of meat. The dietary manager later verified that a double portion should have consisted of two pieces of meat and acknowledged that therapeutic diet orders must be followed. The facility's policy also states that therapeutic diets are to be prescribed by the attending physician.
Failure to Provide Ordered Skilled Therapy After Resident Fracture
Penalty
Summary
A resident sustained a left femur fracture after falling during a transfer from bed to wheelchair. Following the fall, the resident experienced significant pain and required a left knee immobilizer. Physician orders were written for both occupational therapy (OT) and physical therapy (PT) evaluations and treatments, specifying the frequency and duration of therapy sessions to address the resident's pain, mobility limitations, and activities of daily living (ADL) needs. The OT and PT plans of care outlined the necessity for skilled therapy to improve the resident's independence, manage pain, and reduce fall risk. Despite these orders and documented clinical needs, there was no evidence in the medical record that the resident received any OT or PT services after the initial evaluations. The rehabilitation director confirmed that therapy had not been provided, citing difficulties in obtaining insurance authorization and a change in the resident's insurance provider. No attempts to secure authorization from the new insurance were documented, resulting in the resident not receiving the required skilled rehabilitative services.
Failure to Timely Change Soiled Central Venous Catheter Dressing
Penalty
Summary
A deficiency occurred when the facility failed to follow its policy regarding the timely changing of a central venous catheter dressing for one resident. The resident was observed with a soiled, discolored, and lifting dressing on a midline IV site, and was unsure how long it had been in place or the cause of the discoloration. Staff interviews revealed confusion about responsibility and policy for dressing changes, with the Infection Preventionist needing to check the policy and the Director of Nursing stating that dressings should be changed weekly or when soiled or not intact. Record review showed the midline was inserted 12 days prior, exceeding the facility's policy of changing dressings every 5 to 7 days or as needed if soiled, wet, or not intact. The dressing was not dated, and staff could not explain why it had not been changed as required. The facility's policy, dated 10/25/14, specifies that central venous catheter dressings must be changed at specific intervals or when soiled, wet, or not intact to prevent infection, but this was not followed for the resident in question.
Failure to Implement and Document Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to implement and document appropriate pressure ulcer prevention and care interventions for a resident with multiple risk factors and existing wounds. Upon the resident's return from the hospital, there was no documentation of a sacral wound during the initial evaluation, and staff were unable to specify when or under what condition the sacral wound was first identified. The wound care team, including the Wound Care Coordinator, Wound Care Technician, and Wound Care Physician, could not recall or provide documentation regarding the initial discovery or staging of the sacral wound. Additionally, there was a lack of timely notification and documentation to ensure that appropriate interventions were initiated promptly. The resident, who had diagnoses including stage 3 pressure ulcer of the right hip, deep tissue injury to the foot, dysphagia, failure to thrive, heart failure, and COPD, was at high risk for pressure ulcers as indicated by a Braden Scale score of 11. The care plan and physician orders required the use of a low air loss mattress, daily skin checks, and specific wound dressing changes. However, after hospice services were revoked and the hospice-provided air mattress was removed, there was a delay in ordering and providing a replacement low air loss mattress. Documentation shows the mattress was not ordered until several days after the resident's return, and staff were unaware of the resident's hospice status change for about a week. There were multiple missed and undocumented dressing changes and daily skin assessments as ordered. The Treatment Administration Record (TAR) showed gaps in documentation for both wound care and skin checks, with several days where required interventions were not recorded as completed. The sacral wound progressed from an unstageable or early-stage wound to a stage 4 pressure ulcer with necrosis and infection, as documented by the wound care physician. The facility's own policy required daily or at least weekly skin checks and prompt documentation and intervention for new skin alterations, which were not consistently followed in this case.
