Lutheran Home For The Aged
Inspection history, citations, penalties and survey trends for this long-term care facility in Arlington Hts, Illinois.
- Location
- 800 West Oakton Street, Arlington Hts, Illinois 60004
- CMS Provider Number
- 145739
- Inspections on file
- 47
- Latest survey
- December 1, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Lutheran Home For The Aged during CMS and state inspections, most recent first.
A resident with right-sided hemiplegia and impaired cognition, who required two-person assistance for turning, was left with only one CNA during a bed bath. After water was spilled, making the mattress slippery, the CNA attempted to turn the resident alone, resulting in the resident falling from the bed and sustaining a right patella fracture. Staff interviews confirmed that the resident's care plan required two-person assistance and that the wet surface contributed to the fall.
A resident who is cognitively intact and dependent on two staff for transfers sustained a fractured toe when her foot became caught between the bars of a mechanical lift during a transfer. The resident reported that staff usually guide her feet, but this was not done during the incident, leading to significant pain and bruising. Staff interviews revealed confusion about who performed the transfer and whether proper procedures were followed, and radiology confirmed an acute fracture.
A resident sustained a right leg fracture after being improperly secured and transferred with a mechanical sit-to-stand lift. During the transfer, the resident became unresponsive, the lift malfunctioned, and staff were unable to safely lower her, resulting in her leg coming off the platform and being injured as she was assisted to the floor.
A resident with severe dementia and a known behavior of placing her feet on the floor during wheelchair transport was not provided with adequate supervision or care planning, resulting in a fall and facial injury. Multiple staff and the resident's POA confirmed this longstanding behavior, but the care plan lacked interventions addressing the risk, and the CNA involved was not informed of the resident's tendencies.
A resident with a history of cancer and compression fracture experienced increased pain due to a delay in receiving prescribed morphine, as pharmacy and order issues prevented timely administration. Staff provided Tylenol, which was insufficient for severe pain, and did not contact the physician for alternative pain control, resulting in inadequate pain management until the correct medication was obtained.
A resident's credit card was misappropriated after her niece left it at the nurse's desk in a white envelope. The resident needed the card for transportation to a medical appointment. Despite the niece's description of the nurse who took the envelope, facility staff did not recall receiving it, and unauthorized charges were made on the card. The facility's investigation could not determine how the card was misappropriated.
A resident's credit card went missing after being dropped off at the nurse's desk by her niece. Despite the facility's policy requiring notification to the police within 24 hours for suspected theft, the administrator did not report the incident, as requested by the resident and her niece. Unauthorized charges were later discovered on the card.
A resident with prostate cancer experienced continued pain due to the facility's failure to manage and communicate effectively about his pain medication. Despite a prescription for a Fentanyl patch, the facility did not obtain or administer it promptly, leading to the resident's distress. Communication breakdowns among staff, pharmacy, and the resident's family contributed to the delay, and the resident's scheduled Norco dose was held without explanation.
The facility failed to properly store and label insulin and controlled medications. Insulin pens and vials were not refrigerated or dated, and controlled medications were not double-locked, as required by policy. An RN confirmed the need for refrigeration and dating of insulin, and the ADON emphasized the importance of a two-lock system for controlled substances.
The facility failed to maintain resident dignity by not providing feeding assistance in a dignified manner and not using a catheter dignity bag. A CNA stood over a cognitively impaired resident during feeding, against policy requiring seated assistance. Another resident's catheter bag was visible from the hallway, despite the resident's preference for privacy and facility policy requiring dignity bags.
A facility failed to complete a Level I PASSAR screening for a resident with a serious mental health diagnosis, including major depressive disorder and behaviors like paranoia and hallucinations. The Social Services Director encountered a system error when attempting the screening, and the facility's policy lacked guidance on the PASSAR process.
A resident dependent on staff for grooming and personal hygiene was observed with a disheveled appearance and reported not receiving adequate care. Despite being assessed as needing assistance, the resident had long facial hair and debris under fingernails, and staff interviews revealed inconsistencies in care provision. The care plan was revised to indicate resistance to care only after surveyor observations, and no specific policies on hygiene were provided.
