Meadowbrook Manor - Naperville
Inspection history, citations, penalties and survey trends for this long-term care facility in Naperville, Illinois.
- Location
- 720 Raymond Drive, Naperville, Illinois 60563
- CMS Provider Number
- 145874
- Inspections on file
- 46
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Meadowbrook Manor - Naperville during CMS and state inspections, most recent first.
Multiple residents experienced significant delays in receiving incontinence care, assistance with call lights, and other essential services due to insufficient nursing staff. Observations included residents left in soiled briefs for hours, unaddressed medical needs, and staff unable to complete scheduled care tasks. Staffing schedules confirmed frequent understaffing compared to facility requirements, and there was no formal staffing policy in place.
A resident developed a pressure ulcer and UTI after admission, reporting long waits for incontinence care and needing to contact a family member for assistance. Staff observed dried feces and skin redness, and confirmed that incontinence care and repositioning were not provided as required. Facility policy mandates timely care to prevent skin breakdown, but this was not followed, resulting in the resident's condition.
A diabetic resident with multiple comorbidities developed a necrotic ulcer on the left heel after staff failed to perform and document routine foot and skin checks as required by facility policy. Despite being at high risk for skin breakdown and having a care plan that included regular monitoring, no skin alterations were recorded prior to the discovery of the advanced wound, which ultimately required vascular consultation.
A resident with a history of falls, cognitive impairment, and mobility issues was left unsupervised in their room, leading to an unwitnessed fall while attempting to self-transfer from a wheelchair. Despite a care plan calling for increased supervision and visual monitoring, the resident experienced multiple unwitnessed falls, culminating in a serious head injury and seizure that required hospitalization.
A resident with cognitive impairment alleged that a family member stole money from their bank account and revoked the family member's power of attorney. Although the allegation was communicated to the DON and Social Services, the abuse coordinator did not investigate or report the incident, believing it was a misunderstanding. No documentation of an investigation or state report was found, despite facility policy requiring such actions.
A resident with multiple pressure wounds was found on a non-functioning air-loss mattress, which was disconnected from the pump and emitting a beeping alarm that staff did not address. The resident was also lying on bunched-up pads and a sheet, and subsequently developed a new deep tissue injury despite care plans and orders requiring regular monitoring and use of a pressure-reducing mattress. Staff interviews revealed a lack of specific policy for air-loss mattresses and failure to respond to equipment alarms.
A resident with cognitive and physical decline requested assistance to revoke a POA and pursue a divorce, but staff did not make a referral to the Ombudsman or provide needed legal aid support, leaving the resident without necessary social services.
A resident with diabetes was administered fast-acting insulin despite refusing meals, contrary to medication instructions requiring insulin to be given with food. Staff failed to follow hypoglycemic protocols and did not ensure an emergency glucagon order was in place. The resident was later found unresponsive with severe hypoglycemia and required emergency intervention and hospitalization.
A CNA transferred a high fall risk resident with severe cognitive impairment without a gait belt and without a second staff member, contrary to the resident's care plan and facility policy. The resident, who had a recent history of multiple falls and was wearing only socks, was left unattended during the process. The correct transfer procedure was only followed after another CNA joined and a gait belt was applied.
The facility failed to provide adequate pressure ulcer care for two residents, resulting in delayed healing. One resident was not repositioned regularly and received inadequate incontinence care, while both residents missed scheduled wound care treatments. Staff interviews revealed a lack of awareness and oversight, and facility policies were not followed.
The facility failed to provide timely incontinence care, showers, oral care, and shaving assistance for several residents. One resident, dependent on staff for ADLs, was not receiving scheduled showers or oral care, with his spouse performing these tasks instead. Another resident had not received oral care, and others expressed a desire for shaving assistance. The Director of Nursing acknowledged the deficiency, noting that residents should receive showers twice a week.
A resident was transferred to the hospital due to acute medical issues, but the facility failed to notify the resident's spouse or other emergency contacts. The LPN called the wrong area code and did not attempt further contact, leaving the spouse unaware until the hospital reached out the next day. This oversight violated the facility's policy on immediate notification of changes in a resident's condition.
A resident with severe cognitive impairment and multiple diagnoses developed pressure wounds that worsened due to the facility's failure to provide ordered wound treatment. The resident's right buttock wound, initially a stage 2, became unstageable due to lack of dressing and exposure to contaminants. The facility did not document the prescribed treatment, and the resident was not repositioned as required, leading to the deficiency.
