Harmony Park Ridge
Inspection history, citations, penalties and survey trends for this long-term care facility in Park Ridge, Illinois.
- Location
- 1001 North Greenwood Avenue, Park Ridge, Illinois 60068
- CMS Provider Number
- 145324
- Inspections on file
- 41
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Harmony Park Ridge during CMS and state inspections, most recent first.
Two residents with respiratory disorders did not receive oxygen therapy as ordered by their physicians. One resident used a nasal cannula incorrectly and received inconsistent oxygen flow rates, with infrequent tubing changes and incomplete documentation in the MAR. Another resident received a lower oxygen flow rate than ordered, with tubing not changed as scheduled and no documentation of oxygen administration. Staff acknowledged these deviations from physician orders and facility policy.
A resident was not protected from employee-to-resident abuse when a CNA entered the room without knocking, leading to an altercation in which the CNA struck the resident in the face. The resident, who was alert and oriented, sustained facial bruising and scratches as a result of the incident, which was confirmed by staff, police, and hospital records.
A resident with multiple chronic conditions was found with unexplained bruising, but staff did not report the injury of unknown origin to the state agency as required by facility policy. Interviews confirmed that staff were aware of the reporting protocol, yet the incident was not reported in a timely manner, resulting in a deficiency for failure to follow abuse prevention and reporting procedures.
A resident with significant mobility and cognitive impairments, requiring a two-person assist for mechanical lift transfers, was transferred by a single CNA in violation of facility policy and the resident's care plan. During the transfer, the resident slid from the lift and sustained a left femoral neck fracture, necessitating hospitalization and surgery. Staff interviews confirmed awareness of the two-person assist requirement, but it was not followed due to staffing availability.
A resident with dementia and a significant fall risk was left unsupervised in a common area while a CNA attended to her cellphone, resulting in the resident being found on the floor by another resident. The care plan identified the need for close monitoring and specific interventions, but these were not followed, leading to a lapse in supervision.
A resident with multiple chronic conditions reported being physically and verbally abused by an agency CNA, including being punched and threatened. Facility staff failed to assess the resident for injuries, did not notify the family or physician, and did not document any follow-up. Additionally, the facility did not ensure agency staff were properly screened or trained in abuse prevention, contrary to facility policy.
A resident reported verbal and physical mistreatment by a CNA, but the facility failed to conduct a thorough investigation as required by policy. Key staff and the CNA involved were not interviewed, other potentially affected residents were not assessed, and there was no documented physical or psychosocial assessment of the resident after the incident. The DON was not informed or involved in the investigation, and required notifications and documentation were incomplete.
A resident reported verbal and physical mistreatment by a CNA, but the facility failed to conduct a comprehensive investigation as required by policy. Key staff and the CNA involved were not interviewed, other potentially affected residents were not assessed, and there was no documented psychosocial or thorough physical assessment of the resident after the incident.
The facility failed to follow its weight monitoring policy, leading to significant unplanned weight loss for three residents. One resident on a pureed diet was not assisted during meals, resulting in a 6.15% weight loss. Another resident with multiple health conditions lost 11.2% of their weight due to lack of documented weights and dietitian awareness. A third resident with a history of cancer experienced a 15.3% weight loss as their nutritional supplement was not implemented, and their food preferences were not accommodated.
The facility failed to follow its policies on oxygen administration and CPAP/BiPAP support, affecting four residents. Observations showed issues such as unlabeled humidifier bottles, lack of oxygen use signage, and deviations from physician orders. One resident used a CPAP machine without a physician's order for setup and flow, while another received oxygen at a rate higher than prescribed.
The facility failed to provide language support for a Bulgarian-speaking resident, leaving them unable to communicate effectively. Additionally, two residents with indwelling catheters were observed without privacy bags, compromising their dignity. These actions violate the facility's policies on resident rights and communication.
A facility failed to assess and manage the pain of a Bulgarian-speaking resident who reported daily headaches and migraines. The resident was unaware of receiving any pain medication and communicated their pain by pointing to their head. This was the first instance of using an interpreter since the resident's admission. The nursing supervisor was informed of the resident's migraine during the surveyor's visit, highlighting a lapse in following the facility's medication administration policy.
The facility failed to follow its infection control policy for enhanced barrier precautions, affecting two residents. Staff were observed not wearing appropriate PPE, such as gowns, while providing care to residents with enhanced barrier precautions. Interviews revealed inconsistencies in staff understanding of the policy, leading to non-compliance with infection prevention protocols.
The facility failed to report abuse allegations to the IDPH in a timely manner, affecting two residents. One resident reported being hit by another, leading to a police report, but the incident was not reported to the state due to communication lapses. Another incident was reported late due to the Administrator's focus on investigation and police contact, contrary to the facility's policy requiring immediate reporting.