A resident with a recent hip surgery experienced issues with a non-operational wound vacuum, leading to prolonged exposure to wound drainage. The facility failed to have appropriate physician orders and care interventions in place, resulting in the wound vacuum being removed without documented orders. The resident's care plan lacked necessary interventions, and staff were unaware of how to manage the device, highlighting a deficiency in wound care management.
Three residents in a facility experienced deficiencies in pressure ulcer care and prevention. One resident did not receive updated wound care treatment, another had a flattened pressure relief cushion and delayed treatment updates, and a third had an air mattress set incorrectly for their weight, compromising care.
A resident with multiple sclerosis and dysphagia was left unsupervised during meals, despite requiring a pureed diet and supervision to prevent choking. Observations showed the resident eating alone in both the dining room and their room. Staff confirmed the need for supervision, but the facility lacked a policy for supervising residents with swallowing difficulties.
A resident's indwelling urinary catheter bag was improperly handled, being placed on the floor and stepped on, contrary to the facility's infection control policy. The resident, with multiple health issues including urinary retention, had a care plan requiring enhanced precautions. Staff confirmed the catheter bag should not be on the floor to prevent infection.
The facility failed to implement enhanced barrier precautions (EBP) for residents with surgical wounds and ensure proper PPE use during catheter care. A resident with a hip surgery wound vacuum lacked EBP signage and PPE, while another with a Foley catheter had improper PPE use. Additionally, a resident with a stage 3 pressure wound had no EBP sign or care plan, indicating deficiencies in infection control practices.
The facility failed to prevent and timely identify pressure ulcers in two residents, leading to severe health issues. One resident developed a Stage 4 infected sacral pressure ulcer due to lack of preventive measures, while another resident's unstageable pressure wound was not identified early enough for intervention. The facility's Pressure Injury Prevention Policy was not adequately followed, resulting in these deficiencies.
Two residents experienced unsafe wheelchair transfers due to the facility's failure to use footrests as required by policy. One resident fell and suffered a brain hemorrhage, while another was observed with feet sliding on the floor during transport. Staff interviews confirmed the expectation of using footrests for safety, which was not adhered to.
A resident at high risk for falls slipped and fell on a wet floor after showering because the CNA did not dry the floor before the resident stood up. The RN confirmed the floor was wet, and the facility's policy identifies wet floors as a fall risk factor.
A resident with prostate cancer did not receive ordered chemotherapy drugs due to medication shortages at the facility. The MAR showed multiple instances of unavailability, and staff struggled to obtain the medications through the usual specialty pharmacy. Communication issues and insurance problems were noted, contributing to the deficiency.
A resident with a history of joint replacement and femur fracture fell while attempting to transfer himself from the toilet. A CNA moved the resident back into the wheelchair without waiting for a nurse to assess for injuries, contrary to the facility's policy. The incident occurred during a shift change, delaying the nursing staff's response.
A resident with multiple diagnoses was discharged without necessary medications, despite being told they would be sent home with a few days' worth. The facility had recently changed pharmacies and did not have a policy for discharge medications, leading to a delay in the resident obtaining their medications. The LPN did not verify medication availability with the family, and nursing staff did not attend care plan meetings to discuss medication needs.
Failure to Provide Adequate Supervision During Resident Repositioning Resulting in Fall and Fracture
Penalty
Summary
A resident with a history of cerebrovascular accident, right-sided hemiplegia, dysarthria, and right leg pain, who was care planned for impaired cognition, limited mobility, and high fall risk, was not safely repositioned during in-bed care. The resident required staff assistance for turning and bed mobility, including instruction cues and hand guidance. During a bed bath, a CNA was providing care alone when a basin of water was spilled, making the mattress wet and slippery. Despite the resident's inability to use her right side and the increased risk due to the wet surface, the CNA proceeded to turn the resident without additional assistance. As the resident was turned to her right side, she lost her balance and fell from the bed onto the floor. Following the fall, the resident complained of right knee pain, and an X-ray confirmed a mildly displaced fracture of the superior margin of the patella. The resident's care plan and staff interviews confirmed that two staff members were typically required for turning due to her physical limitations. The CNA involved acknowledged that the wet and slippery mattress contributed to the fall and that the resident's previous bed was smaller, which may have increased the risk. The facility's policy identified wet surfaces, cognitive impairment, and poor grip strength as fall risk factors, and the DON stated that a second person should have been called to assist after the water spill.