Failure to Accurately Document and Account for Controlled Substances
Penalty
Summary
The facility failed to follow its controlled substance policy and ensure that hydrocodone 5-325 mg was properly documented and accounted for in the cases of two residents. For both residents, the control drug receipt/record/disposition forms indicated that hydrocodone doses were signed out on multiple dates and times. However, a review of the Medication Administration Records (MAR) for the same periods showed no documentation that these doses were actually administered. The physician orders for both residents specified hydrocodone/APAP to be given as needed for pain, with one resident having orders for different dosages based on pain severity. During interviews, the Director of Nursing confirmed that controlled substances should be signed out on the MAR after administration, in accordance with facility policy, which requires accurate accountability of all controlled drugs at all times. One resident stated that her pain medication was as needed and that she did not request or take the medication multiple times during the month in question. The discrepancies between the control drug records and the MARs, along with the lack of resident requests for medication, demonstrate a failure to maintain accurate records and accountability for controlled substances as required by facility policy.
Resident Falls from Bed During Incontinence Care
Penalty
Summary
The facility failed to ensure the safety of a resident during incontinence care, resulting in the resident falling out of bed. The resident, who has a history of heart failure, end-stage renal disease, weakness, lack of coordination, and muscle wasting, was being attended to by a CNA. During the care, the CNA turned away to grab a new pad, leaving the resident near the edge of the bed. The resident, who was weak and unable to maintain balance, rolled out of the bed and fell to the floor. Interviews and records indicate that the resident required partial to moderate assistance with bed mobility due to significant weakness and deconditioning. The CNA acknowledged that the resident was positioned too close to the edge of the bed and that they were unable to reposition the resident to the center of the bed due to the resident's size. The CNA admitted to taking their eyes off the resident, which contributed to the fall. The incident was documented in the nursing notes and fall report, and the resident was subsequently taken to the emergency department for evaluation. Although no injuries were noted, the incident highlights a failure in providing adequate supervision and safe positioning during care. The facility's assessments and care plans identified the resident as a fall risk, yet the necessary precautions were not effectively implemented during the incident.
Failure in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident, resulting in the development of a stage 4 pressure ulcer on the sacrum, which required hospitalization for infection treatment and surgical debridement. The resident, a female with a history of multiple medical conditions including existing pressure ulcers, was admitted to the facility with orders for weekly skin assessments. However, these assessments were not documented, and the resident's condition worsened without timely intervention. Observations revealed that the resident was left unchanged and without proper wound dressing for extended periods, contributing to the deterioration of her condition. The resident reported feeling wet and not being changed, and staff confirmed that her incontinence brief was stained with wound drainage. Despite the presence of a wound care team, there was a lack of communication and follow-up, leading to the resident's sacral wound being left uncovered and untreated for significant periods. The facility's pressure injury prevention protocol and skin assessment policy were not adhered to, as evidenced by the lack of documented weekly skin checks and the failure to identify and address the resident's worsening condition promptly. The wound care team was unaware of the sacral wound until it had significantly progressed, highlighting a gap in communication and protocol adherence that contributed to the resident's severe pressure ulcer and subsequent hospitalization.
Inadequate PPE Use and Hand Hygiene in Infection Control
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) and adherence to hand hygiene protocols, affecting two residents under enhanced barrier precautions. A female resident with a history of local skin infection, pressure ulcers, and other medical conditions was observed receiving wound care without the staff wearing gowns or performing hand hygiene between glove changes. The LPN involved admitted to not noticing the enhanced barrier precaution sign and was unaware of the requirement to perform hand hygiene between glove changes, as per her previous training. Additionally, a male resident with a history of acute and chronic respiratory failure and other medical conditions was observed receiving incontinence care without the staff wearing gowns, despite the enhanced barrier precaution sign on the door. The staff involved were unsure of the last time the resident was changed and did not adhere to the facility's policy requiring gown use during high-contact care activities. The facility's policies on hand hygiene and enhanced barrier precautions were not followed, as staff failed to perform hand hygiene before and after care and did not wear gowns during high-contact activities. The Director of Nursing acknowledged the expectations for hand hygiene and PPE use but did not intervene during the surveyor's presence.