A CNA failed to report a fall involving a resident who required substantial assistance for transfers. The resident attempted to get water during the night, fell, and was returned to bed by a male staff member without a nurse's assessment. This resulted in a delay of over 10 hours before medical evaluation, during which the resident sustained a laceration requiring sutures and broken ribs. The facility's protocol for reporting falls and observing residents post-fall was not followed.
A facility failed to investigate a resident's bruise of unknown origin and did not inform the family of the investigation's outcome. The resident, with severe cognitive impairment, was reported to have bruises allegedly caused by rough handling. The facility did not interview staff or collect statements as required by policy, and the Administrator admitted to the lack of documentation and communication with the family.
The facility failed to implement its fall prevention program, affecting three residents. A resident's call light was not within reach, leading to a fall and hip fracture. Another resident, identified as high risk, did not have the required fall star marking, and fall interventions were inconsistent with care plans. A third resident's bed was not in the lowest position, and their care card was outdated. The facility's policies on fall prevention and accident investigation were not adequately followed.
A resident with hemiplegia and other medical conditions experienced two falls due to inadequate supervision and equipment failure. The resident slid from a geriatric chair without footrests, resulting in a tibial fracture, and later fell from a bed that could not be lowered due to a malfunctioning remote. The facility's fall prevention policy was not followed, contributing to these incidents.
A resident with a history of falls and multiple medical conditions sustained a displaced nasal bone fracture due to inadequate supervision. Despite interventions in the fall care plan, the resident continued to fall when staff were not looking. The facility's fall policy and staffing levels were insufficient to prevent these incidents.
The facility failed to follow food service and sanitation policies, including improper hair net use, inadequate dishwasher temperature verification, and lack of hand hygiene by kitchen staff. These deficiencies affected all 98 residents receiving meals from the kitchen.
The facility failed to have a pest control policy and did not implement effective pest control treatments, affecting all 98 residents receiving meals from the kitchen. Observations revealed multiple gnats and roach-like insects in the kitchen area, with repeated pest control treatments documented from February to April 2024. Despite these treatments, the pest problem persisted, and the facility did not provide a pest control policy when requested.
The facility failed to follow its enhanced barrier precaution policy by not placing signage or making PPE available for residents with wounds, indwelling catheters, or G-tubes. This affected 26 residents and had the potential to impact all 104 residents. The interim ADON/IP admitted that in-services on enhanced barrier precautions had just started, despite policy requirements.
A resident reported an allegation of abuse by a CNA, but the facility failed to report the incident in accordance with its policies. The Administrator was not informed, and no Facility Reported Incident was filed at the time, leading to a significant delay in addressing the allegation.
The facility did not follow its abuse policy by failing to immediately suspend a staff member accused of hitting a resident on the head. The staff member continued to work the day after the allegation was reported before being suspended pending investigation.
The facility failed to provide restorative nursing services to two residents with limited range of motion. One resident reported not receiving any therapy for his contracted leg and experiencing discomfort from prolonged sitting. Another resident expressed frustration about being confined to a wheelchair since being discharged from therapy. Interviews confirmed the absence of a restorative program, despite facility policy requiring such services.
A resident at risk for weight loss and requiring extensive feeding assistance did not receive adequate help with meals. Staff members delivered meal trays but did not assist the resident with eating, leading to untouched meals. The facility's policy for feeding assistance was not followed, and the resident's nutritional needs were not met.
Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to follow physician orders regarding oxygen therapy for two residents with respiratory disorders. For one resident with COPD and chronic respiratory failure, surveyors observed the resident using a nasal cannula incorrectly by placing it in his mouth instead of his nose, and noted discrepancies in oxygen flow rates between the concentrator and portable tank. The resident reported infrequent changes of oxygen tubing and delays in replacing portable oxygen tanks. The oxygen concentrator and tank were set at different flow rates than ordered, and the resident's Medication Administration Record (MAR) did not accurately reflect the physician's order or document the amount of oxygen administered to maintain the required oxygen saturation. Additionally, the nebulizer mask was left exposed and the machine was placed on the floor, contrary to infection control practices. The Director of Nursing confirmed that the MAR and Treatment Administration Record (TAR) did not accurately reflect the physician's orders, and that tubing changes were not documented as required. For another resident with chronic respiratory failure and emphysema, surveyors found the resident receiving oxygen at a lower flow rate than ordered and using tubing that had not been changed according to the prescribed schedule. The MAR indicated the correct order, but there was no documentation of oxygen administration on the day of the survey. The resident's nebulizer masks were also left exposed, and staff acknowledged that the physician's orders for oxygen flow rate and tubing changes were not being followed. Facility policies require that physician orders be followed as written and that oxygen therapy be administered and documented according to those orders, but these procedures were not adhered to for the residents reviewed.