Failure to Ensure Safe Mechanical Lift Transfer Results in Resident Toe Fracture
Penalty
Summary
A deficiency occurred when a resident, who is cognitively intact and dependent on two staff members for transfers, sustained a displaced fracture to her right great toe during a mechanical lift transfer. The resident reported that, during the transfer from her wheelchair to bed, her foot became caught between the center bars of the lift, resulting in significant pain and bruising. The resident stated that staff usually guide her feet during transfers, but on this occasion, her foot was not properly guided, leading to the injury. The incident was not immediately reported to the nurse on duty, and there was confusion among staff regarding who performed the transfer and who was present in the room at the time of the incident. Interviews with staff revealed that the resident requires a full body mechanical sling lift and cannot transfer herself, with the care plan indicating a two-person assist for transfers. However, staff were unable to clearly identify who performed the transfer or if the required number of staff were present. The resident's injury was later confirmed by radiology as an acute, mildly displaced fracture of the right first proximal phalanx, with associated swelling. Documentation and interviews indicated a lack of adequate supervision and failure to ensure safe transfer practices, resulting in the resident's injury.
Resident Fracture Due to Improper Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident was not safely transferred using a mechanical sit-to-stand lift, resulting in the resident sustaining a proximal tibia and fibula fracture of the right leg. The incident began when a CNA was assisting the resident to use the toilet with the lift. After the resident had a large bowel movement, she became unresponsive while being cleaned and transferred. The CNA called for assistance, and additional staff responded. During this time, the lift failed to lower the resident, and the emergency release button was also not functioning. Staff attempted to lower the resident manually while the nurse tried to operate the lift controls. Observations from staff interviews revealed that the resident's right leg was off the platform, the leg strap was either loose or removed, and the resident was not fully secured in the lift. The resident's leg was positioned awkwardly, and staff were concerned about causing further injury while lowering her to the floor. Despite these concerns, the resident was slowly lowered to the ground, during which her right lower leg was bent and under her body. After being placed on the floor, the resident was found to have a bruise and abrasion on her right shin, and subsequent assessment confirmed a fracture. Facility policy and staff statements indicated that residents should be securely fastened in the lift, with straps snugly applied and feet placed flat on the platform. Proper procedure was not followed, as the resident was not adequately secured, and her leg was able to come off the platform. The failure to ensure the resident was safely transferred and properly secured in the mechanical lift directly led to the injury.
Failure to Safely Transport Resident with Known Wheelchair Safety Risk
Penalty
Summary
A deficiency occurred when the facility failed to safely transport a resident with severe cognitive impairment and a history of putting her feet on the floor while being pushed in a wheelchair. The resident, an eighty-year-old female with severe dementia and agitation, was observed and reported by staff and her power of attorney to frequently place her feet on the ground during wheelchair transport. On one occasion, while being pushed toward the shower room, the resident placed her feet on the floor and fell forward out of the wheelchair, resulting in a laceration above her right eye that required three sutures and caused significant bruising. Multiple staff members, including CNAs and an LPN, confirmed that the resident had a longstanding behavior of putting her feet down during wheelchair movement, both when self-propelling and when being pushed by others. Despite this known behavior, the resident's care plan did not include any interventions or focus on this risk until after the incident. Additionally, the CNA who was pushing the resident at the time of the fall was not made aware of this behavior. The facility's fall prevention policy requires identification and documentation of resident risk factors for falls and the establishment of a resident-centered prevention plan, which was not followed in this case.
