Landmark Of Lincoln Park Rehabilitation And Nursin
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 735 West Diversey, Chicago, Illinois 60614
- CMS Provider Number
- 145654
- Inspections on file
- 45
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Landmark Of Lincoln Park Rehabilitation And Nursin during CMS and state inspections, most recent first.
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.
A resident with significant mobility and self-care deficits, but intact cognition, was care planned to require substantial assistance with personal hygiene, including nail care and shaving. Over time, CNAs documented long toenails and nail bed issues, and a podiatry note later described elongated, dystrophic toenails with painful onychomycosis. Staff reported the resident’s toenails were long and aching, fingernails extended beyond the skin with dried black material the resident identified as stool, and that the resident repeatedly requested nail trimming. The resident also reported going about two months without being shaved despite requests, and was observed with a long, unshaven beard and mustache; staff described his facial hair as long, thick, and grizzly, and cited broken clippers and ineffective disposable razors. An observation also found the resident lying on a yellowish, unclean fitted sheet with dark particles, and a CNA acknowledged it did not appear changed and that the resident had been in bed for a prolonged period, demonstrating a failure to provide required ADL assistance.
A resident with a history of emphysema and prior smoking had conflicting nicotine-related information between hospital records, facility assessments, and the face sheet. Hospital documentation and a CT lung screening indicated nicotine dependence in remission, while the facility’s social history recorded no nicotine/tobacco history or current use, and the medical record listed an active nicotine dependence diagnosis with inconsistent onset dates. The resident, who reported having quit smoking and was concerned about assisted living acceptance, identified the discrepancy. The MDS coordinator and DON reported that diagnoses are entered from hospital records and updated when aware of new information, but they were not aware of all outside appointments and records, leading to the nicotine diagnosis being coded as dependence instead of remission and resulting in an incomplete and inaccurate medical record.
A CNA physically abused a resident with severe cognitive impairment by pulling the resident's ear and forcibly removing him from a chair, resulting in bruising and a scratch. The abuse was discovered after staff noticed injuries and behavioral changes, leading to a review of surveillance footage that confirmed the incident. The CNA had no prior history of abuse and had completed required training.
Surveyors found expired milk cartons in the walk-in cooler and a wet sanitation cloth left on the food preparation counter instead of in the sanitizing solution, contrary to facility policy. These lapses in food safety and sanitation procedures had the potential to affect all residents receiving food from the kitchen.
The facility did not keep outside garbage dumpsters properly closed, resulting in overfilled containers with partially open lids. Multiple departments contributed to the issue, and staff were unsure who was responsible for leaving the dumpsters open, despite facility policy requiring dumpsters to remain closed and the area kept clean. This affected all residents in the facility.
Two residents with confirmed COVID-19 were not provided with trash receptacles for PPE disposal in their rooms, leading staff to discard used PPE in hallway trash cans. One resident used both a shared bathroom and a communal rehab bathroom despite orders for a dedicated bathroom, with no signage or clear cleaning schedules in place. Another resident on isolation was observed leaving their room, interacting with others, and using a cloth mask instead of a required disposable mask, contrary to facility policy. These failures were confirmed by staff and management, and were not in line with infection control protocols.
Surveyors found that the lint trap in the dryer used for residents' personal laundry was not being emptied, resulting in a large buildup of lint. Staff confirmed there was no log or procedure for cleaning this lint trap, and it was not being checked regularly, despite facility policy requiring lint screens to be cleaned and documented after every two loads. This failure created an unsafe environment and a fire hazard potentially affecting all residents.
Several dependent residents did not receive timely oral hygiene or incontinence care as required by their care plans and facility policy. Two residents were observed with significant dental debris and reported a lack of staff assistance with mouth care, while two others, both paraplegic and always incontinent, experienced prolonged waits for incontinence care, sometimes exceeding an hour. Staff interviews confirmed that care was not consistently provided every two hours as required.
A resident with multiple risk factors for pressure ulcers was found in bed on a non-functioning low air loss mattress, despite physician orders and care plan interventions requiring its use. The LALM was observed to be almost flat with the power off, and the ADON confirmed it was not working at the time, resulting in a failure to provide appropriate pressure ulcer prevention.
Surveyors found that several residents requiring oxygen therapy did not have their equipment properly contained, labeled, or dated, with tubing often left unbagged or touching the floor. Required oxygen-in-use signage was missing in some rooms, and at least one resident received oxygen at a higher flow rate than ordered by the physician. These deficiencies occurred despite clear care plans and facility policies, affecting residents with significant respiratory and medical needs.
Surveyors found that medications, including insulin and eye drops, were not properly labeled with open dates, some were not refrigerated as required, and expired medications were not discarded. Temperature logs for medication refrigerators had missing entries, and staff did not consistently monitor temperatures as required, especially when vaccines were present. These failures affected multiple residents and had the potential to impact all residents on the affected floor.
Several residents' personal refrigerators lacked required temperature log sheets and thermometers, with staff failing to consistently document daily temperature checks as required by facility policy. Interviews confirmed that staff were responsible for these tasks, but the procedures were not followed, affecting residents with various medical conditions.
Two residents with significant physical and cognitive impairments were unable to access their call lights, as required by their care plans. In both cases, the call lights were found out of reach, despite facility policy and staff job descriptions mandating that call lights be kept within easy reach to allow residents to request assistance.
A resident with multiple psychiatric diagnoses received an increased dose of Venlafaxine HCL ER without documented clinical rationale or physician justification. The DON could not provide evidence of an IDT meeting or behavioral interventions prior to the dosage change, contrary to facility policy requiring assessment and documentation for psychotropic medication adjustments.
Three residents with limited mobility and contractures did not receive required range of motion (ROM) exercises or restorative devices as specified in their care plans and physician orders. Staff confirmed that necessary splints and palm protectors were unavailable and that temporary alternatives were not used. Two residents reported not receiving ROM exercises, and staff cited outdated lists and time constraints as reasons for missed care. Facility policies and job descriptions require these interventions, but they were not consistently provided.
Surveyors found that controlled medications were not double locked, completed medications were not returned to the pharmacy, and shift-to-shift count sheets were missing outgoing nurse signatures. These failures involved a resident with completed Lorazepam orders and two residents receiving other controlled substances, with staff acknowledging the lapses in required storage and documentation practices.
Two residents with histories of behavioral issues and susceptibility to abuse were involved in a verbal and physical altercation, during which one threw water on the other and both exchanged offensive language. The incident was witnessed by an LPN, reported to the administrator, and resulted in police involvement. The facility failed to ensure the right of these residents to be free from abuse, as required by its abuse prevention policy.
Two residents experienced physical and verbal abuse from another resident with moderate cognitive impairment and a history of aggressive behavior. One resident was pushed and sustained a minor injury, while another was punched in the eye and verbally threatened after a dispute over loud television volume. Staff intervened in both cases, but the incidents highlight a failure to prevent and protect residents from abuse.
The facility failed to respond to nurse call activations promptly, affecting three residents. Resident Council Meeting Minutes and resident interviews revealed ongoing issues with CNAs not answering call lights and being rude. On one occasion, a surveyor observed a call light going unanswered for an extended period, despite staff being aware of it. The facility's policy requires prompt responses, which were not followed, leading to the deficiency.
Two cognitively intact residents engaged in a physical altercation over a disagreement, resulting in minor injuries. Staff intervened promptly, and both residents were sent for psychiatric evaluations. Despite the incident, both residents felt safe and declined police involvement.