The facility failed to maintain sanitary practices during dishwashing and storage of dish rags, affecting 199 residents. Observations revealed improper handling of clean dishes by dietary aides without changing gloves or washing hands, and inadequate storage of dish rags. The Director of Dining Services confirmed the lack of a policy for these procedures, contributing to the deficiency.
The facility failed to assist seven residents with personal hygiene and grooming, despite their care plans indicating the need for substantial assistance. Residents with various medical conditions were observed with unkempt appearances, including overgrown facial hair and dirty fingernails. Staff acknowledged the need for care but did not provide the necessary assistance, contrary to facility policies on ADLs and nail care.
The facility failed to label and date opened medications, leading to expired insulins being stored in medication carts. Additionally, a narcotic medication was improperly handled with a torn package. These issues affected ten residents, with the Director of Nursing acknowledging the need for proper labeling and disposal procedures.
A resident with Parkinson's disease and upper extremity impairment was not consistently provided with a prescribed resting hand splint to prevent contractures. Despite care plans and physician orders, the splint was often not applied, as confirmed by observations and staff interviews. The splint was found in a dresser drawer, and staff reported inconsistencies in its application, leading to a deficiency in care.
A resident with Alzheimer's and dementia, under hospice care, was transferred by a single CNA using a mechanical lift, despite care plan instructions requiring two staff members. The Restorative Director confirmed the need for two staff during transfers for safety.
Two residents with significant weight loss received substitute meals that did not meet the facility's policy for equivalent nutritive value. The main meal provided 3 oz of protein, while the substitute egg salad sandwich contained only 2 oz. The Director of Dining Services acknowledged the discrepancy.
Two residents in a LTC facility experienced medication administration errors, resulting in a 15.63% error rate. A nurse administered a lower dosage of Vitamin D3 and omitted other medications for one resident. Another nurse gave three puffs of Albuterol without the required interval and omitted a nasal spray for a second resident. The DON highlighted the need to follow physician's orders and the five rights of medication administration.
The facility failed to follow infection control practices, including improper gown removal and inadequate hand hygiene. A nurse did not remove her isolation gown after administering medication to a resident on Enhanced Barrier Precaution, and a CNA carried soiled linens without a plastic bag. Another CNA did not perform hand hygiene after assisting a resident, violating the facility's policies.
A resident was found with bruising around her eye and indicated she was punched by a man. Despite this, the incident was not reported to the appropriate authorities. An LPN reported the injury to a nurse practitioner but did not escalate it further. The DON and Assistant DON were not informed, and the administrator was unaware of the incident. The facility's policy requires such injuries to be reported, but this was not followed.
A resident with a known surgical wound was readmitted to the facility without proper assessment or treatment orders. Despite being informed of the wound, the facility staff did not assess the wound or obtain necessary treatment orders until several days later, contrary to the facility's policies on skin assessment and care.
Facility staff failed to report an allegation of mistreatment and potential sexual abuse involving a resident. Despite the resident's report of rough handling and pain during incontinence care, the staff did not inform the administrator as required by the facility's abuse policy.
Failure to Provide Adequate Nursing Staff and Timely Resident Care
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the care needs of residents, resulting in multiple instances where residents did not receive timely assistance with incontinence care, prevention of pressure wounds, and response to call lights. One resident, recently admitted with a pressure wound and urinary tract infection, reported waiting hours for incontinence care, sometimes needing to call a family member for help in contacting staff. Upon observation, dried feces and skin redness were noted, and the resident had not received incontinence care or repositioning for several hours during the shift. Staff confirmed that care was delayed and that the wound nurse, not the assigned CNA, provided the necessary care during a dressing change. Another resident was observed repeatedly calling for help, with the call light on and staff walking past without responding. The resident reported nausea and discomfort from knee braces, and stated that requests for medication and assistance were not addressed for several hours. Staff interviews confirmed that the resident's complaints were reported to the nurse multiple times, but the nurse had not administered the ordered medication. Facility policy requires prompt response to call lights, but this was not followed. Additional residents and family members reported similar issues, including long waits for incontinence care, missed showers, and insufficient staff to meet scheduled care needs. Staff interviews revealed that CNAs were assigned to care for up to 20 residents at a time, making it difficult to complete all required tasks. The facility's staffing schedules showed that, on at least 22 shifts, the number of nurses or CNAs was below the facility's own requirements. The administrator confirmed there was no formal staffing policy in place.