Failure to Maintain Resident Hygiene and Grooming
Penalty
Summary
The facility failed to ensure proper hygiene care for a dependent resident, identified as R2, who was unable to perform activities of daily living independently. R2 was admitted with multiple diagnoses, including severe cognitive impairment, and was dependent on staff for all care. During an observation, R2 was found in bed with wet and bloody sheets, and actively bleeding scratch marks on her hips, buttocks, and thighs. R2's fingernails were long, jagged, and had debris underneath, indicating a lack of proper grooming. A CNA stated that nails are typically cut during scheduled showers, but R2's tendency to scratch herself led to frequent changes of her sheets during incontinence care. The facility's policy mandates that residents unable to perform activities of daily living independently should receive necessary services to maintain good grooming and hygiene, which was not adhered to in this case.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident received prescribed oral medication and topical creams, resulting in deficiencies for two of the three residents reviewed. One resident, identified as R2, was admitted with multiple diagnoses including dysphagia, thrombocytopenia, and severe cognitive impairment, and was dependent on staff for care. Observations revealed that R2 had extremely dry, flaking skin with areas actively bleeding due to scratching. Despite having physician orders for Ammonium Lactate, Cetaphil, and Triamcinolone creams to manage her skin conditions, R2 missed numerous applications due to the unavailability of these medications. Progress notes indicated that the creams were often on order or awaiting delivery, and the Director of Nursing confirmed the absence of these medications in the facility. Another resident, R1, with diagnoses including hemiplegia, Type 2 Diabetes, and major depressive disorder, also experienced medication administration issues. R1's prescribed medications included Venlafaxine, Metformin, Lotrimin AF cream, and Nystatin powder. The eMAR showed that R1 missed several doses of Venlafaxine and other topical treatments due to unavailability. Progress notes corroborated these findings, indicating that medications were not on the cart or unavailable for administration on multiple occasions. The facility's policy on the administration of drugs, revised in May 2017, states that medications should be administered as prescribed by the attending physician. However, the failure to reorder and ensure the availability of medications led to missed doses and incomplete treatment for both residents. The Director of Nursing expressed expectations for timely reordering and communication with the pharmacy, but these procedures were not effectively followed, contributing to the deficiencies observed.
Inadequate Incontinence Care Leading to Cross-Contamination
Penalty
Summary
The facility failed to provide incontinence care in a manner that prevents cross-contamination for one resident with severe cognitive impairment and multiple medical conditions, including dysphagia, thrombocytopenia, and chronic kidney disease. During an observation, two CNAs were providing incontinence care to the resident. The CNAs did not spread the resident's legs to properly clean the perineal area and used the same washcloth multiple times without changing gloves or performing hand hygiene. The washcloth was left between the resident's legs, and stool was observed on the washcloth after cleaning the buttocks. The Director of Nursing (DON) stated that staff should have all necessary supplies and follow proper procedures to clean, rinse, and dry the resident to prevent infection and skin conditions. The facility's policy requires using a clean surface of the washcloth for each wipe, rinsing if necessary, and drying the resident with a clean towel. The CNAs did not adhere to these guidelines, as they did not change gloves or wash their hands during the care process.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to perform a safe transfer for a resident (R2) who was dependent on staff for transfers, resulting in an acute mildly displaced fracture of the distal femoral diaphysis on the resident's left leg. On the day of the incident, R2 was being transferred to a dialysis chair by a CNA without the use of a mechanical lift, despite R2's request for it. The CNA, V9, stated there was no time to retrieve the mechanical lift and proceeded with a manual transfer with the help of another CNA, V10, who was unfamiliar with R2's transfer needs. During the transfer, R2 slid down and had an assisted fall, leading to the injury. R2's medical history includes conditions such as Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Stage 5 Chronic Kidney Disease, Peripheral Vascular Disease, and a Right Above the Knee Amputation. R2 was dependent on renal dialysis and had been assessed as requiring a mechanical lift for transfers since July 2024. The facility's records indicated that R2 was non-weight bearing and required a full body mechanical lift for transfers. Despite this, the staff did not use the mechanical lift, and R2 was transferred manually, which was against the facility's policy and R2's care plan. The incident occurred because the staff did not follow the established procedure for transferring R2, which required the use of a mechanical lift. The CNAs involved in the transfer did not ensure the availability of a lift pad, and V9 admitted to having transferred R2 without a mechanical lift in the past. The facility's policy required that if a lift pad was not available, staff should notify the on-call person, but this was not done. The failure to adhere to the transfer protocol and the lack of communication among staff members contributed to the unsafe transfer and subsequent injury to R2.