Failure to Protect Resident from Employee-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from employee-to-resident abuse, resulting in the resident sustaining redness, mild swelling, and facial bruising. The incident began when a Certified Nurse Aide (CNA) entered the resident's room without knocking or announcing herself, which upset the resident. The CNA retrieved the resident's urinal jug for the roommate, further agitating the resident, who then threw coffee at the CNA. In response, the CNA became aggressive, threw items in the room, and struck the resident in the face with a closed fist. The resident sustained visible injuries, including scratches and a bruise under the right eye, as confirmed by staff observations, police, and hospital records. The resident, who was alert and oriented with a BIMS score of 15, refused a full body assessment but was observed with new facial injuries not present during the previous shift. The incident was witnessed by staff who responded to the CNA's call for help and observed both the coffee stain on the CNA and the resident's injuries. The police and emergency medical services were called, and the resident was transported to the hospital for evaluation. Documentation from nursing progress notes, police, and hospital records corroborated the sequence of events and the resulting injuries.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its abuse prevention policy by not reporting an injury of unknown origin in a timely manner. On 6/18/25, a resident was assessed by the Restorative Nurse and the Director of Nursing, with the surveyor present, and was observed to have discoloration on both sides of the breasts. Staff interviews confirmed that any injury of unknown origin should be reported immediately to the Administrator for investigation and to the state agency, but this was not done. The Director of Nursing acknowledged that the incident was not reported to the Illinois Department of Public Health (IDPH) as required, and the Administrator admitted that the initial report was not sent in a timely manner, despite staff being aware of the reporting protocol. The resident involved had multiple diagnoses, including cerebral infarction, coronavirus, anemia, type 2 diabetes mellitus, hyperlipidemia, heart failure, and hypertension. A progress note indicated that bruising was observed on 6/13/25, but the incident was not reported to IDPH until 6/18/25. The facility's abuse prevention policy, revised in November 2023, requires prompt reporting of all injuries of unknown source to appropriate authorities, including the state licensing agency, the resident's representative, attending physician, and medical director. The failure to follow this policy resulted in a deficiency for not reporting the injury of unknown origin as required.
Failure to Provide Required Two-Person Assist During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident, who required a two-person assist for transfers using a mechanical lift, was transferred by only one certified nurse aide (CNA). The resident had a complex medical history including a displaced fracture of the left femur, osteoarthritis, hemiplegia, dementia, and was identified as being at high risk for falls. The care plan and facility policy both specified that two staff members were required for mechanical lift transfers, and this was known to the CNA involved. During the transfer, the CNA noticed the resident's left foot was not positioned correctly on the lift and attempted to adjust it. At that moment, the resident let go of the grab bar and slid off the lift to the floor. The CNA, who was alone, assisted the resident back to bed. The incident was not immediately reported as a fall, and initial assessments did not reveal injury. However, the following day, the resident complained of hip pain, and an X-ray confirmed a left femoral neck fracture, requiring hospital transfer and surgical intervention. Interviews with staff, including the CNA, nurses, the DON, and the administrator, confirmed that the facility's policy and the resident's care plan required a two-person assist for mechanical lift transfers. The CNA stated she was aware of this requirement but proceeded alone because other staff were unavailable. Facility documentation and staff interviews consistently indicated that the standard of care was not followed, directly resulting in the resident's fall and injury.
Failure to Provide Adequate Supervision for High Fall Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision to a resident with a significant risk for falls. The incident involved a resident with a history of multiple falls, dementia, impaired balance, and other co-morbidities, who was found sitting on the floor after being left unsupervised. At the time of the incident, a CNA assigned to supervise the resident in the dining room was observed attending to her cellphone and was unaware that the resident had slid off the wheelchair. The incident was reported by another resident, not by staff, indicating a lapse in direct supervision. The resident's care plan and fall risk assessment identified her as being at high risk for falls, with interventions in place such as offering toileting after dinner and monitoring due to impulsivity and unsteadiness. Despite these documented risks and interventions, the staff member responsible for supervision was distracted and did not notice the resident's fall. Facility policy requires staff to provide an environment free from accident hazards and to supervise residents to prevent avoidable accidents, but this was not followed in this instance.