Failure to Provide Timely Incontinence Care and Repositioning for Resident with Pressure Ulcer
Penalty
Summary
A resident who was recently admitted to the facility developed a pressure wound on her buttocks and a urinary tract infection (UTI) after arrival. The resident reported that the facility was short staffed and that she had experienced significant delays in receiving incontinence care, sometimes waiting for hours after calling for assistance. On at least one occasion, she contacted a family member to call the nursing station on her behalf due to the prolonged wait for care. During an observation, a CNA and a physical therapist found the resident's undergarment dry but with large streaks of dried feces, and dried, caked feces were present between the gluteal fold. The resident's labia and gluteal fold were reddened, and there was a small open area on her coccyx. The CNA confirmed that she had not provided incontinence care or repositioned the resident during her shift until the time of the observation, and that the wound nurse had provided care during a dressing change. The resident is obese, incontinent of bowel and bladder, and unable to reposition herself without assistance from two staff members. Interviews with staff and review of records indicated that there was no documentation of a pressure wound or UTI at the time of admission, and the wound was first documented two days after admission. Facility policy requires that all residents receive appropriate care to decrease the risk of skin breakdown, including cleaning skin at the time of soiling and at routine intervals, and providing incontinence care to keep residents dry and comfortable. The failure to provide timely incontinence care and repositioning contributed to the resident's skin breakdown and development of a pressure wound.
Failure to Monitor and Document Diabetic Foot Care
Penalty
Summary
A diabetic resident with multiple comorbidities, including hemiplegia, vascular disease, and immobility, was admitted to the facility and identified as being at high risk for skin breakdown. The resident's care plan included regular skin and foot inspections as per facility protocol, and the podiatrist provided recommendations for daily foot care and monitoring. Despite these interventions, documentation and interviews revealed that routine skin checks, particularly of the feet, were either not performed adequately or not documented accurately by nursing staff and CNAs. Over the course of a month, no skin alterations were recorded, even though the resident was dependent on staff for mobility and hygiene and at high risk for ulcers. On assessment, the resident was found to have developed a necrotic diabetic ulcer on the left heel, which was not identified until it had progressed to a significant size with 100% hard eschar. The wound required a vascular consultation for possible surgical intervention. Staff interviews confirmed that the wound should have been detected earlier, and the facility's own policies required daily skin assessments and prompt reporting of changes, especially for residents with diabetes and vascular disease. The failure to monitor and document the resident's foot condition in accordance with professional standards and facility policy led to the development and progression of the necrotic ulcer.
Failure to Provide Adequate Supervision for High-Risk Resident Resulting in Fall and Hospitalization
Penalty
Summary
A resident with a significant history of falls, traumatic brain injury, hydrocephalus, vascular dementia, severe cognitive impairment, and mobility issues was not adequately supervised, resulting in an unwitnessed fall in their room. The resident's care plan identified them as high risk for falls and included interventions such as increased supervision, conducting rounds, and placing the resident in common areas for visual monitoring. Despite these interventions, the resident experienced multiple unwitnessed falls in their room, with the most recent incident occurring when the resident attempted to self-transfer from their wheelchair without assistance. At the time of the fall, the assigned CNA was assisting in the dining room, and the assigned nurse was at the nurse's station, leaving the resident unsupervised. Following the unwitnessed fall, the resident was initially assessed and found to have no apparent injury or change in condition, but later developed a bump on the head and subsequently experienced a massive seizure while being transported to the hospital. Hospital records indicated the resident suffered a significant head trauma, acute encephalopathy, and seizures, leading to hospice care. The facility's policy required staff to implement and adjust individualized fall prevention interventions based on ongoing risk and incident review, but the repeated unwitnessed falls and lack of supervision in the resident's room demonstrated a failure to provide adequate supervision and prevent accident hazards as required.
Failure to Investigate and Report Alleged Financial Abuse
Penalty
Summary
The facility failed to investigate and report an allegation of financial abuse involving a resident and a family member. The resident, who was noted to have cognitive impairment and physical decline, reported that a family member had stolen money from his bank account and subsequently revoked the family member's access and power of attorney. The allegation was communicated to the Director of Nursing by another family member, who then informed Social Services. Social Services followed up with the resident, who verbally revoked the financial power of attorney from the accused family member. Despite being aware of the allegation, the facility's abuse coordinator did not initiate an investigation or report the incident, believing it to be a misunderstanding. The resident's care plan identified a risk for abuse and included interventions to report potential abuse or neglect per policy. However, there was no documentation of an abuse allegation investigation or a report to the state health department regarding the financial abuse claim, contrary to the facility's abuse prevention policy, which requires all allegations to be investigated and reported.