Removal Plan
- Inservices for safer transfers began at the facility.
- Competency by return demonstration of safe transfer training.
- Safe transfer audits are being completed.
- QA meeting held with administrator, DON, and medical director to discuss improvement plan.
- Interviews with staff regarding transfer status knowledge.
- DON said there was 90% staff training completed on initial inservicing. There were 4 CNAs left to train. They are PRN (as needed) staff.
- The CNA who performed the improper transfer had not returned to work because she refused to come to the facility for training.
Failure to Provide Admission Paperwork to Residents
Penalty
Summary
The facility failed to ensure that residents received necessary admissions paperwork, including notice of rights, rules, and responsibilities, either prior to or upon admission. This deficiency was identified in three out of four residents reviewed for residents' rights. Specifically, the admissions packets for these residents were missing signatures and dates that would verify receipt and agreement to the information contained within. The residents involved included a male with a history of quadriplegia and other serious health conditions, a female with multiple sclerosis and dementia, and a male with Down syndrome and epilepsy, all of whom were admitted to the facility at different times. Interviews and record reviews revealed that the Admissions Director had not documented all attempts to complete and upload the admissions packets to the electronic health record. In one case, a family member was uncomfortable completing the packet electronically, and a hard copy was provided but never returned. Another resident's packet was initiated but not given to the family member for signing. The facility's Admission Agreement Policy requires that residents or their representatives receive an admission agreement at the time of admission, outlining services covered and any additional services requested. However, this process was not consistently followed, leading to the deficiency.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement effective interventions to reduce the risk of falls for three residents, resulting in one resident being hospitalized with a femoral fracture. Resident R80, identified as a high fall risk, was observed with only one floor mat instead of the required two. Despite multiple falls and injuries, including a femur fracture, interventions were inconsistently applied or absent. The resident's care plan indicated a need for bilateral floor mats and a low bed position, but these measures were not consistently in place. Resident R69, also at high risk for falls, was found in a precarious position in bed without the necessary floor mats on both sides and the bed not in the lowest position. The staff acknowledged the need for these interventions, yet they were not consistently implemented. The resident's care plan highlighted the necessity of these precautions due to cognitive and physical impairments, but observations showed lapses in adherence to the plan. Similarly, Resident R58 was observed with only one floor mat and the bed not in the lowest position, contrary to the fall prevention plan. The resident's care plan required bilateral floor mats and a low bed position due to a high risk of falls from various health conditions. Despite the facility's fall prevention policy, these safety measures were not consistently applied, indicating a systemic issue in implementing fall prevention strategies.
Failure to Apply Anti-Embolism Stockings as Ordered
Penalty
Summary
The facility failed to apply anti-embolism (TED) elastic stockings to a resident, identified as R73, as ordered by the physician. This deficiency was observed during a survey when R73 was seen sitting in a wheelchair with swollen bilateral ankles. R73, who is alert and oriented, reported that staff elevate her legs when she is in bed but do not apply the anti-embolic stockings. She was unaware of the need to wear these stockings during the day and remove them at bedtime, as per the physician's orders. The Registered Nurse (RN), identified as V14, acknowledged the physician's order for the stockings to be applied every morning and removed at bedtime but admitted to not applying them because R73 is often up and about, making it difficult to catch her in bed. The Director of Nursing (DON), identified as V2, was informed of the observation and confirmed that treatments should be implemented as ordered by the physician. R73 was readmitted with multiple diagnoses, including chronic diastolic congestive heart failure and chronic kidney disease, and had an active physician order for anti-embolism stockings. The facility's policy on elastic stockings, revised in May 2017, outlines the procedure for applying them, which was not followed in this case.