A resident with a history of mental health disorders reported being punched by another resident, R1, in a LTC facility. Despite no visible injuries, the incident was considered physical abuse by witnesses. Staff confirmed the altercation, and R1 was sent for psychiatric evaluation. The facility failed to follow its abuse prevention policy, as R1 lacked an abuse care plan despite a history of aggressive behavior.
A former receptionist at an LTC facility verbally abused a resident by using profanity when the resident shared a security code. The incident was witnessed by another resident and reported to the administrator. Despite the resident feeling safe, staff members agreed that the behavior constituted verbal abuse. The facility's investigation could not substantiate the abuse claim, but it was determined that the receptionist's communication was inappropriate.
A resident with progressive systemic sclerosis did not receive her scheduled Tramadol medication for pain management due to lapses in communication and procedure among nursing staff and pharmacy. The resident, who is cognitively intact, experienced significant pain and discomfort without the medication. The RN was unable to find Tramadol in the medication cart and offered Tylenol instead, which the resident accepted despite its ineffectiveness. The DON later retrieved Tramadol from the emergency medication system after system issues. The resident's medication administration record confirmed the lapse, and the nurse practitioner was unaware of the situation.
Two residents engaged in a physical altercation over a bathroom dispute, resulting in one resident sustaining a foot fracture. Despite complaints of pain, the injury was not promptly addressed by the facility staff. The incident was witnessed by multiple staff members, but effective intervention was lacking, highlighting a deficiency in the facility's abuse prevention and response measures.
The facility failed to maintain a safe environment and adhere to professional standards, resulting in injuries to two residents. One resident experienced a delayed diagnosis of a foot fracture after an altercation, while another suffered a knee fracture with delayed assessment and notification. The facility did not follow its policies for immediate assessment and physician notification, leading to deficiencies identified by surveyors.
A resident with a history of self-harm and aggressive behavior was inadequately supervised, resulting in a nasal fracture after hitting himself in the face. Despite being in a supervised area, staff failed to prevent the incident, and monitoring was inconsistent. The facility's policies for handling behavioral emergencies were not effectively implemented, contributing to the deficiency.
A resident was found with lidocaine patches applied without proper orders or documentation. The patches were observed on both knees, with one dated incorrectly and the other undated. The LPNs involved were unaware of the patches, and the Director of Nursing confirmed there was no active order until a later date. Facility policy requires medications to be administered and documented according to physician orders, which was not adhered to in this instance.
The facility failed to conduct timely criminal background checks for new residents, impacting their safety and well-being. Several residents, including those with mental health conditions, were affected due to delays in the Criminal History Information Response Process (CHIRP) and fingerprinting. Staff interviews revealed confusion over responsibilities, and facility policies on abuse prevention were not followed, highlighting significant procedural gaps.
The facility failed to complete timely Health Care Worker Background Checks, as evidenced by an employee hired in 1998 whose work eligibility was still 'Not Yet Determined' over 20 years later. The Regional HR Director acknowledged the oversight, which contradicts facility policies requiring background checks before employment. This deficiency potentially affects all 137 residents.
The facility failed to post accurate and timely daily nursing staffing information, affecting all 137 residents. The outdated posting was observed multiple times, and the updated version still contained inaccuracies, such as an incorrect census and lack of specific unit details. The receptionist responsible for posting was absent, leading to the oversight.
The facility failed to adequately monitor food storage temperatures, potentially affecting all residents. A review of the Milk Cooler refrigerator temperature log revealed missing recordings for several shifts. The Dietary Manager confirmed the importance of tracking temperatures to prevent milk spoilage, as per facility policy.
A facility failed to ensure proper PPE disposal by a laundry aide who reused a gown throughout a shift, contrary to infection control guidelines. Additionally, a resident requiring enhanced barrier precautions due to a gastrostomy tube and indwelling catheter did not have the necessary precaution sign posted on their door. These deficiencies in PPE use and signage could increase the risk of spreading infections.
A facility failed to assess a resident's ability to self-administer medication, leaving a tube of topical medication on the resident's bedside table without a care plan or physician's order. The resident had a severely impaired mental status, and the Director of Nursing noted the risk of other residents accessing the medication. Facility policy requires an interdisciplinary assessment and physician's order for self-administration, which were not completed.
The facility failed to maintain a homelike environment for several residents, with issues such as holes and cracks in walls, peeling faux wood on a bed footboard, and chipped paint. These conditions were acknowledged by staff as not contributing to a homelike environment. Residents involved were cognitively intact, with some having significant medical diagnoses.
The facility failed to set low air loss mattresses to the correct weight settings for four residents, compromising pressure ulcer prevention. Observations showed that the mattresses were set higher than the residents' actual weights, which could affect circulation and pressure relief. Despite having care plans that included pressure-reducing mattresses, the incorrect settings were confirmed by staff, highlighting a significant oversight in care.
A resident's dignity was compromised when personal medical information was left uncovered in their room, visible to others. Signs detailing dietary and aspiration precautions were posted by an SLP to ensure staff compliance but were not covered, violating HIPAA and dignity standards. The resident had a history of dysphagia and required a mechanically altered diet.
A resident with a diagnosis of Cerebral Infarction and Aphasia was not provided with necessary communication devices as outlined in their care plan. Despite the resident's primary language being Spanish, the facility did not utilize communication aids, relying instead on Spanish-speaking housekeeping staff for translation. This oversight led to increased frustration for the resident, as confirmed by the resident's family and the responsible LPN.
A facility failed to follow its policy for changing a midline catheter dressing for a resident. The dressing, applied to the resident's left arm, was not changed for a week, leading to redness around the chlorohexidine patch, which could indicate infection. The RN confirmed the dressing had not been changed since application, and the DON stated that dressings should be changed weekly and monitored for infection signs. The facility's policy requires dressing changes 24 hours after insertion, every 5-7 days, or if compromised.
The facility failed to follow infection control practices for respiratory care equipment for two residents. A nebulizer mask was not stored in a plastic bag when not in use, and a nasal cannula was not changed weekly as required. Both residents had chronic conditions and moderately impaired cognitive status. These lapses were contrary to the facility's policies for infection control.
A resident with a complex medical history reported a fall to a CNA, who informed the assigned nurse. The nurse did not perform a comprehensive assessment or document the incident as required by the facility's policy. The resident's electronic health record lacked necessary documentation, and no incident report was completed by the night shift nurse.
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 Provide Adequate Nail Care and Shaving for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance with activities of daily living (ADLs), specifically nail care and shaving, for one cognitively intact resident who required substantial/maximal assistance with personal hygiene. The resident had multiple medical diagnoses, including hemiplegia, gait abnormalities, muscle weakness, and a history of falls, and was care planned as having a self-care deficit requiring assistance with all ADLs. The facility’s own A.M. care policy required cleaning under fingernails and maintaining nails at a smooth, safe length, and the resident rights policy affirmed the right to a dignified existence and accommodation of individual needs. Documentation and staff interviews showed that the resident’s toenails and fingernails were not maintained appropriately over time. CNA skin/shower worksheets on multiple dates documented long toenails and nail bed issues, and a foot and ankle clinic note later described elongated, dystrophic toenails with subungual debris and pain on palpation, with onychomycosis affecting all toenails. CNAs reported that the resident’s toenails were long and causing aching, and that podiatry services were dependent on being placed on a list. One CNA stated that when the resident returned from the hospital, the fingernails were beyond the skin with a lot of black dried material under them, which the resident identified as stool, and that the resident repeatedly requested fingernail clipping. The resident also did not receive consistent shaving and facial hair care despite requesting it. The resident reported it had probably been two months since staff had shaved him, despite asking aides to do so, and was observed with a long, unshaven beard and mustache. Staff interviews confirmed that the resident’s facial hair was long, thick, grizzly, and not well maintained, and that clippers were broken and disposable razors were reported as ineffective. A hospital social worker and a physical therapist raised concerns about the resident’s hygiene, including long facial hair, fingernails, and poor foot condition. During an observation, the fitted sheet under the resident was yellowish and unclean with multiple small dark particles, and a CNA acknowledged it did not appear to have been changed and that it had been a while since the resident had been out of bed. These observations and statements demonstrate that the facility did not consistently provide the personal hygiene assistance required by the resident’s condition and care plan.