Failure to Ensure Functionality of Pressure-Relieving Mattress for Resident with Pressure Wounds
Penalty
Summary
A resident with multiple pressure wounds was observed lying on an air-loss mattress that was not functioning due to being disconnected from the pump, as indicated by a continuous beeping alarm and lack of mattress inflation. Despite the alarm, staff, including a Certified Nurse Assistant and a Wound Care Nurse, did not address the malfunction during wound care. The resident was also found lying on two overlapping cloth pads and a sheet that were bunched up, which could further compromise pressure relief. The Wound Care Nurse believed the mattress was working properly, even though it was not. The resident had a recent history of readmission with multiple pressure wounds and was identified as being at risk for further skin breakdown, with care plans and physician orders specifying the use and regular monitoring of a pressure-reducing mattress. Documentation showed the development of a new deep tissue injury to the left buttock while under these interventions. Staff interviews confirmed that expectations included responding to and troubleshooting medical equipment alarms, but there was no specific facility policy regarding air-loss mattresses. The facility's general policy required the provision of support devices and assistance as needed for pressure injury prevention.
Failure to Assist Resident with Social Service Needs for POA and Legal Aid
Penalty
Summary
A resident with a history of cognitive impairment and recent physical decline expressed a desire to revoke an existing Power of Attorney (POA) and pursue a divorce, as communicated by a family member to the facility. The Director of Nursing was informed of the resident's request for legal aid, and the matter was relayed to the Social Services staff. The Social Services staff followed up with the resident, who verbally confirmed his wish to revoke the POA and proceed with the divorce, indicating another family member as the preferred new POA. The Social Services staff believed the new POA documents were with the out-of-state family member and informed the resident that he would need to obtain these documents and manage the divorce process independently. Despite the resident's ongoing requests and his declining cognitive and physical abilities, there was no evidence that the facility made a referral to the Ombudsman or provided assistance in securing legal aid, as required by facility policy. The Ombudsman confirmed that no referral had been received for the resident. The facility's policy mandates making referrals to social service agencies as necessary, but this was not done, resulting in a failure to assist the resident with his social service needs.
Failure to Follow Insulin Administration Protocols Leads to Hypoglycemic Emergency
Penalty
Summary
A diabetic resident experienced a significant medication error when nursing staff failed to follow insulin administration instructions. On the day in question, the resident refused both breakfast and lunch, but was still administered scheduled doses of fast-acting insulins (Humalog and Fiasp) as documented in the Medication Administration Record. The instructions for Humalog specifically required administration with meals. The Certified Nurse Assistant documented the meal refusals and informed the nurse on duty, but the insulin was administered regardless. Later that day, the resident was found unresponsive with abnormal breathing, and emergency paramedics determined the resident's blood sugar was critically low at 22. Emergency interventions, including intravenous fluids and glucagon, were required, and the resident was transferred to the hospital for further evaluation. Interviews with staff revealed a lack of awareness and adherence to the facility's hypoglycemic protocol. One nurse stated she was not aware of the protocol, and another believed an active order for emergency glucagon was required for diabetic residents. The resident's care plan included monitoring and reporting signs and symptoms of hypoglycemia, but there was no active order for glucagon in the resident's records. Facility policies required verification of insulin orders and administration instructions, but these were not followed, resulting in the resident's hypoglycemic episode.
Failure to Follow Two-Person Transfer and Gait Belt Protocol for High Fall Risk Resident
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident with a history of multiple falls and severe cognitive impairment from a wheelchair to the toilet without the required use of a gait belt and without a second staff member present, as specified in the resident's care plan and the facility's policies. The CNA used the resident's waistband and incontinence brief to lift her, which resulted in the brief tearing and the resident being unable to bear full weight during the transfer. The resident, identified as a high fall risk by a yellow wristband, was wearing only socks at the time, and the CNA was unaware that shoes were available for her. The CNA left the resident unattended in the bathroom to seek assistance, and only upon return with another CNA was a gait belt used and the transfer completed according to protocol. The resident's electronic medical record (EMR) and care plan clearly indicated the need for a two-person assist and the use of a gait belt for all transfers, due to her multiple diagnoses including dementia, Alzheimer's disease, and a recent history of falls. The facility's policies also required staff to verify transfer techniques and use gait belts unless contraindicated or refused. Despite these documented requirements, the CNA failed to follow established procedures, resulting in an unsafe transfer process for the resident.