Failure to Protect Resident from Abuse and Inadequate Response to Allegation
Penalty
Summary
A cognitively intact resident with chronic kidney disease, spinal stenosis, hypertension, and hyperlipidemia reported being physically and verbally abused by an agency CNA during the night. The resident described being roughly handled, punched in the back multiple times, threatened, and intimidated by the staff member, who also instructed her not to use the call light. The resident was left feeling unsafe and distressed, ultimately leading her to discontinue her rehabilitation and request discharge home. The incident was not immediately reported to the resident's family or physician, and the resident's family only learned of the abuse when visiting later that day. Facility staff, including an RN and the LPN night supervisor, failed to conduct or document any physical or psychosocial assessment of the resident following the allegation of abuse. Both staff members acknowledged in interviews that no assessment was performed to determine if the resident had sustained injuries. Additionally, there was no documentation of efforts to notify the resident's family or physician about the incident, and no interdisciplinary notes reflected any follow-up assessment or intervention for the resident's well-being after the alleged abuse. The facility also failed to ensure proper screening and training of agency staff. The human resources director stated that agency staff records and training were not reviewed or maintained by the facility, and no documentation was provided to demonstrate that the agency CNA involved in the incident had been appropriately screened or trained in abuse prevention and reporting. The facility's own policy required prompt investigation, assessment, and reporting of abuse allegations, but these procedures were not followed in this case.
Failure to Thoroughly Investigate Alleged Abuse and Assess Resident
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of abuse involving an alert and cognitively intact resident with chronic kidney disease, spinal stenosis, hypertension, and hyperlipidemia. The resident reported to the night nurse that a CNA was verbally inappropriate, treated her roughly during incontinence care, and threatened her not to use the call light again. The CNA also refused to provide her name when asked. The nurse notified the administrator, who directed the CNA to leave the facility immediately. Although a body check was reportedly done with no injuries noted, there was no documented physical or psychosocial assessment of the resident after the incident, nor were efforts made or documented to reach the family, physician, or medical director at that time. The administrator did not interview or obtain statements from all relevant staff, including the night supervisor and the CNA involved in the incident. Other staff members who were working during the CNA's shift were not interviewed, and only residents from different units were interviewed as part of the internal review. The staffing agency manager confirmed that the CNA was simply blocked from future shifts but was not interviewed or reported to the CNA registry. The interim DON was not informed of the incident or involved in the investigation, despite being responsible for oversight of the nursing staff. Facility policy requires that all reports of abuse be thoroughly investigated, including interviews with all relevant staff, witnesses, and other residents who may have been affected, as well as a physical and psychosocial assessment of the alleged victim. The investigation did not meet these requirements, as key interviews and assessments were omitted, and documentation was incomplete regarding the resident's condition and notifications to appropriate parties.
Failure to Conduct Thorough Abuse Investigation and Resident Assessment
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of abuse involving an alert and cognitively intact resident with chronic kidney disease, spinal stenosis, hypertension, and hyperlipidemia. The resident reported to the night nurse that a CNA was verbally inappropriate, treated her roughly during incontinence care, and threatened her not to use the call light. The nurse notified the administrator, who directed the CNA to leave the facility and performed a body check, noting no visible injuries. However, there was no documented assessment of the resident's psychosocial well-being or further physical assessment after the incident. The internal investigation was incomplete, as the administrator did not obtain written statements or conduct interviews with all relevant staff, including the night supervisor and the CNA involved in the incident. Other staff members working during the CNA's shift were not interviewed, and the Director of Nursing was not informed or involved in the investigation. Additionally, the facility did not attempt to interview other residents who may have been affected by the alleged abuser, despite having access to a list of residents cared for by the CNA on the night of the incident and previous shifts. Facility policy requires a comprehensive investigation, including interviews with all relevant staff, witnesses, and potentially affected residents, as well as thorough documentation and assessment of the alleged victim. The investigation did not meet these requirements, as key interviews and assessments were omitted, and there was a lack of documentation regarding communication with the resident's family, physician, or medical director.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to adhere to its weight monitoring policy, resulting in significant unplanned weight loss for three residents. One resident, on a pureed diet, experienced a 6.15% weight loss over a month. Despite being observed consuming only 20% of meals, staff did not assist or encourage eating, and the resident was not re-weighed as required by policy. The registered dietitian was unaware of the weight loss and no documentation indicated that the physician was notified. Another resident, with a history of muscle weakness, dementia, and other conditions, experienced an 11.2% weight loss over six months. The resident's weight was not documented as per the physician's orders, and the dietitian was only made aware of the appetite change after a significant period. The facility's policy required weekly weights to monitor stability and effectiveness of interventions, which was not followed. A third resident, diagnosed with malignant neoplasm of the endometrium and other conditions, experienced a 15.3% weight loss over six months. The resident's care plan included a nutritional supplement, but it was not implemented or documented in the medication administration record. The resident's family often brought food from home, and the resident expressed a preference for Polish food, which was not accommodated by the facility. The dietitian's recommendations were not followed, contributing to the resident's continued weight loss.