Inaccurate Documentation of Nicotine Dependence Status in Resident Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one cognitively intact resident with a history of centrilobular emphysema and other chronic conditions. Hospital admission records documented the resident’s social history as a current cigarette smoker on some days, and a later CT chest lung screening documented nicotine dependence, cigarettes, in remission. However, the facility’s social history and assessment recorded no history of nicotine/tobacco use and no current use of smoking products. The resident’s face sheet and diagnosis list initially reflected nicotine dependence, unspecified and uncomplicated, rather than nicotine dependence in remission, and at one point showed differing onset dates and diagnosis descriptions for nicotine dependence. The resident, who reported having stopped smoking months earlier and expressed concern that an active nicotine dependence diagnosis would affect acceptance into assisted living, identified the coding issue and requested correction. The MDS coordinator stated that diagnoses are typically entered from hospital records at admission and updated when aware of new information, but acknowledged not knowing about the resident’s additional hospital visit and CT results, and that the nicotine diagnosis had been entered as dependence instead of remission. The DON reported that the resident makes her own appointments and provides records to medical records staff, and that multiple outside physicians with differing diagnoses contributed to confusion. The former nurse practitioner stated that diagnoses should be carried over from the hospital stay and updated to manage new problems, but the nicotine-related diagnosis in the facility record was not accurately aligned with the resident’s remission status, resulting in an incomplete and inaccurate medical record.
Failure to Protect Resident from Physical Abuse by CNA
Penalty
Summary
A certified nursing assistant (CNA) physically abused a resident with severe cognitive impairment in the facility's dining room. The CNA was observed on video grabbing and pulling the resident's ear, forcibly removing the resident from a chair, causing the resident to fall to the ground, and then picking the resident up and pushing him out of the dining room. The incident resulted in the resident sustaining bruising on both upper arms and a scratch on the ear. The resident, who has a history of dementia, cognitive communication deficit, and other neurological and psychiatric conditions, was at high risk for confusion and wandering. The abuse was not immediately witnessed by other staff, but signs of injury were noted over the following days. A CNA noticed a scratch and bleeding on the resident's ear, and a registered nurse trimmed the resident's nails, suspecting self-inflicted injury. The next day, bruising was observed on the resident's arms during a shower, and the nurse was informed. The resident initially stated he had bumped into a wall, but later reported that a man had touched or hit him, and subsequently refused to enter the dining room. These behavioral changes and physical findings prompted further investigation by facility management. Upon review of surveillance footage, the manager and administrator confirmed the abusive actions of the CNA. The CNA was not assigned to the resident but was responsible for monitoring the dining room. Staff interviews revealed no prior concerns or incidents involving the CNA, and the CNA had previously completed abuse prevention training. The abuse was substantiated through the facility's investigation, which included medical record review, staff statements, and direct observation of the video evidence.
Expired Milk and Improper Sanitation Cloth Storage in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to maintain proper food safety and sanitation practices in the kitchen. Specifically, two 8-ounce cartons of skim milk with expired dates and one additional carton with a different expired date were found in the walk-in cooler. The dietary manager from the corporate office confirmed that dietary aides were responsible for checking and discarding expired food items but had not done so in this instance. Additionally, a wet kitchen sanitation cloth was found left on the food preparation counter rather than being stored in the sanitizing solution as required by facility policy. Facility documentation and policies reviewed by surveyors indicated that all towels must be returned to the sanitation bucket after use and that food products must be rotated and discarded by their expiration dates. The observed failures to discard expired milk and to properly store the sanitation cloth were not in accordance with these established procedures and had the potential to affect all 150 residents receiving food from the kitchen.
Improper Disposal and Management of Garbage Dumpsters
Penalty
Summary
The facility failed to ensure that outside garbage waste dumpsters were properly closed with lids, as required by facility policy, to prevent pest infestation and foul odor. Observations revealed that two out of three dumpsters were overfilled with garbage and had lids left partially open. Staff interviews indicated that multiple departments, including dietary and housekeeping, contributed to the use of these dumpsters, and there was uncertainty regarding who was responsible for leaving the lids open. The facility's policy specifies that dumpsters must be kept closed at all times and the surrounding area clean, with instructions to contact the garbage service if dumpsters become full. At the time of the deficiency, 150 residents were residing in the facility.
Failure to Implement Infection Control Protocols for COVID-19 Positive Residents
Penalty
Summary
The facility failed to follow infection control protocols for residents on transmission-based precautions for COVID-19. Specifically, two residents with confirmed COVID-19 diagnoses were not provided with trash receptacles in their rooms for the disposal of personal protective equipment (PPE), as required by facility policy. Staff, including CNAs, RNs, and housekeeping, reported that there was no designated place to discard used PPE in these rooms, leading them to dispose of PPE in hallway trash cans. Management and the infection preventionist confirmed that isolation rooms should have dedicated trash receptacles for PPE, but these were not present. Additionally, the facility did not maintain proper contact and droplet isolation for COVID-19 positive residents. One resident was observed using both their own bathroom, which was shared with other residents, and a communal rehab bathroom, contrary to orders and facility policy that called for a dedicated bathroom. There were no signs posted to redirect the resident to the appropriate bathroom, and staff were unaware of the cleaning schedules for these shared spaces. The infection preventionist and DON acknowledged the risk of infection spread due to improper bathroom use and lack of cleaning oversight. Furthermore, another resident on isolation for COVID-19 was observed leaving their room, interacting with other residents, and using a cloth mask instead of a required disposable mask. This resident was seen smoking outside near others and attending resident council while removing their mask and coughing. Staff confirmed that the resident was not supposed to be off isolation and should have been using a surgical mask and maintaining distance from others. These lapses in infection control protocols were observed and confirmed by multiple staff members, and were not in accordance with the facility's own policies and CDC guidelines.
Failure to Maintain Lint Trap in Residents' Personal Dryer Creates Fire Hazard
Penalty
Summary
The facility failed to ensure the lint compartment and filter of the dryer used for residents' personal laundry were emptied, resulting in a significant buildup of lint. During a tour of the laundry area, surveyors observed a large accumulation of lint in the lint trap/screen compartment of the residents' personal use dryer. The Housekeeping/Laundry Director confirmed that there was no log sheet or established procedure for cleaning the lint trap/screen for this dryer, and stated uncertainty about who checks it when not present. The Housekeeper/Laundry Aide also reported that laundry aides do not check or log the lint trap/screen for the residents' personal dryer, only for the main dryers, and had never checked it during their shifts. Facility policy requires that all dryer lint screens be cleaned by laundry staff after every two loads and documented on a daily cleaning form. Job descriptions for both the Laundry Aide and Director of Housekeeping specify responsibilities for safe equipment use and adherence to facility policies and procedures. Despite these requirements, the lack of a cleaning schedule, documentation, and staff awareness regarding the residents' personal dryer led to the deficiency, creating an unsafe environment and a fire hazard with the potential to affect all 150 residents.