Failure in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for residents, resulting in delayed healing of pressure ulcers for two residents. One resident, who was admitted with multiple diagnoses including a Stage 4 pressure ulcer, was not repositioned at regular intervals as ordered by the physician. Observations showed the resident lying in the same position for extended periods without repositioning or the use of positioning aids. Additionally, the resident was found with soiled incontinence briefs and inadequate incontinence care, which contributed to the deterioration of the pressure ulcer. The facility also failed to document and administer wound care treatments as ordered by the physician for both residents. The electronic medical records showed multiple instances where the scheduled wound care treatments were not documented, indicating that the treatments may not have been provided. This lack of documentation and potential omission of care was noted over several months, despite the residents' high risk for developing new or worsening wounds due to their medical conditions. Interviews with facility staff, including the Wound Care Nurse Practitioner and the Director of Nursing, revealed a lack of awareness and oversight regarding the missed treatments and inadequate repositioning. The facility's policies on pressure injury prevention and wound care were not followed, as evidenced by the failure to reposition residents every two hours and to provide timely wound care. The interdisciplinary team responsible for wound care management had not been meeting regularly, contributing to the oversight and deficiencies in care.
Failure to Provide Timely ADL Assistance
Penalty
Summary
The facility failed to provide timely incontinence care, showers, oral care, and assistance with shaving for five out of six residents reviewed for assistance with Activities of Daily Living (ADLs). This deficiency was observed through various instances where residents were not receiving the necessary care as per their care plans. For instance, one resident, who is cognitively intact and dependent on staff for transfers and substantial assistance with ADLs, was found with facial hair stubble and visible debris on his teeth. His spouse reported that she had to perform his shaving and oral care because the facility staff did not do it. Additionally, the resident expressed a preference for showers, which he was not receiving, contrary to the facility's schedule. Another resident was found with teeth caked with black debris and reported not receiving oral care from the facility staff. This resident, who is also cognitively intact, requires supervision with oral hygiene and substantial assistance with other ADLs. The facility lacked documentation to show that this resident received oral care, highlighting a failure to adhere to the care plan. Further observations included residents with long facial hair who expressed a desire for assistance with shaving, which was not provided. The Director of Nursing acknowledged that residents should receive showers twice a week and that there was no reason for any resident not to get their showers. The facility's policy states that residents unable to carry out ADLs independently should receive necessary services to maintain good grooming and hygiene, which was not consistently followed, as evidenced by the lack of documentation and resident reports.
Failure to Notify Resident's Family of Hospital Transfer
Penalty
Summary
The facility failed to adhere to its policy of immediately notifying a resident's representative when there was a significant change in the resident's condition requiring hospital transfer. This deficiency was identified in the case of a resident who was sent to the hospital due to acute medical issues, including vomiting, clamminess, and an elevated heart rate. The LPN documented that the resident's doctor and family were notified, but it was later revealed that the nurse called the wrong area code and did not reach the resident's spouse or any other emergency contacts. The resident's spouse was not informed of the hospital transfer and only learned of the situation when contacted by the hospital the following day. This lack of communication was distressing for the spouse, who was unaware of the resident's critical condition and subsequent surgery. The facility's Director of Nursing acknowledged the error, noting that the nurse should have continued attempts to contact the spouse or other family members listed in the resident's chart. The facility's policy clearly states that changes in a resident's condition must be immediately communicated to the resident's representative, which was not followed in this instance.
Failure to Provide Ordered Wound Treatment
Penalty
Summary
The facility failed to provide wound treatment as ordered for a resident, resulting in the worsening of a pressure ulcer from stage 2 to an unstageable wound. The resident, who had severe cognitive impairment and required substantial assistance with activities of daily living, developed pressure wounds on the sacrum and right buttock. The wound on the right buttock was initially identified as a stage 2 wound but worsened to an unstageable wound due to lack of proper dressing and exposure to urine and fecal contamination. The treatment administration record showed no documentation of the prescribed treatment being administered on the specified dates. Observations revealed that the resident remained seated in a wheelchair for extended periods without repositioning, contrary to the care plan's intervention to turn and reposition at regular intervals. The facility's policy required that new wounds be reported, assessed, and treated according to physician orders, but this protocol was not followed. The CNA assigned to the resident did not report the missing dressing, and the nurse did not replace it as required. The facility's Director of Nursing stated that residents should be repositioned every two hours, but there was no specific intervention for repositioning the resident while seated in the wheelchair.