Failure to Follow Oxygen and CPAP/BiPAP Policies
Penalty
Summary
The facility failed to adhere to its policies on oxygen administration and CPAP/BiPAP support, affecting four residents. Observations revealed that a resident was receiving oxygen at 2 liters per minute via nasal cannula without appropriate signage on the door, which was later corrected. Another resident's oxygen concentrator machine had a humidifier bottle without a label or date, and there was no signage indicating oxygen use. This resident had been using a CPAP machine every night without a physician's order for its setup and flow, despite having a long history of CPAP use at home. Further observations showed another resident receiving oxygen at 4 liters per minute, contrary to the physician's order of 2-3 liters per minute, and the humidifier bottle was not labeled or dated. Additionally, a fourth resident was on 3 liters per minute of oxygen without a physician's order, and the humidifier bottle was also not labeled or dated. The Director of Nursing confirmed the need for proper signage, labeling, and adherence to physician orders as per the facility's policies.
Failure to Ensure Communication and Privacy for Residents
Penalty
Summary
The facility failed to ensure that residents could communicate with staff in their preferred language and did not maintain privacy and dignity for residents with medical devices. Specifically, a resident who only speaks Bulgarian reported that an interpreter was used for the first time during the surveyor's visit, despite the facility's policy requiring timely language access services. This lack of communication support left the resident feeling isolated and unable to express their needs effectively. Additionally, the facility did not maintain privacy for residents with indwelling catheters. Two residents were observed with catheter bags not placed in privacy bags, compromising their dignity. One resident had a catheter bag secured to the bed frame without a privacy bag, while another had a catheter bag dangling from the side of the bed. These observations indicate a failure to adhere to the facility's resident rights policy, which emphasizes treating residents with respect, kindness, and dignity.
Failure to Assess and Manage Pain for Non-English Speaking Resident
Penalty
Summary
The facility failed to accurately assess and manage the pain of a resident who only speaks Bulgarian. The resident reported experiencing daily headaches and migraines, which affected their sleep, but was unaware if any pain medication was being administered. The resident communicated their pain by pointing to their head, yet this was the first time an interpreter was used to facilitate communication since their admission. The nursing supervisor was informed of the resident's migraine during the surveyor's visit. The facility's medication administration policy requires staff to review the active medication list with residents, which was not effectively done in this case.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its infection control policy regarding enhanced barrier precautions, which affected two residents out of a sample of 40. During an initial tour, signage indicating enhanced barrier precautions was observed outside the rooms of two residents. However, a registered nurse was seen providing gastrostomy tube care to one of these residents without wearing the appropriate personal protective equipment (PPE), specifically a gown. Additionally, a certified nurse aide was observed entering the room of the second resident to provide incontinence care without donning a gown, despite the enhanced barrier precautions in place. Interviews with facility staff revealed inconsistencies in understanding and implementing the infection control policy. The Infection Prevention Nurse stated that staff are expected to wear gowns and gloves when providing direct care to residents under enhanced barrier precautions. However, the registered nurse involved in the incident indicated that gowns should be worn only if there is a risk of spillage, which contradicts the facility's posted signage. This lack of compliance with the infection control policy highlights a deficiency in the facility's infection prevention and control program.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to adhere to its Abuse Investigation and Reporting policy by not submitting an initial report of an abuse allegation to the Illinois Department of Public Health (IDPH) in a timely manner. This deficiency affected two residents. One resident, who was alert and oriented, reported an incident where another resident hit him, causing him to spill coffee on himself. The police were called, and a report was filed. However, the Director of Nursing was not aware of the incident until the following day, and the Administrator was not fully informed, resulting in the failure to report the incident to the state. In another case, the facility did not report an abuse allegation involving another resident within the required timeframe. The incident occurred early in the morning, but the initial and final reports were only submitted three days later. The Administrator admitted to not reporting the incident immediately due to being occupied with the investigation and contacting the police. The facility's policy mandates that abuse or serious bodily harm should be reported immediately, but this was not followed, leading to a delay in reporting the incident to the appropriate authorities.
CNA Fails to Report Resident Fall, Resulting in Delayed Medical Attention
Penalty
Summary
Facility staff, specifically a Certified Nursing Assistant (CNA) identified as V3, failed to report a fall incident involving a resident, R2, to the nursing staff. This incident occurred when R2, who was admitted with diagnoses including Covid-19, urinary tract infection, Parkinson's, and overactive bladder, attempted to get water during the night and fell. R2, who required substantial assistance for transfers, was picked up by a male staff member and returned to bed without a nurse's assessment, resulting in a delay of over 10 hours before medical evaluation. The fall led to R2 sustaining a laceration on the left ear requiring eleven sutures and broken ribs. The facility's investigation revealed that V3 did not adhere to the protocol of reporting falls or changes in a resident's condition to a nurse. The Director of Nursing (DON) and the Administrator confirmed that the staff should have stayed with R2 and called for a nurse immediately after the fall. The facility's fall policy mandates that a licensed nurse should observe and document the clinical status of a resident for 72 hours following a fall. However, this protocol was not followed, leading to a significant delay in R2 receiving necessary medical attention.