Failure to Implement Splint Program for Resident with Limited ROM
Penalty
Summary
The facility failed to follow physician orders and implement care plan interventions for a resident with limited range of motion due to a history of cerebrovascular accident (CVA). The resident, identified as R86, was observed without a hand splint despite having a physician's order for a left-hand splint and sling to be used when up in a chair. The care plan also indicated the need for these devices to prevent contractures. However, the resident was not on the splint program, and the restorative nurse, V21, was unaware of the order for the splint and sling. This oversight was noted during an observation and interview with the registered nurse, V14, who confirmed the resident's contractures and flaccid left arm. The resident's medical records revealed a lack of a restorative assessment upon readmission, with the most recent assessment indicating no risk for contractures and no use of a splint. The facility's policy on restorative programming requires assessments upon admission and with any significant change in condition, but this was not adhered to in R86's case. The restorative nurse, V21, later assessed the resident and found severe joint mobility issues, indicating the resident would benefit from the splint. The facility's policy on splint/brace assistance outlines the need for a scheduled program of applying and removing splints, which was not followed, leading to the deficiency.
Failure to Prevent Accidents and Ensure Resident Safety
Penalty
Summary
The facility failed to ensure that coffee was served at a safe temperature below 140-degrees Fahrenheit, leading to a resident spilling hot coffee on herself and sustaining full thickness burns to her thighs. The resident, who had severe cognitive impairment and a history of impulsive behaviors, was given hot coffee by an activity aide who did not wait for the coffee to cool down. Despite the resident's known behaviors of throwing items when upset, the staff did not take adequate precautions to prevent the incident, resulting in significant injuries to the resident's thighs. Another deficiency involved a resident who rolled out of bed while a CNA was changing the bed linens. The resident, who required partial assistance for bed mobility and had a bed support safety rail on only one side of the bed, was not properly positioned or supervised during the linen change. The CNA did not ensure that the resident grabbed the bed support safety rail before proceeding, leading to the resident falling and sustaining a laceration to the left eyebrow, a subarachnoid hemorrhage, and a nondisplaced patella fracture. The facility also failed to develop adequate fall prevention interventions for a resident with a history of falls, severe cognitive deficits, dementia, and restless agitation. The resident had multiple incidents of attempting to get out of bed or a chair, resulting in falls. Despite these behaviors, the facility did not implement sufficient monitoring or environmental modifications to prevent further falls, leading to the resident being found on the floor on multiple occasions.
Failure to Provide Adequate Feeding Assistance
Penalty
Summary
The facility failed to provide adequate feeding assistance for residents with visual deficits, leading to significant unplanned weight loss for two residents. One resident, diagnosed with dementia, was observed struggling to feed herself without assistance, resulting in an 8.99% weight loss in one month. Despite the resident's care plan indicating the need for 1:1 feeding assistance, staff only provided setup assistance and did not intervene until prompted by the surveyor. The resident's weight had been steadily declining over the past six months, with the lowest weight recorded being 79 pounds in May 2024. Another resident, diagnosed with dementia, glaucoma, intraocular lens, and multiple sclerosis, also experienced significant weight loss, losing 10.6% of her body weight over four months. This resident was observed attempting to feed herself with a spoon held backward and expressed difficulty in feeding herself. Despite her care plan indicating the need for assistance due to visual impairment and impaired coordination, staff did not regularly provide the necessary feeding assistance. The resident's weight had been declining each month, with a dietary note indicating that her oral intake was insufficient for weight maintenance. The facility's weight maintenance policy requires monitoring and investigating significant or trending weight changes, but these protocols were not adequately followed for the two residents. The policy outlines steps to determine the cause, plan of action, and notify the physician and responsible party, but these measures were not effectively implemented, resulting in the residents' unplanned weight loss and inadequate nutritional support.
Failure to Follow Hot Beverage Policy Results in Resident Burns
Penalty
Summary
The facility failed to follow their hot beverage policy by not ensuring coffee was below 140 degrees Fahrenheit and not logging coffee temperatures prior to each service. This deficiency was observed when coffee temperatures were measured at 145 degrees Fahrenheit in the common dining area. The Dietary Manager confirmed that coffee should be served at a temperature between 130-140 degrees Fahrenheit and acknowledged that temperatures were checked weekly but not logged. This failure affected a resident who had multiple sclerosis, Alzheimer's disease with late onset, major depressive disorder, and anxiety, and who had severe cognitive impairment as indicated by a mental status score of 5/15 on the Minimum Data Set. The incident occurred when the resident requested coffee from an activity aide, who served it without allowing it to cool down. The resident spilled the hot coffee on her lap, resulting in full-thickness burns on her thighs. The wound doctor documented significant burn injuries, including fluid-filled blisters. The facility's hot beverage policy required that all hot beverages be served at a safe temperature and that temperatures be logged prior to each meal service, but these procedures were not followed, leading to the resident's injury.