Failure to Provide Timely Oral and Incontinence Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for several residents who were dependent on staff for care, specifically in the areas of oral hygiene and timely incontinence care. Observations revealed that two residents had visible accumulations of brown sediments on their teeth, indicating a lack of oral care. One of these residents was unable to communicate due to cognitive impairment, while the other, who was cognitively intact, reported that staff had not assisted with mouth care for an extended period. Both residents had care plans indicating the need for staff assistance with oral hygiene due to self-care deficits related to their medical conditions. In addition, two other residents who were paraplegic and always incontinent reported and were observed to experience delays in receiving incontinence care. One resident stated that incontinence care was typically provided only twice daily, resulting in prolonged periods spent in wet undergarments while seated in a wheelchair. Another resident was found in bed with a strong odor of urine and feces, having activated the call light for assistance approximately five minutes prior to being attended to. This resident reported that wait times for incontinence care could exceed one hour, and staff interviews confirmed that care was not consistently provided every two hours as required by facility policy. The affected residents had significant medical histories, including hemiplegia, paraplegia, neuromuscular dysfunction of the bladder, and other conditions resulting in self-care deficits. Facility policies and job descriptions for CNAs, LPNs, and the DON outlined the expectation for regular oral care and incontinence care every two hours or as needed, but these standards were not met for the residents reviewed. The deficiencies were identified through direct observation, resident interviews, record reviews, and staff interviews.
Failure to Ensure Functioning Pressure-Relieving Mattress for At-Risk Resident
Penalty
Summary
A resident identified as being at risk for pressure ulcers was observed in bed with a low air loss mattress (LALM) that was not functioning, as the mattress was almost flat and the power was off. The Assistant Director of Nursing confirmed that the machine was not working due to the power being off and indicated that the mattress would not function unless the power was turned on. The resident's care plan and physician orders specified the use of a pressure-reducing mattress as an intervention for pressure ulcer prevention, and the facility's guidelines require adherence to such interventions for residents at risk. The resident's medical history included diagnoses such as protein calorie malnutrition, venous insufficiency, dementia, muscle wasting and atrophy, poly-osteoarthritis, and dermatitis, all of which increase the risk for pressure ulcers. The resident was assessed as being at risk for pressure ulcers, and the care plan included the use of a pressure-reducing mattress. Despite these documented needs and interventions, the required equipment was not operational while the resident was in bed, constituting a failure to provide appropriate pressure ulcer prevention as ordered.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
Surveyors observed multiple failures in the provision of respiratory care for six residents requiring oxygen therapy. Oxygen equipment, including nasal cannulas and tubing, was found not properly contained, labeled, or dated in several resident rooms. In some cases, oxygen tubing was left hanging on tanks or concentrators, touching the floor, or not stored in a clean manner, contrary to facility policy and infection control standards. Additionally, oxygen equipment was not consistently bagged when not in use, and there was a lack of labeling to indicate when tubing was last changed, despite physician orders and facility protocols requiring weekly changes and proper documentation. Further deficiencies included the absence of required signage indicating oxygen was in use in resident rooms, as observed with one resident receiving oxygen therapy without any visible warning sign. Staff interviews confirmed that signage should have been present and that its absence was an oversight. In another instance, a resident's oxygen concentrator was set at a higher flow rate than prescribed by the physician, with both the resident and a registered nurse acknowledging the discrepancy. This failure to follow physician orders for oxygen flow rates was noted as a direct deviation from the resident's care plan and medical orders. The residents affected had significant medical histories, including chronic obstructive pulmonary disease, emphysema, acute respiratory failure, and other serious conditions requiring careful respiratory management. Documentation reviewed by surveyors showed that care plans and physician orders specified the need for monitoring, proper storage, and regular changing of oxygen equipment. Despite these directives, staff did not consistently adhere to established protocols, resulting in lapses in safe and appropriate respiratory care for all six residents reviewed.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's medication storage and labeling practices. During observations, it was found that several multi-dose medications, such as Latanoprost and Fluticasone nasal spray, were not labeled with open dates, making it unclear how long they had been in use. Additionally, artificial tears for two residents were found with open dates that exceeded the recommended 30-day usage period. These lapses in labeling and timely discarding of medications could result in the administration of expired drugs. Unopened insulin pens requiring refrigeration were found stored in the medication cart instead of the refrigerator, contrary to pharmacy auxiliary labels and facility policy. Staff interviews confirmed that unopened insulin should be refrigerated, and that failure to do so could compromise medication integrity. Furthermore, the daily refrigerator temperature logs on the 3rd floor had missing entries, and staff acknowledged that temperature checks were not consistently performed as required. This inconsistency in monitoring could affect the safety and efficacy of temperature-sensitive medications stored for all residents on the floor. Vaccines were also found stored in the refrigerator, but temperature monitoring was only performed once daily instead of the expected twice daily when vaccines are present. Staff were unclear about the correct monitoring frequency, indicating a lack of adherence to established protocols. The facility's own policies require medications to be stored according to manufacturer recommendations, with proper labeling and timely removal of outdated drugs, but these procedures were not consistently followed for the residents involved.
Failure to Monitor and Document Personal Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of personal refrigerators used by residents for food storage. Observations revealed that several residents' personal refrigerators were missing required temperature log sheets and thermometers. Specifically, one resident's refrigerator had multiple days with missing temperature checks and staff initials, while another resident's refrigerator had no documentation of temperature checks at all. Additional refrigerators were found without log sheets or thermometers, and in some cases, residents were unaware of the missing items or stated that staff were responsible for maintaining them. Interviews with staff, including the Director of Nursing (DON) and Housekeeping Director, confirmed that facility policy requires daily temperature checks and documentation for each resident's personal refrigerator. Staff are expected to record the temperature and their initials on a log sheet every shift, and each refrigerator should be equipped with a thermometer. The purpose of these checks is to ensure that food is stored at safe temperatures to prevent spoilage and potential illness. However, the observed lack of documentation and missing equipment indicated that these procedures were not consistently followed. The residents affected by these deficiencies had various medical conditions, including weakness, abnormalities of gait and mobility, repeated falls, diabetes, and other chronic illnesses. Some residents were cognitively intact and able to report on the situation, while others were unable to participate in interviews due to altered mental status. Despite the presence of food in the refrigerators, there were no immediate concerns about the condition of the food itself, but the absence of required monitoring and documentation represented a failure to comply with facility policy and safe food storage practices.
Failure to Ensure Call Lights Accessible to Residents
Penalty
Summary
The facility failed to ensure that call lights were accessible to residents as required by their care plans. One resident, who is blind and has multiple diagnoses including encephalopathy, weakness, and reduced mobility, was observed trying to locate his call light, which was found out of reach between the siderail and the floor. The resident expressed difficulty in finding the call light, and his care plan specifically required that the call light be kept within reach due to his self-care deficits and moderate cognitive impairment. Another resident, who was lying on a low air loss mattress and has a history of falls, osteoarthritis, and cognitive impairment, was unable to locate the call device. The call device was found stuck on the headboard and not within the resident's reach. The care plan for this resident also required that the call light be placed within reach due to fall risk and decreased safety awareness. Facility policy and CNA job descriptions further specify that call lights should be kept within easy reach of residents, but these procedures were not followed in these instances.