Failure to Investigate Resident's Bruise and Notify Family
Penalty
Summary
The facility failed to conduct a thorough investigation into a resident's bruise of unknown origin and did not notify the family member of the investigation's outcome. The resident, a male with severe cognitive impairment and requiring maximal assistance for daily activities, was reported to have skin alterations on his left inner ear and cheekbone. The family member alleged that the bruises resulted from rough handling by a staff member and reported the incident to the police. Despite the facility's policy requiring interviews with all staff members in contact with the resident during the incident and the preceding 72 hours, no such interviews were conducted, and no statements were collected from the staff. The Quality Nursing Director and other staff members confirmed that the investigation was not conducted according to the facility's policy. The Administrator, responsible for the investigation, acknowledged the lack of documentation and communication with the family regarding the investigation's findings. The Director of Nursing also admitted to not participating in the investigation and failing to inform the family of the results. The facility's policy mandates thorough investigations and communication with the resident's representative, which were not adhered to in this case.
Failure to Implement Fall Prevention Program
Penalty
Summary
The facility failed to implement its fall prevention program policy, resulting in deficiencies affecting three residents. For Resident 1, the facility did not ensure that the call light was within reach, which contributed to a fall incident where the resident sustained a hip fracture. Despite being identified as high-risk for falls, the interventions from fall investigations were not consistently updated in the care plan. The resident had a history of multiple falls, and the fall risk assessment was inaccurately recorded as moderate instead of high risk. Resident 2 was identified as very high risk for falls and was supposed to be on the fall star program, which requires a star to be placed next to the resident's nameplate. However, this was not done, and the fall interventions developed from investigations were inconsistent with the care plan updates. The resident experienced seven falls in 2024, yet the fall risk assessments continued to indicate a moderate risk, contrary to the resident's history of multiple falls. For Resident 3, the facility did not maintain the bed in the lowest position, and the care card was not updated to reflect the resident's high fall risk. The resident had a fall incident resulting in a forehead laceration, but the fall risk assessment was inaccurately recorded as moderate. The facility's policies on fall prevention and accident investigation were not adequately followed, leading to these deficiencies.
Inadequate Supervision and Equipment Failure Lead to Resident Falls
Penalty
Summary
The facility failed to adequately supervise a resident at risk for falls, resulting in two separate incidents where the resident was injured. The resident, who is a total assist and dependent on staff for all activities of daily living, was left unsupervised in a dining area during an activity. The resident slid down from a high-back geriatric chair, bending and twisting his right leg, which led to a tibial fracture. The incident was not initially reported as a fall by the nurse on duty, as she did not consider it a fall since the resident did not hit the ground. The resident was later sent to the emergency department after swelling and pain were observed, where the fracture was diagnosed. In a second incident, the same resident was found on the floor beside his bed, which was not lowered to the ground due to a malfunctioning remote. The CNA on the previous shift had noticed the issue but did not take action to resolve it or report it to the appropriate personnel. The resident was again transferred to the emergency department after this fall. The facility's policy on fall prevention, which includes maintaining an environment free from accident hazards and providing supervision to prevent avoidable accidents, was not adhered to in these instances. The resident involved in these incidents is a male with a medical history that includes hemiplegia, diabetes, neoplasm of the prostate, and epilepsy. He is nonverbal, slightly confused, and requires a mechanical lift for transfers. The lack of supervision and failure to provide necessary assistive devices, such as footrests on the wheelchair and a functioning bed, contributed to the resident's falls and subsequent injuries.
Inadequate Supervision Leads to Resident Injury
Penalty
Summary
The facility failed to adequately supervise a resident with a history of falls, resulting in a displaced nasal bone fracture. The resident, who has multiple medical conditions including progressive supranuclear palsy and unsteadiness on feet, had three falls since January 2024. These falls were unwitnessed and occurred at the nursing station and activities room, leading to injuries including a minimally displaced nasal bone fracture. Despite interventions in the fall care plan, such as closely monitoring the resident and keeping her near the nurses' station, the resident continued to fall when staff were not looking. Observations revealed that the resident was often placed in a regular wheelchair instead of a broader chair, which her POA had requested for better safety. The POA expressed concerns about the resident's care, stating that the facility did not have enough staff to provide 1:1 supervision and often placed the resident in areas where she was not adequately monitored. The Director of Nursing (DON) acknowledged that the resident required constant supervision and that the facility's interventions were not effectively preventing falls. Staff interviews confirmed that the resident was a high fall risk and required constant supervision. On the day of the incident, the activity aide reported that she could not watch the resident due to the high number of residents in the activities room. The resident followed a nurse out of the room and fell face down from her wheelchair before the aide could reach her. The facility's fall policy emphasizes the need for fall risk assessments and close monitoring, but these measures were insufficient in preventing the resident's falls and subsequent injury.