Failure to Provide Timely and Adequate Pain Management
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate pain management for a female resident with a history of lung cancer and a compression fracture. Upon admission, the resident experienced increased pain, reporting scores as high as 10 out of 10. The resident did not receive her scheduled morphine dose as ordered due to issues with pharmacy delivery and medication order clarification. Instead, she was given Tylenol, which was acknowledged by the physician as inadequate for severe pain. The LPN on duty did not contact the physician to obtain an alternative as-needed pain medication when the morphine was unavailable. The resident's pain was not effectively controlled until several hours after the initial complaint, when the correct morphine medication was finally administered. Documentation and interviews confirmed that the resident's pain was more controlled after receiving the appropriate medication, but she had experienced significant discomfort during the delay. The facility's records and staff interviews corroborated that the delay in obtaining and administering the prescribed narcotic pain medication led to inadequate pain control for the resident during the specified period.
Misappropriation of Resident's Credit Card
Penalty
Summary
The facility failed to protect a resident from the misappropriation of her credit card, which was not listed on her inventory list upon admission. The resident, who was cognitively intact and required assistance for daily activities, had requested her niece to drop off her credit card at the facility to pay for transportation to a medical appointment. The niece left the card in a white envelope at the nurse's desk, but the card was never received by the resident, leading to unauthorized charges. The niece described the nurse who took the envelope as wearing burgundy scrubs, two face masks, and glasses, but the facility staff interviewed did not recall receiving the envelope or seeing the niece on the specified date. The facility's electronic log confirmed the niece's brief visit to the facility. Despite the niece's detailed description, the staff could not identify the nurse, and the credit card was used for several unauthorized transactions at local stores and restaurants. The facility's investigation into the incident revealed that the credit card was reported missing by another niece, and the facility's policy on abuse and neglect was reviewed. The policy emphasizes the resident's right to be free from misappropriation of property, but the investigation did not determine how the card was misappropriated. The facility's administrator noted the possibility of the envelope being misplaced or discarded, allowing someone else to find and use the card.
Failure to Report Missing Credit Card to Police
Penalty
Summary
The facility failed to notify the police when a resident's credit card went missing and could not be located. The incident involved a resident whose niece reported that she had dropped off a credit card for the resident at the nurse's desk in a white envelope. Despite the resident's initial reluctance to involve the police, the facility's policy required them to report such incidents to local authorities within 24 hours if no serious bodily injury was involved. The administrator acknowledged the situation but did not report the missing credit card to the police, as the resident and her niece requested to hold off on the report. The resident later discovered unauthorized charges totaling $346.87 on her credit card, which were identified by the credit card company's fraud department. The facility's electronic sign-in system confirmed the niece's brief visit to the facility. The facility's policy on abuse and neglect clearly outlined the requirement to report suspected crimes, including theft, to the police and the Department of Public Health. However, this protocol was not followed, resulting in a deficiency in handling the suspected misappropriation of the resident's funds.
Failure in Pain Management and Communication
Penalty
Summary
The facility failed to effectively manage and communicate regarding a resident's pain management needs, resulting in the resident experiencing continued pain and emotional distress. The resident, who had a history of prostate cancer and other medical conditions, was transferred from a hospital where he was receiving two Norco tablets for pain management. Upon transfer to the facility, his medication was reduced to one Norco tablet, and his pain worsened. Despite a tele-visit with a pain nurse practitioner who prescribed a Fentanyl patch in addition to the Norco, the facility did not obtain or administer the patch in a timely manner. The breakdown in communication and coordination among the facility staff, pharmacy, and the resident's family contributed to the delay in pain management. The resident's spouse attempted to communicate the new prescription to the facility, but the information was not effectively relayed or acted upon by the nursing staff. The pharmacy received the prescription but did not deliver the medication due to a discrepancy in the order quantity, and there was no follow-up communication to resolve the issue promptly. The resident continued to express severe pain and frustration, feeling that his concerns were not being addressed. The facility's staff, including nurses and the assistant director of nursing, acknowledged the communication failures and lack of documentation regarding the resident's pain management. The resident's scheduled Norco dose was also held without proper documentation or explanation, further exacerbating the situation. The facility's pain management policy emphasizes the importance of timely and effective pain management, which was not adhered to in this case.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure proper storage and labeling of insulin and controlled medications for several residents. During an inspection of the 2B unit medication cart, it was found that insulin pens and vials belonging to residents were not refrigerated as required. Specifically, an insulin pen and a multi-dose vial were found in the cart's top drawer, both unopened and labeled to be kept refrigerated. Additionally, opened insulin containers were not labeled with dates, which is necessary to track their expiration. The RN present confirmed that insulin should be refrigerated until opened and dated once opened to ensure it is used within 28 days. Furthermore, the facility did not adhere to the policy of double-locking controlled medications. In the 2B unit medication room, the refrigerator containing multi-dose vials of lorazepam was found unlocked. The RN stated that the refrigerator is typically left unlocked between shifts, and initially, he was unsure if he had the keys to lock it. The Assistant Director of Nurses later confirmed that controlled medications should always be secured with a two-lock system to prevent unauthorized access. The facility's Medication Storage policy also mandates that controlled substances in the refrigerator be secured in a separately locked compartment.