Lack of Clinical Justification for Psychotropic Medication Increase
Penalty
Summary
The facility failed to provide clinical rationale or physician documentation justifying the increase in dosage of a psychotropic medication for a resident diagnosed with multiple psychiatric conditions, including depression, schizoaffective disorder/bipolar type, major depressive disorder, alcoholism-dependence/withdrawal, and anxiety disorder. The resident was cognitively intact, as indicated by a BIMS score of 15. The physician order sheet documented an increase in Venlafaxine HCL ER from 225 mg to 300 mg daily, but there was no corresponding progress note or documentation from the interdisciplinary team (IDT) or physician explaining the need for this dosage increase or describing any behavioral interventions considered prior to the change. Review of the medication administration records confirmed that the resident received the increased dosage as ordered. The Director of Nursing (DON) was unable to provide documentation of an IDT meeting or clinical justification for the medication change. The facility's policy requires that psychotropic drug use be based on comprehensive assessment and that gradual dose reductions and behavioral interventions be implemented unless contraindicated, with dosage reductions attempted per CMS guidelines unless clinically contraindicated. These requirements were not met in this instance.
Failure to Provide Range of Motion Exercises and Restorative Devices
Penalty
Summary
Surveyors identified that the facility failed to provide appropriate range of motion (ROM) exercises and apply restorative devices for three residents with limited mobility and contractures. One resident with contractures of both hands and quadriplegia was observed without hand protectors or splints in place, despite care plans and physician orders specifying the use of such devices. Staff confirmed that the required splints and palm protectors were not available, and temporary alternatives such as rolled towels were not implemented as directed. The restorative nurse acknowledged the lack of supplies and indicated that the administrator had been informed, but no interim measures were put in place. Another resident with left-sided weakness from a stroke reported that staff had not been providing ROM exercises for the affected limbs, expressing concern about developing contractures. A third resident also complained of not receiving ROM exercises for over two weeks. The restorative aide responsible for these residents stated that one of the residents was not on the current list for ROM exercises and admitted that the list was outdated. The aide also noted being unable to perform ROM exercises for all assigned residents due to time constraints and other duties, such as escorting residents or covering for staff absences. Record reviews for the affected residents showed documented diagnoses of contractures, hemiplegia, muscle weakness, and reduced mobility, with care plans and physician orders specifying the need for restorative interventions, including ROM exercises and the use of assistive devices. Facility policies and job descriptions for restorative staff and CNAs require the provision and documentation of ROM exercises and the use of restorative equipment to maintain or improve residents' mobility. Despite these requirements, the facility did not ensure that restorative care was consistently provided, and necessary devices were not available or used as ordered.
Failure to Secure and Account for Controlled Medications
Penalty
Summary
Surveyors identified several deficiencies related to the management of controlled medications. During an observation of the medication storage area, a nurse accessed a refrigerator containing controlled substances without a lock, despite the presence of Lorazepam for a resident whose medication order had already been completed. The nurse acknowledged that the refrigerator should have been locked due to the presence of controlled medications and found the lock on the floor, indicating it was not in use. Additionally, the completed Lorazepam medication, which should have been returned to the pharmacy after the order ended, was still present in the facility. Further review of medication administration records and interviews revealed that the facility failed to ensure proper documentation on the Narcotic/Controlled Substance Shift-to-Shift Count Sheet. Specifically, there were missing signatures from outgoing nurses on two separate dates, which was confirmed by staff. The expectation, as stated by facility leadership, is that both incoming and outgoing nurses count and sign for controlled medications at each shift change to ensure accountability and accurate record-keeping. The residents affected by these deficiencies included individuals with diagnoses such as osteoarthritis, hypertension, seizure history, neuralgia, hemiplegia, low back pain, post-traumatic stress disorder, and sleep disorder. The facility’s policies and job descriptions require that controlled substances be double locked, properly disposed of or returned when no longer needed, and that accurate shift-to-shift counts and documentation be maintained. These requirements were not met, as evidenced by the unsecured storage, retention of completed medications, and incomplete shift count records.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, as evidenced by a verbal and physical altercation between them. One resident, a female with emphysema, hypothyroidism, and liver disease, and a history of conflictual behavior and susceptibility to abuse, was involved in a dispute with a male resident who has a vertebra fracture, neurogenic bowel, anxiety disorder, depressive disorder, and angina pectoris, and is also care planned as susceptible to abuse. During the incident, the male resident threw water on the female resident during a verbal altercation, and both exchanged derogatory and offensive language. The altercation was witnessed by an LPN, who separated the residents and reported the incident to the administrator/abuse prevention coordinator. The incident was also reported to the police. Both residents had documented histories of behavioral issues, including verbal threats, use of profanity, and difficulty coping with stress. The facility's abuse prevention policy prohibits and aims to prevent resident abuse, neglect, and mistreatment, but the altercation and subsequent investigation revealed that the facility did not ensure the right of these residents to be free from abuse. The incident was documented in progress notes and an abuse prevention investigation, with both residents expressing that they felt safe after the event, but the deficiency centers on the facility's failure to prevent the abusive interaction from occurring.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent and protect residents from resident-to-resident physical and verbal abuse, affecting two residents out of five reviewed. In one incident, a resident with moderate cognitive impairment and diagnoses including parkinsonism and weakness was pushed by another resident after a verbal disagreement in the hallway, resulting in a minor scrape to the elbow. Staff intervened and separated the residents, and the injured resident reported feeling safe afterward. In a separate incident, another resident with intact cognition and a history of chronic heart failure and mobility issues was punched in the eye by the same aggressor after requesting that the television volume be lowered late at night. The aggressor also yelled derogatory language and threatened further violence. Staff, including an LPN and a CNA, responded to the altercation, attempted to redirect the aggressor, and called for additional assistance when the aggressor became physically and verbally aggressive toward both staff and the other resident. The injured resident declined police involvement and reported no lasting distress. The aggressor resident had a history of major depressive disorder, aphasia, and hemiplegia, with documented moderate cognitive impairment. Care plans noted the resident's risk for abuse and socially inappropriate behaviors, including playing loud music and difficulty with interpersonal interactions. Despite these known risks and previous incidents, the facility did not effectively prevent further altercations, resulting in physical and verbal abuse between residents.
Failure to Respond to Nurse Call Lights in a Timely Manner
Penalty
Summary
The facility failed to meet the needs of residents by not responding to nurse call activations in a timely manner for three out of ten residents sampled. Resident Council Meeting Minutes from January and February 2025 highlighted ongoing issues with CNAs not responding to call lights, being rude, and not providing timely assistance, especially during meal times. Residents reported waiting for extended periods, sometimes up to two hours, for assistance after activating their call lights. Specific incidents included residents waiting for ADL care and remaining in soiled conditions due to delayed responses. On March 24, 2025, a surveyor observed a nurse call light activated on the 2nd floor, which went unanswered for an extended period. Despite being aware of the call light, both an LPN and a CNA failed to respond, citing being too busy. The facility's policy requires all staff to promptly and courteously respond to call lights, but this was not adhered to, leading to the deficiency. The lack of timely response to call lights was corroborated by resident statements and direct observations by the surveyor.