Failure to Notify Family and Hospice of Resident's Fall
Penalty
Summary
The facility failed to follow their change in condition policy by not notifying the family (responsible party) and hospice in a timely manner of a fall incident involving a resident diagnosed with Dementia with behavior disturbance, general anxiety disorder, restlessness, and agitation. The hospice referral paperwork required notification of falls or injuries. On the specified date, the resident was found on the floor in a praying position after attempting to get out of bed. The Assistant Director of Nurses (ADON) confirmed that the family was not notified because they were out of town, and the Hospice Director confirmed that hospice was not notified of the incident. The facility's policy mandates notification of the resident, attending physician, and representative of any change in the resident's condition or status.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to follow their abuse policy by not investigating or determining how an injury of unknown origin occurred for one of the residents. The incident involved a resident (R2) who was found with a bruise on the back of her right hand. The hospice nurse inquired about the bruise with a new staff nurse (V36), who denied any knowledge of a fall or injury. Despite the facility's policy requiring immediate reporting and investigation of such injuries, no notification or investigation was initiated for R2's bruise. The Director of Nurses (V2) confirmed that the administrator should have been notified and an investigation should have been started, but this did not happen. V36, who was on orientation, was informed to report any bruising or marking on a resident to the administrator. The facility's abuse policy mandates that any suspicious bruises or injuries of unknown origin be reported immediately and documented on a facility incident report. However, this protocol was not followed in the case of R2, resulting in a failure to investigate the cause of the injury.
Failure to Supervise Impulsive Resident
Penalty
Summary
The facility failed to supervise an impulsive, confused resident (R2) with an unsteady gait, resulting in R2 getting into bed with another resident (R1). This incident caused R1 to scream, cry, and feel nervous. R1 was found gripping a butter knife but was not aiming it towards R2. R1's diagnoses include Dementia, Anxiety, Adjustment Disorder with Mixed Anxiety, Weakness, History of Transient Ischemic Attack, and Osteoporosis. R2's diagnoses include Diabetes Mellitus, Heart Failure, Vascular Dementia, and Major Depressive Disorder. Staff interviews revealed that R2 had a history of aggressive behavior, including hitting staff and other residents, and required frequent monitoring and redirection, especially during the evening when her behaviors worsened. On the night of the incident, a CNA heard yelling and found R2 on top of R1 in R1's bed. R1 was calling for help and was visibly upset. Staff noted that R2 had a behavior of crawling on the floor and was often verbally and physically aggressive. Despite these known behaviors, R2 was not adequately supervised, leading to the incident. The Director of Nursing and Social Service Director were not aware of the extent of R2's aggressive behaviors or the issues between R1 and R2, indicating a lack of communication and proper documentation within the facility. R2's care plan documented her need for constant or near-constant observation due to her impulsive behaviors and lack of safety awareness. However, this level of supervision was not provided, as evidenced by the incident. R1's care plan noted her impaired vision and cognitive decline, making her particularly vulnerable. The failure to provide adequate supervision and address the known behavioral issues of R2 directly led to the distressing event for R1.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Matteson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Landmark Of Richton Park Rehab & Nsg Ctr | 2.3 mi | ★★★★★ | 25 | 0 |
| Aperion Care Chicago Heights | 3.1 mi | ★★★★★ | 12 | 0 |
| Elevate Care Country Club Hill | 3.6 mi | ★★★★★ | 6 | 0 |
| Prairie Manor Nrsg & Rehab Ctr | 3.8 mi | ★★★★★ | 14 | 0 |
| Frankfort Terrace | 4 mi | ★★★★★ | 0 | 0 |
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