Failure to Maintain Resident Dignity in Feeding and Catheter Care
Penalty
Summary
The facility failed to provide feeding assistance in a dignified manner for a resident with severe cognitive impairment. During a meal, a CNA stood over the resident while providing feeding assistance, contrary to the facility's policy that requires staff to be seated and make eye contact with residents during feeding. This policy aims to ensure that residents receive assistance with meals in a safe and dignified manner. The Assistant Director of Nursing confirmed that standing over residents while assisting them with meals is not considered dignified. Additionally, the facility did not use a catheter dignity bag for a resident whose catheter drainage bag was visible from the hallway. The resident, who was cognitively intact, expressed a preference for privacy regarding his catheter bag. The facility's policy and staff interviews indicated that catheter bags should be covered with dignity bags to maintain resident privacy and dignity. The Assistant Director of Nursing acknowledged that the catheter bag should have been covered or positioned away from the hallway to prevent visibility.
Failure to Complete PASSAR Screening for Resident with Mental Health Diagnosis
Penalty
Summary
The facility failed to obtain a Level I Preadmission Screening and Resident Review (PASSAR) for a resident who was admitted with a serious mental health diagnosis. The resident, identified as R77, was admitted with a history of major depressive disorder and exhibited behaviors such as paranoia, hallucinations, and wandering. The care plan for R77 indicated the use of psychotropic medications for behavior management and depression. Despite these indicators, the necessary PASSAR screening was not completed upon the resident's admission or readmission following hospitalization. The Social Services Director, identified as V4, attempted to complete the Level I PASSAR screen but encountered a system error. V4 acknowledged that the hospital typically conducts the screening before admission, but if not done, it was her responsibility to complete it. The facility's policy on the referral and admission process did not include information related to the PASSAR screening process, indicating a gap in the facility's procedures for ensuring compliance with PASSAR requirements.
Failure to Assist Resident with Daily Living Activities
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living for a resident, identified as R166, who was assessed to be dependent on staff for grooming and personal hygiene. R166, who has a medical history including cerebral infarction, dementia, and anxiety disorder, was observed multiple times over several days with a disheveled appearance, long facial hair, and debris under her fingernails. Despite being dependent on staff for showering and personal hygiene, R166 reported not receiving a bed bath since the previous Sunday and no recent assistance with oral hygiene. The care plan for R166 indicated a preference to stay in bed but did not document any resistance to care. Interviews with facility staff revealed inconsistencies in the provision of care. A registered nurse stated that R166 receives weekly bed baths and daily grooming, but also mentioned that refusals of care should be documented, which was not found in the progress notes. A certified nursing assistant assigned to R166 did not mention providing grooming or hygiene care beyond changing linens and checking for skin issues. The clinical educator confirmed that residents should receive daily hygiene care, including grooming and shaving, but acknowledged that R166's care plan was revised to indicate resistance to care only after the surveyor's observations. The facility's policy on activities of daily living was not adhered to, and no specific policies on bathing, grooming, or personal hygiene were provided upon request.