Failure to Prevent Resident Altercation
Penalty
Summary
The facility failed to ensure the right to be free of abuse for two residents, resulting in minor injuries. The incident involved two female residents, both with a BIMS score of 15/15, indicating they were cognitively intact. The first resident, with a history of Diabetes 2, Anxiety Disorder, Heart Disease, and Pyoderma Gangrenosum, and the second resident, with a history of Diabetes 2, Chronic Respiratory Failure, Peripheral Vascular Disease, and Congestive Heart Failure, engaged in a physical altercation. The altercation occurred during a disagreement over whether the door to their shared room should remain open while they were playing cards. The first resident sustained a superficial scratch on her forearm, while the second resident received a small mark under her eye. The incident was promptly addressed by staff, who intervened and separated the residents. Both residents were sent to the hospital for psychiatric evaluations, although they did not require treatment for injuries. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the physical contact between the residents. Despite the altercation, both residents expressed feeling safe in the facility and declined police involvement. The facility's failure to prevent the altercation constitutes a deficiency in protecting residents from abuse.
Failure to Prevent Resident Abuse
Penalty
Summary
The facility failed to follow its policy to ensure a resident is free from abuse, affecting one resident (R2) out of three reviewed for abuse. R2, who has a history of various medical conditions including epilepsy, cerebral infarction, and mental health disorders, reported being physically abused by another resident (R1) on 11/30/24. R2 stated that R1 punched him in the back without provocation as he was coming off the elevator. Although R2 did not sustain visible injuries, he expressed feeling abused by the incident. Multiple staff members and residents provided accounts of the incident. An LPN, who did not witness the event, responded to a Code PURPLE and found R1 agitated and wanting to smoke. The LPN was informed by a receptionist that R1 had hit R2. A social service director confirmed that R1 was sent to the hospital for psychiatric evaluation following the altercation. A CNA and another resident corroborated R2's account, stating that R1 deliberately hit R2. The facility's Director of Nursing and other staff members acknowledged the incident, with the DON noting that R1 made contact with R2 and was subsequently placed on 1:1 supervision until transferred to the hospital. The facility's policies on abuse prevention and residents' rights were not adequately followed, as evidenced by the lack of an abuse care plan for R1, who had a history of aggressive behavior. The facility's abuse prevention program defines abuse as the willful infliction of injury or harm, and the incident between R1 and R2 was considered physical abuse by several witnesses. Despite the facility's policy to prevent abuse, the incident occurred, highlighting a deficiency in the implementation of the facility's abuse prevention measures.
Verbal Abuse by Receptionist Towards Resident
Penalty
Summary
The facility failed to prevent verbal abuse by a staff member, specifically a former receptionist, towards a resident. The incident involved the receptionist, identified as V3, who allegedly used profanity towards a resident, R2, when R2 verbally shared the security code for the door with others. This interaction was witnessed by another resident, R4, who confirmed hearing the receptionist curse at R2. The incident was reported to the facility's administrator, V1, who apologized to R2. Despite the resident feeling safe and not experiencing physical or emotional distress, the use of profanity was considered verbal abuse by several staff members interviewed. The facility's investigation into the incident involved interviews with various staff members and residents. V5, another receptionist, and V7, a restorative aide, both acknowledged that swearing at a resident constitutes verbal abuse. V10, a CNA, did not recall the incident but agreed that such behavior is abusive. V2, the Director of Nursing, and V11, the Social Service Coordinator, both indicated that if the statement was made, it would be considered verbal abuse, regardless of the resident's feelings of safety. The administrator, V1, conducted an investigation and concluded that while the abuse could not be substantiated, the receptionist's communication was inappropriate and made R2 uncomfortable. The facility's policy on abuse prevention clearly prohibits verbal abuse, defining it as the use of disparaging or derogatory language towards residents. Despite the facility's inability to substantiate the abuse claim, the incident highlights a failure to protect the resident from verbal abuse, as defined by the facility's policy. The receptionist was suspended pending the investigation, and the facility's protocol was implemented, although the report does not detail specific corrective actions taken post-incident.
Failure to Administer Scheduled Pain Medication
Penalty
Summary
The facility failed to provide a scheduled pain medication, Tramadol, per doctor's order for effective pain management for a resident diagnosed with progressive systemic sclerosis, Raynaud's syndrome, and other mobility issues. The resident, who is cognitively intact, reported experiencing significant pain and discomfort due to the lack of Tramadol, which was not administered on specific days. The resident expressed that without Tramadol, she was unable to get out of bed without experiencing a lot of pain and discomfort in her joints and body. On the day of the survey, a registered nurse (RN) was observed attempting to administer medications but found that the Tramadol was not available in the medication cart. The RN offered Tylenol as an alternative, which the resident accepted despite stating it would not be effective. The Director of Nursing (DON) later retrieved Tramadol from the emergency medication system after encountering issues with the system being offline. The resident's medication administration record confirmed that Tramadol was not administered on a specific date, and there was no documentation of the resident refusing the medication. The report highlights communication and procedural lapses among the nursing staff and pharmacy, leading to the resident not receiving her prescribed medication. The nurse practitioner was not aware of the medication lapse and indicated that the staff could have contacted the on-call provider for an emergency refill. The facility's documentation guidelines state that medications should be administered as prescribed, but the resident's care plan and medication records were not followed, resulting in the deficiency.
Failure to Protect Residents from Abuse and Address Injury
Penalty
Summary
The facility failed to protect two residents from physical and verbal abuse, resulting in one resident experiencing a right foot injury. The incident began with a verbal disagreement between the two residents over the use of the washroom in their shared room. One resident, who was eating lunch, became upset when the other resident used the bathroom with the door open. This led to a heated argument, during which the resident in the wheelchair felt threatened and physically engaged with the other resident, resulting in both residents falling to the floor. The resident in the wheelchair sustained a right foot injury during the altercation, which was later diagnosed as a subacute fracture of the distal right fourth metatarsal. Despite the resident's complaints of foot pain following the incident, the facility staff initially failed to address the injury adequately. The resident reported the pain to several nurses, but it was not until a week later that an LPN arranged for an X-ray, which confirmed the fracture. The resident's foot was swollen and painful, and the resident was unable to stand, which was a change from their previous ability to stand independently. Interviews with staff revealed that the altercation was witnessed by multiple staff members, including a Social Service Director and a Certified Nursing Assistant, who observed the residents arguing and physically engaging with each other. The facility's policy on abuse prevention emphasizes the importance of creating a safe environment and preventing abuse, yet the staff did not intervene effectively to prevent the altercation or address the resulting injury promptly. The facility's failure to protect the residents from abuse and to respond appropriately to the injury constitutes a deficiency in care.
Failure to Follow Professional Standards and Timely Report Injuries
Penalty
Summary
The facility failed to maintain a safe environment and follow professional standards of practice, resulting in injuries to two residents. One resident, R2, experienced new onset right foot pain after an altercation with another resident, R1, on 6/24/24. Despite R2's repeated complaints of pain, the facility delayed notifying the physician until 6/28/24, and an X-ray on 6/30/24 revealed a new healing subacute fracture of the distal right fourth metatarsal. The facility did not document any assessment or follow-up related to R2's right foot injury until the physician was notified. Another resident, R5, suffered a left knee fracture after an incident on 6/20/24, where R5's wheelchair collided with a brick wall. R5 later reported right knee pain after hitting it on a bedframe on 7/3/24, but the facility failed to promptly assess or notify the physician of this new injury. Despite R5's complaints and the physical therapist's recommendation for an X-ray, the facility did not take action until 7/10/24, when a CT scan revealed an acute inter-articular fracture of the right femoral condyle. The facility's policies require immediate assessment and notification of the physician for any incidents resulting in injury or significant changes in a resident's condition. However, in both cases, the facility did not adhere to these policies, leading to delays in diagnosis and treatment. The lack of timely communication and documentation contributed to the deficiencies identified by the surveyors.