Sanitary Practices Deficiency in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary practices during dishwashing procedures and storage of dish rags, affecting 199 residents who receive food from the facility kitchen. During an inspection, multiple dry and wet/dirty rags were observed on free-standing carts in the kitchen. Additionally, a dietary aide, while wearing gloves, was seen washing and rinsing dirty dishes and then handling clean dishes without changing gloves or washing hands. Another dietary aide entered the kitchen from outside, handled clean dishes without washing hands or wearing gloves, and later admitted to not washing hands after returning from upstairs where he had collected used tableware. The Director of Dining Services acknowledged the need to rewash the dishes touched by the aides and confirmed that the facility lacked a policy for dishwashing procedures to prevent cross-contamination. Furthermore, the director noted that clean dish rags should have been stored in a designated bucket with sanitizing solution, while dirty rags should have been placed in a separate container for dirty linen. The absence of a policy for these procedures contributed to the observed deficiencies.
Failure to Assist Residents with Personal Hygiene and Grooming
Penalty
Summary
The facility failed to provide necessary assistance with personal hygiene and grooming for seven residents who were identified as needing such assistance. These residents, who had various medical conditions including dementia, hemiplegia, and metabolic encephalopathy, were observed with unkempt appearances, including overgrown facial hair, long and dirty fingernails, and uncombed hair. Despite their care plans indicating the need for substantial or maximum assistance with activities of daily living (ADLs), the staff did not adequately address these needs. For instance, one resident with dementia was observed with facial hair that needed shaving, and another resident with metabolic encephalopathy had long, jagged fingernails with black substances underneath. Both residents expressed the need for assistance, and staff acknowledged the necessity but failed to provide the required care. Similarly, other residents with cognitive impairments and physical limitations were found with unkempt facial hair and dirty fingernails, despite their care plans specifying the need for grooming assistance. The facility's policies on ADLs and nail care emphasize the importance of maintaining residents' hygiene and grooming, yet these were not adhered to. The Director of Nursing and other staff members acknowledged the deficiencies in providing grooming and hygiene care, which are essential for the residents' well-being. The lack of adherence to care plans and facility policies resulted in the observed deficiencies in personal hygiene and grooming for the affected residents.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to properly label and date medications after they were opened, which is necessary to determine their expiration dates. This deficiency was observed during an inspection of multiple medication carts, where several instances of insulin medications, such as Insulin Glargine and Insulin Lispro, were found to be opened but not dated. Additionally, some medications were found to be expired but still present in the medication carts. This issue affected ten residents, including those with insulin medications that had been opened for more than the recommended 28 days without being discarded. Furthermore, the facility did not adhere to proper procedures for handling narcotic medications. A container of Alprazolam was found to be torn open and taped over, which is against the facility's policy that requires such medications to be discarded in the presence of a nurse and a witness. The Director of Nursing confirmed that opened insulins should be labeled and dated, and narcotic medications with damaged packaging should be wasted with a second nurse as a witness to prevent diversion.
Failure to Apply Resting Hand Splint for Resident
Penalty
Summary
The facility failed to apply a resting hand splint for a resident, identified as R155, to prevent contractures. R155, who has diagnoses including Parkinson's disease and upper extremity impairment, was observed without the prescribed hand splint on multiple occasions. The care plan and physician orders specified that the splint should be applied in the morning and removed after lunch, with checks every shift. However, during an observation, the splint was not on the resident's hand, and it was found in a dresser drawer after a search. The resident's spouse confirmed that the splint was only applied twice a week by the restorative aide during exercise sessions. Interviews with staff revealed inconsistencies in the application of the splint. The restorative aide claimed to apply the splint regularly, but a certified nursing assistant reported that the resident was not wearing the splint during a shower. The occupational therapist had previously recommended the splint to prevent further contractures, and the facility's policy emphasized the importance of such devices in preventing joint contractures. Despite these guidelines, the splint was not consistently applied, leading to a deficiency in the resident's care.