Failure to Ensure Proper Wound Vacuum Operation and Care
Penalty
Summary
The facility failed to ensure proper operation and care of a wound vacuum for a resident who had undergone left hip surgery. The resident, who was cognitively intact, reported being wet under her left buttocks, and it was observed that the wound vacuum was not operational, with the fluid collection chamber appearing dry and empty. The resident's clothing was soaked due to the surgical site draining, and the wound vacuum was found disconnected after a therapy session. The staff, including a CNA and an RN, were unaware of how long the device had been non-functional, and there were no scheduled orders for the surgical site care. The resident's progress notes indicated that the wound vacuum's battery was dead upon admission, and there was no charger available. Despite this, the treatment administration record documented that the wound vacuum placement and functioning were checked twice daily, even on the day it was found not operating. The wound care nurse confirmed the absence of treatment orders for the surgical wound site and acknowledged the importance of having such orders to ensure wound healing and reduce infection risk. The Director of Nurses stated that physician care orders should be in place within 24 hours of admission, and a baseline care plan should be completed within 48 hours. The facility's failure to have appropriate physician orders and care interventions in place for the resident's surgical site care led to the deficiency. The wound vacuum was removed without any documented orders, and the care plan lacked interventions related to the surgical site or wound vacuum use. This oversight resulted in the resident experiencing prolonged exposure to wound drainage, which could potentially delay healing and increase the risk of infection.
Deficiencies in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to ensure proper pressure ulcer care and prevention for three residents, leading to deficiencies in treatment and care. Resident R197 was observed with a flat pillow under his calves, failing to offload his heels as required. Despite having a stage 3 pressure wound on his right heel, the treatment orders were not updated in the Treatment Administration Record (TAR) following a change by the wound care physician. The resident did not receive the correct wound care treatment, as the orders for calcium alginate were not implemented, and his heels were not consistently offloaded as per the care plan. Resident R280 had a stage 3 pressure ulcer on his right inner buttock, but the pressure relief cushion in his wheelchair was flattened, compromising its effectiveness. The treatment orders for his pressure ulcer were not updated promptly in the physician orders, resulting in a delay of five days before the correct treatment was administered. The wound care physician's orders for foam silicone border dressing were not followed, and the resident continued to receive the previous treatment of calcium alginate and foam dressing. Resident R466, who was admitted with a stage 3 pressure wound to the sacrum, had an air mattress set to the maximum weight of 400 pounds, despite weighing only 110 pounds. The air mattress was not adjusted to the resident's weight, which is crucial for promoting healing and preventing further skin breakdown. The facility's failure to verify and adjust the air mattress settings as per the resident's weight contributed to the deficiency in care.
Failure to Supervise Resident with Dysphagia During Meals
Penalty
Summary
The facility failed to provide adequate supervision for a resident with difficulty swallowing, identified as R8, during meal times. R8 has multiple diagnoses, including multiple sclerosis and dysphagia, which necessitate a pureed diet and supervision while eating to prevent choking. Despite these needs, observations revealed that R8 was left unsupervised during meals on multiple occasions. On one occasion, R8 was in the dining room without any nursing staff present, and on other occasions, R8 was alone in his room while eating. Interviews with facility staff, including a Licensed Practical Nurse, a Diet Technician, and the Assistant Director of Nurses, confirmed that R8 requires supervision during meals due to the risk of choking. The staff acknowledged that R8 should be eating in the dining room where supervision is available. However, the facility was unable to provide any policy related to the supervision of residents with dysphagia, indicating a lack of formal guidelines to ensure the safety of residents with swallowing difficulties.
Improper Handling of Catheter Bag Leads to Deficiency
Penalty
Summary
The facility failed to ensure proper handling of a resident's indwelling urinary catheter bag, which was observed on the floor and stepped on by the resident. During an observation, a CNA was seen picking up the catheter drainage bag from the floor, threading it through the resident's pants, and placing it back on the floor. The resident, who was sitting on the toilet, had her right foot stepping on the catheter drainage bag. After assisting the resident to stand and cleaning her, the CNA placed the drainage bag in a dignity bag under the wheelchair, but it was initially left on the floor. The resident, identified as having multiple diagnoses including congestive heart failure, neuropathy, and urinary retention, had a care plan that required enhanced barrier precautions for the indwelling catheter. The facility's policy on catheter care emphasized that the catheter and tubing should be kept off the floor to prevent infection. Interviews with nursing staff confirmed that the catheter bag should not be on the floor due to infection control concerns, as the floor is not considered clean.