Inadequate Supervision Leads to Resident Self-Harm
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring of a resident with a history of unsafe and self-harmful behaviors, resulting in the resident sustaining a nasal fracture. The resident, identified as R3, had multiple diagnoses including schizoaffective disorder, depressive type, and a history of physically aggressive behavior. On 6/17/2024, R3 was observed hitting himself in the face in the dining room, which led to a nasal fracture. Despite being in a supervised area, the staff present did not prevent the self-harm incident. The incident was not immediately addressed, as discoloration on R3's face was only noticed two days later on 6/19/2024, prompting a call to the doctor and subsequent x-rays that confirmed the fracture. Staff interviews revealed inconsistencies in monitoring R3, with some staff unsure if R3 was being monitored at the time of the incident. The facility's policy required notification of the resident's physician and representative in case of significant changes in the resident's condition, but it is unclear if this was done promptly. The facility's guidelines for handling behavioral emergencies emphasize early recognition and intervention, but these were not effectively implemented in R3's case. The documentation showed that 15-minute checks were initiated only after the incident, indicating a lapse in proactive supervision. The lack of consistent monitoring and immediate intervention contributed to the resident's injury, highlighting a deficiency in the facility's supervision and safety protocols for residents with known self-harm behaviors.
Failure to Comply with Medication Administration Standards
Penalty
Summary
The facility failed to provide medication in compliance with standards of professional practice and facility policy for a resident, identified as R5. On 7/9/2024, R5 was observed with a lidocaine patch on the right knee dated 7/7/2024 and another patch on the left knee without a date. R5 mentioned that the patches had been on for a few days. A Licensed Practical Nurse (LPN), V4, was unaware of the patches and confirmed there was no order for lidocaine patches for R5. The Director of Nursing (DON), V2, later confirmed that there was no active order for lidocaine patches until 7/8/2024, and the nurse had incorrectly documented the application date. Additionally, there was no documentation of the lidocaine patch application until 7/9/2024. On 7/11/2024, R5 was observed with two lidocaine patches on the right knee, both undated, contrary to the order for one patch. Another LPN, V3, acknowledged the lack of documentation and communication regarding the patches. The DON provided documentation of a lidocaine patch application on 7/11/2024, but it was noted that the order was for only one patch. V10, an LPN who worked with R5 on 7/8/2024, stated that she did not apply the patches and was unaware of their presence. The facility's policy requires medications to be administered and documented according to physician orders, which was not followed in this case.
Failure to Conduct Timely Background Checks for New Residents
Penalty
Summary
The facility failed to perform timely criminal background checks for new residents, which is a critical step in preventing abuse and ensuring the safety of all residents. Specifically, the facility did not complete the Criminal History Information Response Process (CHIRP) within the required 24 hours of admission for several residents, nor did they obtain fingerprint orders within 72 hours when a preliminary criminal history search indicated a potential issue. This deficiency affected multiple residents, including those with serious mental health conditions such as schizoaffective disorder, bipolar disorder, and dementia. Interviews with facility staff revealed a lack of clarity and coordination in the process of conducting these background checks. The Administrator expressed hope that residents were isolated until CHIRP results were received, while the Admissions Director and Social Services Director provided conflicting accounts of their responsibilities. The Admissions Director stated that CHIRP is conducted upon admission, but the Social Services Director indicated that they were responsible for further checks and fingerprinting, which were not completed in a timely manner. The facility's policies on abuse prevention and resident rights emphasize the importance of protecting residents from abuse and ensuring a safe environment. However, the failure to adhere to these policies and complete necessary background checks in a timely manner demonstrates a significant oversight. The lack of documentation for some residents further highlights the gaps in the facility's procedures, which could potentially affect the safety and well-being of all residents.
Incomplete Background Checks Pose Risk to Residents
Penalty
Summary
The facility failed to ensure that Health Care Worker Background Checks were thoroughly completed and conducted in a timely manner, which is crucial for preventing abuse. This deficiency was identified during a survey where it was found that the background check for an employee, a cook hired in 1998, was not completed until over 20 years after their hire date. The Illinois Department of Public Health's Health Care Worker Registry indicated that the employee's work eligibility was 'Not Yet Determined,' and no further action, such as fingerprinting, was taken to resolve this status. The Regional Human Resource Director acknowledged the oversight and could not provide an explanation for why the previous Human Resource Director did not address the issue. The facility's policies, including the Abuse Prevention Program and the Facility Assessment Tool, require that criminal history checks and healthcare work registry checks be completed before a new employee starts working. However, these procedures were not followed in this case, as evidenced by the incomplete background check for the cook. The facility's job description for the Human Resource Director outlines the responsibility for ensuring all new hire paperwork, including background checks, is complete, but this responsibility was not fulfilled, leading to a potential risk for all 137 residents in the facility.
Failure to Post Accurate Daily Nursing Staffing Information
Penalty
Summary
The facility failed to post the daily nursing staffing information accurately and in a timely manner, which has the potential to affect all 137 residents residing in the facility. On multiple occasions, the surveyor observed that the daily nursing staffing information posted near the receptionist area was outdated, showing a date of 5/17/24 instead of the current date. The Director of Nursing acknowledged the issue and replaced the outdated posting with a current one. However, the updated posting still contained inaccuracies, such as an incorrect resident census and lack of specific unit information. The receptionist, who is responsible for posting the daily staffing information, was not present on the day the deficiency was noted and was unsure why the information had not been updated since 5/17/24.
Failure to Monitor Food Storage Temperatures
Penalty
Summary
The facility failed to maintain adequate monitoring of food storage temperatures, which has the potential to affect all residents. During an observation and record review, it was noted that the Milk Cooler refrigerator temperature log for May 2024 lacked temperature recordings for both the AM and PM shifts on specific dates. The Dietary Manager confirmed that the temperature log should have been completed twice daily and acknowledged the importance of tracking the cooler's temperature to prevent milk spoilage. The facility's policy on the storage of refrigerated and frozen foods requires monitoring of food temperatures and the functioning of refrigeration/freezer units.
Infection Control Deficiencies in PPE Use and Signage
Penalty
Summary
The facility failed to ensure proper disposal of personal protective equipment (PPE) by staff handling soiled linens, as observed in the case of a laundry aide who reused a blue plastic gown throughout an entire shift. The aide, who had been working at the facility for six years, was not informed of the requirement to wear a new gown each time they sorted dirty linens. This practice was contrary to the facility's infection control guidelines, which mandate the use of new gowns and gloves after handling soiled items to prevent the spread of infectious microorganisms. Additionally, the facility did not appropriately post precautionary signage for a resident on enhanced barrier precautions. An isolation bin was observed outside the resident's room without the necessary precaution sign on the door. The resident had a gastrostomy tube and an indwelling catheter, which required enhanced barrier precautions as per the facility's policy. Staff acknowledged that the sign should have been posted to inform caregivers of the necessary precautions when providing care to the resident. The facility's infection control policies and guidelines emphasize the importance of handling soiled linens with protective apparel and posting precaution signs for residents requiring enhanced barrier precautions. However, these protocols were not followed, as evidenced by the reuse of PPE by the laundry aide and the absence of a precaution sign for the resident with medical devices. These oversights have the potential to affect all residents by increasing the risk of spreading infectious microorganisms.