Food Service and Sanitation Deficiencies
Penalty
Summary
The facility failed to follow their policy and procedures for food service and sanitation, affecting all 98 residents receiving meals from the kitchen. Observations revealed that a food service worker wore her hair net improperly, exposing her hair. The dietary manager ran temperature test strips through the high-temperature dishwasher, which did not change to the required orange color, indicating the final rinse temperature was not 180 degrees. The temperature gauge on the dishwasher was non-functional, and attempts to measure the temperature with an irreversible maximum registering thermometer were unsuccessful. Despite these issues, the kitchen staff continued to use the dishwasher for cleaning dishes instead of switching to disposable dishware. Additionally, a cook was observed not performing hand hygiene between tasks, and another food service worker touched his face and then handled clean utensils without washing his hands properly. The dietary manager acknowledged these lapses but did not take immediate corrective actions. The facility's policies for dish machine temperature, disposable glove use, and hand hygiene were not adhered to. The dishwasher temperature policy required the use of test strips or an irreversible maximum registering thermometer to verify the surface temperature of dishes, but neither method was effectively used. The disposable glove use policy mandated hand washing before and after glove use, which was not followed by the kitchen staff. The hand hygiene policy required washing hands before handling clean utensils and after touching skin or clothing, which was also not observed. The industrial blender's functionality was incorrectly attributed to the dishwasher's temperature, despite the manufacturer's instructions not mentioning such a feature. These deficiencies indicate a significant lapse in maintaining food service and sanitation standards in the facility's kitchen.
Failure to Implement Effective Pest Control in Kitchen
Penalty
Summary
The facility failed to have a policy for pest control and did not implement effective pest control treatments and interventions, affecting all 98 residents receiving meals from the kitchen. Observations on 04/30/2024 revealed multiple gnats throughout the kitchen area, and the Dietary Manager acknowledged the presence of gnats, expressing concern about their potential contact with food. Additionally, the Maintenance/Housekeeping Director discovered multiple roach-like insects under the dishwashing machine, indicating a pest issue. The facility's pest control invoices from February to April 2024 documented repeated observations and treatments for fruit flies, gnats, and German roaches in the kitchen area, particularly around the dishwashing room. Despite these treatments, the pest problem persisted, with heavy German roach activity noted on multiple occasions. The local health inspector's visit on 04/23/2024 confirmed the presence of more than the allowed number of gnats, necessitating a follow-up inspection. The facility's Pest Control Invoice dated 05/01/2024 further documented multiple German roach nymphs around the dishwashing area. The facility did not provide a pest control policy when requested on 05/01/2024 and later reported on 05/03/2024 that they did not have one. This lack of a formal pest control policy and the ongoing pest issues in the kitchen area highlight the facility's failure to maintain a sanitary environment for food preparation and service, posing a potential risk to the residents' health and safety.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to follow its enhanced barrier precaution policy by not placing any signage with informational material on residents' doors or making personal protective equipment (PPE) available inside or outside residents' rooms. This deficiency affected 9 residents on the first floor and 17 residents on the second floor who were receiving wound care, had an indwelling urinary catheter, IV line, or G-tube, and had the potential to affect all 104 residents at the facility. During a random observation, a unit scheduler was seen putting up enhanced barrier isolation signs without understanding their purpose, and a registered nurse (RN) was observed assisting a resident without using appropriate PPE. The RN mentioned that the facility had not completed any in-services on enhanced barrier precautions before, and the isolation bins were not properly stocked with necessary PPE. The interim Assistant Director of Nursing (ADON) and Infection Preventionist (IP) admitted that the in-services on enhanced barrier precautions had just started that day, despite the policy requiring full implementation in accordance with CMS regulatory requirements for F880. The ADON/IP acknowledged that the signs were posted and in-services initiated only after consulting with the corporate director of quality assurance. The facility's policy stated that enhanced barrier precautions should be implemented for residents with wounds, indwelling medical devices, or colonization with multi-drug resistant organisms (MDROs), but this was not followed, leading to the observed deficiencies.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse in accordance with its policy and procedure. A resident, a [AGE] year old female with diagnoses including mixed anxiety, depressed mood, and dementia, reported to a registered nurse that an evening CNA had removed her clothes, grabbed her, and walked with her. Despite this report, the incident was not communicated to the abuse coordinator or the Administrator, and no Facility Reported Incident was filed for this allegation at the time it occurred. The Administrator only became aware of the incident when informed by the surveyor, and a Facility Reported Incident was subsequently filed with a significant delay. The facility's policies on Abuse Investigation and Reporting and Abuse Prevention require that all reports of resident abuse be promptly reported to local, state, and federal agencies and thoroughly investigated by community management. However, the staff failed to adhere to these policies, as evidenced by the lack of immediate reporting and investigation of the resident's allegation. The Director of Nursing confirmed that there were no Facility Reported Incidents of abuse for the resident over the last three months, indicating a lapse in following the established procedures for handling such reports.