Failure to Implement Enhanced Barrier Precautions and Proper PPE Use
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for residents with surgical wounds and ensure proper use of personal protective equipment (PPE) during catheter care. Resident R371, who had undergone left hip surgery, was observed without any signage or PPE bin outside her room, indicating a lack of EBP. Staff members, including a CNA and an RN, were seen providing care to R371 while only wearing gloves, despite the presence of a wound vacuum indicating a draining wound. The facility's policy required gowns and gloves during high-contact activities, but this was not adhered to. Resident R291, who had a Foley catheter, was also not provided with appropriate PPE during care. A CNA was observed handling the catheter drainage bag without wearing a gown, and the bag was placed on the floor, which is against the facility's EBP policy. Although there was an EBP sign outside R291's room, the CNA was unaware of the requirement to wear a gown, indicating a lack of proper training or communication regarding infection control protocols. Resident R197, with a stage 3 pressure wound on the right heel, did not have an EBP sign posted outside his room, and there was no care plan in place for EBP. The wound care nurse confirmed the absence of the sign, and the resident's care plan did not include EBP measures. The facility's failure to implement and communicate EBP protocols for residents with wounds and devices led to deficiencies in infection prevention and control practices.
Failure to Prevent and Identify Pressure Ulcers
Penalty
Summary
The facility failed to implement necessary interventions to prevent pressure ulcers and did not identify a pressure ulcer in a timely manner for two residents, leading to significant health issues. Resident 1 (R1) was admitted without any pressure wounds but was identified as being at high risk for developing them. Despite this, R1's care plan did not include interventions for pressure injury prevention. Over time, R1 developed a Stage 3 sacral pressure wound, which later merged with another wound and progressed to an infected Stage 4 pressure ulcer with necrotic tissue and infection by E. coli and Morganella morganii. Resident 3 (R3) was admitted with a history of pressure ulcers and was assessed as being at very high risk for developing new ones. Initially, R3's sacrum was clear, but later notes indicated moisture-associated skin damage, which was not considered a pressure injury. Eventually, R3 developed an unstageable sacral pressure wound with significant necrotic tissue. The wound care doctor noted that the wound was severe and should have been identified earlier when it was just redness, allowing for earlier intervention. The facility's Pressure Injury Prevention Policy requires the wound team to manage wound care and implement prevention interventions, with regular assessments and documentation. However, these protocols were not followed, as evidenced by the lack of timely identification and intervention for the pressure ulcers in both residents. The wound care nurse acknowledged the need for a care plan that includes pressure injury prevention measures, such as frequent turning, especially for residents with limited mobility and incontinence.
Failure to Ensure Safe Wheelchair Transfers
Penalty
Summary
The facility failed to ensure safe transfers for two residents, leading to significant incidents. One resident, identified as R1, was admitted with multiple diagnoses including dementia and was at moderate risk for falls. On a specific date, R1 fell from her wheelchair while being propelled by a CNA, resulting in a brain hemorrhage. The incident occurred because R1 impulsively put her feet down while being wheeled without footrests, which were not applied despite the care plan indicating their necessity for safety during transport. Another resident, R3, also experienced unsafe wheelchair transport. R3, who had a history of falls and was at high risk due to confusion and weakness, was observed being pushed in a wheelchair without leg rests. This resulted in R3's feet sliding against the floor, indicating a lack of adherence to safety protocols for wheelchair transport. The facility's policy required the use of footrests during wheelchair transport to prevent accidents, but this was not followed in both cases. Staff interviews confirmed the expectation that footrests should be used for safety, yet they were not applied, contributing to the accidents involving R1 and R3.
Failure to Prevent Resident Fall Due to Wet Floor
Penalty
Summary
The facility failed to ensure that slippery wet floors were dried prior to safely transferring a resident after showering, leading to an accident. A certified nursing assistant (CNA) was asked to give a shower to a female resident who was at high risk for falls due to her medical conditions, including metabolic encephalopathy, cerebral infarction, unsteadiness on feet, difficulty walking, and hypertension. During the shower, the CNA did not dry the floor before the resident stood up, resulting in the resident slipping on the wet floor and falling. The incident was corroborated by another CNA who mentioned the importance of drying the floor to prevent falls. The registered nurse (RN) who attended to the resident after the fall confirmed that the floor was wet and that the resident was not very steady when standing. The facility's final report documented the resident's statement that the floor was very soapy and wet, causing her feet to slip. The facility's Falls and Post-Falls Management Policy identifies wet floors as an environmental factor contributing to fall risks.