Failure to Assess Resident's Ability to Self-Administer Medication
Penalty
Summary
The facility failed to ensure that medication was not left inside the room of a resident whose ability to self-administer medications had not been assessed. This deficiency was observed when a small plastic bag containing a tube of medication was found on a resident's bedside table. The medication was intended for topical application to the resident's right thigh and perineal area for a skin condition. However, there was no self-administration care plan or assessment in place for the resident, and no physician's order had been written to allow the resident to self-administer the medication. The resident involved had a severely impaired mental status, as indicated by a Brief Interview for Mental Status (BIMS) score of 03. The Director of Nursing confirmed that the resident did not have a self-administration assessment or care plan, and highlighted the risk posed by leaving medication at the bedside, as other residents could potentially access and ingest it. The facility's policy requires an interdisciplinary team to assess a resident's ability to self-administer medication and obtain a physician's order, neither of which had been completed for this resident.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for several residents, as observed during a survey. In one instance, holes and cracks were found on the walls inside the room shared by two residents. A registered nurse acknowledged that the damage might have been caused by staff pushing the bed against the wall. A maintenance assistant confirmed the presence of holes, cracks, and chipped paint on the walls and window, admitting that these conditions did not contribute to a homelike environment. Both residents involved were documented as having cognitive intactness, with one diagnosed with cerebral palsy and spinal stenosis, and the other with a wedge compression fracture and gastrointestinal hemorrhage. Additional observations included peeling faux wood covering on the footboard of a resident's bed and a hole in the wall beneath a window in another room. The maintenance director noted that the bed was very old and that the hole in the wall was due to beds being pushed against it. The director also acknowledged that these conditions did not represent a homelike environment for the residents. The facility's resident rights documentation emphasized the right to a dignified existence and a safe, clean, comfortable, and homelike environment, which was not upheld in these instances.
Improper Low Air Loss Mattress Settings for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that low air loss mattresses were set to the appropriate settings for four residents, which is crucial for pressure ulcer prevention. Observations revealed that the mattresses for these residents were set at higher weight settings than the residents' actual weights. For instance, one resident's mattress was set at 240 lbs, while their actual weight was 168.4 lbs. Another resident's mattress was set at 250 lbs, despite their weight being 123.8 lbs. These discrepancies were confirmed by the facility's staff, including the Director of Nursing and the Wound Care Coordinator. The report highlights that the incorrect settings on the low air loss mattresses could interfere with circulation and pressure relief, potentially leading to skin breakdown. The facility's guidelines and the mattress system's intended use emphasize the importance of setting the mattress according to the resident's weight to prevent pressure ulcers. However, the facility did not adhere to these guidelines, as evidenced by the incorrect settings observed during the survey. The residents involved had various medical conditions that increased their risk for pressure ulcers, such as impaired mobility, diabetes, and incontinence. The care plans for these residents included interventions like pressure-reducing mattresses, yet the improper settings on the mattresses compromised these interventions. The facility's failure to ensure the correct settings on the low air loss mattresses represents a significant oversight in pressure ulcer prevention and care.
Resident Dignity Compromised by Uncovered Medical Information
Penalty
Summary
The facility failed to ensure the confidentiality and dignity of a resident by leaving personal medical information in plain view within the resident's room. Specifically, signs detailing the resident's dietary requirements and aspiration precautions were posted on a bulletin board at the head of the resident's bed. These signs were visible to other residents and visitors, compromising the resident's right to privacy and dignity. The signs included instructions for honey thick liquid and aspiration precautions, which were placed by a Speech Language Pathologist (SLP) to ensure staff compliance with the resident's care plan. Interviews with facility staff revealed that the signs had been posted for approximately three months without being covered, despite awareness that they should be concealed to protect the resident's dignity and comply with HIPAA regulations. The Director of Nursing (DON) acknowledged that the information should have been covered to prevent unauthorized viewing by individuals entering the room. The resident in question had a history of dysphagia and essential primary hypertension, requiring a mechanically altered diet, as documented in their care plan and order summary report.
Failure to Provide Communication Devices for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide necessary communication devices for a resident, identified as R54, who was unable to communicate effectively due to a language barrier and medical condition. Observations revealed that R54, whose primary language is Spanish, was unable to answer questions in either English or Spanish and could only use hand gestures. Despite the care plan indicating the need for communication aids such as a communication board, none were present in R54's room. Interviews with R54's family member and the responsible LPN confirmed the lack of communication interventions, with the LPN relying on Spanish-speaking housekeeping staff for translation. R54's medical records document a diagnosis of Cerebral Infarction and Aphasia, contributing to the resident's communication challenges. The Minimum Data Set indicated limited ability to make self-understood requests. The care plan specifically outlined the need for communication devices to assist R54, yet these were not utilized, leading to increased frustration for the resident. The facility's policy on communication with non-English speaking residents was not followed, as it required input from the resident or responsible party and specific care planning for communication barriers.
Failure to Change Midline Catheter Dressing as Per Policy
Penalty
Summary
The facility failed to adhere to its policy regarding the changing of a midline catheter dressing for a resident. A resident had a midline catheter placed on their left arm, and the dressing was applied on the same day. However, the dressing was not changed for a week, as observed by a registered nurse, who noted redness around the chlorohexidine patch under the transparent area of the dressing. The registered nurse confirmed that the dressing had not been changed since its application, and acknowledged that the redness could indicate a potential infection, which should be reported to the resident's physician. The Director of Nursing stated that midline dressings should be changed weekly and monitored every shift for signs of infection, such as redness, swelling, or warmth. The facility's policy specifies that midline catheter dressings should be changed 24 hours after insertion, every 5-7 days, or if compromised.
Infection Control Lapses in Respiratory Care Equipment
Penalty
Summary
The facility failed to ensure proper infection control practices for respiratory care equipment for two residents. For one resident, the nebulizer mask was observed sitting on a bedside table without being contained in a plastic bag when not in use, contrary to the facility's policy for infection control. The Licensed Practical Nurse confirmed that the mask should be stored in a plastic bag to prevent contamination. The resident had a history of chronic obstructive pulmonary disease, anemia, bipolar disorder, and schizoaffective disorder, with a moderately impaired cognitive status. The facility's policy required the nebulizer mask and tubing to be changed weekly, which was not adhered to in this instance. For another resident, the nasal cannula attached to an oxygen tank was not changed weekly as required by the facility's protocol. The cannula was dated two weeks prior, and the Registered Nurse acknowledged that it should have been changed weekly by the night shift nurse. This resident also had a history of chronic obstructive pulmonary disease, pneumonia, and heart failure, with a moderately impaired mental status. The facility's policy mandated that oxygen tubing be changed, cleaned, and maintained no less than weekly, which was not followed, leading to a lapse in infection control practices.
Failure to Follow Fall Assessment and Documentation Procedures
Penalty
Summary
The facility failed to follow their policy and procedure for resident assessment and documentation after a fall/incident for one resident. The resident, who had a complex medical history including hemiplegia, end-stage renal disease, and a history of falling, reported a fall to a CNA early in the morning. The CNA informed the assigned nurse, who checked on the resident but did not perform a comprehensive assessment or document the incident as required by the facility's policy. The resident's electronic health record lacked documentation of the resident's physical and mental status following the fall, and no incident report was completed by the nurse on duty during the night shift. The Director of Nursing stated that after a fall, the nurse is expected to complete an incident report, document in the resident's electronic health record, perform a comprehensive assessment, and check vital signs and range of motion. Additionally, follow-up documentation should be done every shift for 72 hours to monitor the resident for any injury post-fall. However, these procedures were not followed in this case, as evidenced by the lack of documentation and assessment in the resident's health record. The facility's accident incident reporting policy also mandates immediate assessment and documentation, which was not adhered to in this instance.
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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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