Failure to Immediately Suspend Staff Accused of Abuse
Penalty
Summary
The facility failed to follow their abuse policy by not immediately suspending a staff member accused of physical abuse towards a resident. The incident involved a male resident with multiple fractures and a history of traumatic brain injury. The resident reported to his representative that a physical therapy assistant hit him on the head while providing care. The representative then informed the nurse on duty about the incident. Despite the facility's policy requiring immediate suspension of the accused staff member, the physical therapy assistant continued to work the day after the allegation was reported before being suspended pending investigation. The Director of Nursing received the abuse allegation and notified the Administrator. The Director instructed the nurse to conduct a physical assessment of the resident and interviewed the accused staff member the following day. However, the staff member was allowed to work a full shift before being suspended. The facility's policy clearly states that any employee accused of resident abuse should be immediately suspended pending the outcome of the investigation, which was not adhered to in this case.
Failure to Provide Restorative Nursing Services
Penalty
Summary
The facility failed to provide restorative nursing services to two residents who were assessed with limited range of motion. One resident, a [AGE] year old male with multiple diagnoses including anxiety, depression, hypertension, and seizure disorder, reported that he barely ever gets out of bed and never receives any restorative therapy for his contracted left leg. He expressed discomfort and pain from having to sit in his chair for upwards of eight hours due to insufficient staff to assist him back to bed. Another resident, a [AGE] year old male with diagnoses including hypertension, unsteady gait, developmental delay, and dysphagia, was observed sitting in a wheelchair and expressed frustration about not being able to walk since being discharged from therapy. He reported that he is always in his chair and wants to get out, but there is no restorative program to support his mobility needs. Interviews with the Director of Nursing, a Certified Nursing Assistant, and the Director of Rehab confirmed that the facility does not currently have a restorative program. The Director of Rehab mentioned that therapists typically recommend restorative services upon a resident's discharge from therapy, but the absence of a restorative program means that residents are not receiving the necessary support to maintain their functional status. The facility's policy on restorative nursing, last reviewed in December 2022, states that services should be provided per the resident's care plan to promote their highest practicable level of functioning, but this policy is not being implemented due to the lack of a restorative program.
Failure to Provide Adequate Feeding Assistance
Penalty
Summary
The facility failed to provide adequate feeding assistance to a resident (R104) who was at risk for weight loss and required extensive feeding assistance. Observations revealed that staff members delivered meal trays to R104 but did not offer assistance with eating. On multiple occasions, R104's meal trays were left untouched, and no staff members attempted to help her with her meals. Family members also reported that staff did not offer meals or assistance to R104, and the resident herself expressed that she needed more help from the facility. Despite the resident's need for assistance, staff members did not follow the facility's policy and procedures for feeding assistance, which included sitting down with the resident, offering the meal again if initially declined, and providing supplements if necessary. On one occasion, a CNA delivered R104's breakfast tray but did not assist her with eating, and the tray was later collected untouched. During another observation, a CNA was more focused on preparing R104 for a chemotherapy appointment rather than ensuring she had eaten her meal. The CNA did not offer the meal again or provide any alternatives, and R104 left for her appointment without eating. The Director of Nursing (V2) confirmed that the facility's policy required CNAs to offer feeding assistance, reapproach residents if they initially declined, and notify the nurse if the resident continued to refuse food. However, these procedures were not followed in R104's case. R104's care plan and nutritional risk assessment documented her need for extensive feeding assistance and the importance of maintaining her weight due to her medical conditions, including malignant pancreatic cancer and protein-calorie malnutrition. Despite these documented needs, the facility did not ensure that R104 received the necessary feeding assistance, leading to her meals being left untouched and her nutritional needs not being met. The facility also failed to provide a protocol or procedure for feeding residents who require assistance during the survey.
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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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