Failure to Provide Chemotherapy Drugs
Penalty
Summary
The facility failed to provide ordered chemotherapy drugs for a resident diagnosed with prostate cancer, among other conditions. The resident's medication administration record (MAR) indicated multiple instances where the chemotherapy drugs, abiraterone acetate and Orgovyx, were not available over several months. The resident's guardian was informed of the medication shortages, and it was noted that the facility's staff did not have a clear process for obtaining these medications, which were typically ordered through a specialty pharmacy. The Memory Care Manager and the resident's temporary guardian were involved in addressing the medication shortages. The temporary guardian was informed by a floor nurse that the facility was running out of the resident's chemotherapy medications. Despite efforts to communicate with the guardian and the specialty pharmacy, there were delays in obtaining the necessary medications. The facility's registered nurse (RN) also reported difficulties in acquiring the medications and noted a lack of information on how the facility should obtain them. The resident's primary guardian mentioned that the chemotherapy medications were not an issue until the resident moved from the assisted living side to the long-term care side of the facility. The primary guardian also highlighted that there were issues with the resident's insurance, which may have contributed to the medication shortages. The facility's policies on medication administration and physician order entry were referenced, indicating that medications should be administered as ordered by a physician.
Failure to Assess Resident Before Moving After Fall
Penalty
Summary
The facility failed to assess a resident prior to being moved off the floor after a fall. The resident, who had a history of joint replacement, femur fracture, sepsis, and urinary tract infection, required substantial to maximal assistance for toilet transfers. On the morning of the incident, a CNA assisted the resident onto the toilet and left the resident alone with the call light nearby. The resident attempted to transfer himself and fell, resulting in the CNA finding him on the bathroom floor. Despite the resident's discomfort and attempts to get up, the CNA moved the resident back into the wheelchair without waiting for a nurse to assess the resident for injuries, as required by the facility's policy on fall prevention and post-falls management. The CNA then informed an occupational therapist, who subsequently notified an LPN. The LPN assessed the resident only after the resident had already been moved back into the wheelchair by the CNA, contrary to the facility's policy that residents should not be moved until assessed by a nurse to rule out significant injuries. Interviews with the occupational therapist, the LPN, the therapy director, the assistant director of nurses, and a nurse practitioner confirmed that the facility's policy was not followed. The policy mandates that residents who have fallen or are found on the floor without a witness should be assessed for injuries before being moved. The failure to adhere to this policy was acknowledged by the staff, who stated that moving a resident before an assessment could potentially cause more injury. The incident occurred during a shift change, which may have contributed to the delay in the nursing staff's response.
Failure to Ensure Continuity of Medications for Discharged Resident
Penalty
Summary
The facility failed to ensure continuity of medications for a resident being discharged to home. The resident, who had multiple diagnoses including metabolic encephalopathy, acute kidney failure, diabetes type II, and depression, was discharged without any medications despite being told that they would be sent home with a few days' worth of medications. The resident's family had to go to the pharmacy to pick up the medications, which were not available immediately, leading to a delay of 2 to 3 days in obtaining the necessary medications. The medications that were not available included atorvastatin, gabapentin, glipizide, metoprolol, and citalopram. The Licensed Practical Nurse (LPN) responsible for the discharge did not check with the family to ensure they had sufficient medications prior to the discharge. The facility had recently changed pharmacies, and the new pharmacy did not provide pill packs that could be sent home with the resident. The Director of Nursing (DON) and Assistant DON acknowledged that the facility did not have a policy regarding discharge medications for the new pharmacy. Additionally, nursing staff did not attend the care plan meetings where medications should have been discussed, leading to a lack of communication and planning for the resident's medication needs post-discharge.
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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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