Inadequate Staff Assistance During Resident Transfer
Penalty
Summary
The facility failed to ensure safe transfer procedures for a resident requiring two staff members for assistance. The resident, who is under hospice care and has multiple medical diagnoses including Alzheimer's disease and dementia, was transferred by a single hospice CNA using a mechanical lift, contrary to the care plan instructions. The resident's care profile and care plan both specify the need for a full lift with the assistance of two staff members due to the resident's cognitive impairment and limited mobility. This incident was confirmed by the Restorative Director, who stated that two staff members should always be present during such transfers for safety reasons.
Failure to Provide Nutritive Equivalent Substitute Meals
Penalty
Summary
The facility failed to provide an alternate meal with similar nutritive value as the main entree for residents with a history of weight loss. This deficiency was observed in two residents, R60 and R152, during a lunch meal service. The main meal consisted of a Turkey Burger Patty Melt with a 3 oz protein portion. However, the substitute meal, an egg salad sandwich, was prepared with only 2 oz of egg salad, which did not meet the facility's policy of providing a substitute with equivalent nutritive value. The facility's scoop guidance indicated that the egg salad sandwiches were prepared with a #16 scoop, equating to 2.07 fluid oz, which was less than the required 3 oz protein serving. Resident R152, who had diagnoses including cerebrovascular disease, type 2 diabetes, and dementia, received the egg salad sandwich with tater tots. R152's weight history showed a significant decline over several months. Similarly, Resident R60, diagnosed with conditions such as hemiplegia, dysphagia, and dementia, also received the egg salad sandwich with tater tots. The dietitian's progress notes indicated that both residents had experienced significant weight loss, and R60 had requested extra portions. The Director of Dining Services acknowledged that the substitute meal should have equaled the main meal's protein content, as per the facility's policy.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to adhere to physician's orders during medication administration, resulting in a medication error rate of 15.63%, which is significantly above the acceptable threshold of 5%. This deficiency was observed in two residents. In the first instance, a nurse administered Vitamin D3 to a resident using a tablet with a lower dosage than prescribed. Additionally, the nurse did not administer other scheduled medications, including Cyanocobalamin and Polyethylene Glycol, to the same resident. In the second instance, another nurse administered three puffs of Albuterol Sulfate HFA inhaler to a resident without the required one-minute interval between doses, contrary to the physician's order of two puffs. The nurse justified this by stating that the resident preferred three puffs. Furthermore, the nurse did not administer the prescribed Fluticasone Propionate nasal spray, as the resident usually refused it. The Director of Nursing emphasized the importance of following physician's orders and the five rights of medication administration, and noted that persistent refusal of medication should be communicated to the physician.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection control practices, as observed in the cases of three residents. A nurse, identified as V4, did not remove her isolation gown after administering intravenous medication to a resident on Enhanced Barrier Precaution (EBP). Instead, she left the resident's room wearing the gown, prepared oral medications, and re-entered the room without changing the gown. This action was contrary to the facility's policy, which requires the removal of isolation gowns before leaving the room to prevent the spread of infection. Additionally, a CNA, V34, was seen carrying soiled linens and a gown without using a plastic bag, transporting them down the hallway, and disposing of them in the soiled linen bin while wearing gloves. Another CNA, V36, failed to perform hand hygiene after assisting a resident with repositioning and meal setup, leaving the room without washing hands. These actions violated the facility's hand hygiene policy, which emphasizes hand hygiene as the primary means to prevent infection spread and requires handwashing after glove removal and direct resident contact.
Failure to Report Alleged Abuse of a Resident
Penalty
Summary
The facility failed to report allegations of resident abuse for one resident, identified as R1, who was observed with yellow/green bruising around her left eye orbit and a small purple mark under her left eye. When questioned, R1 indicated through gestures and words that a man had punched her. Despite this, the incident was not reported to the appropriate authorities as required. V5, an LPN, stated that he would report such injuries to a supervisor and the administrator, but V4, another LPN, only reported the incident to the nurse practitioner and did not escalate it further. V8 and V9, R1's family members, confirmed that R1 consistently reported being hit by a man during their visits. The Director of Nursing (V2) and Assistant DON (V3) were not informed of the potential abuse, and V3 did not consider the bruise as related to abuse, thus did not report it to the administrator (V1). V1 stated that he had not been informed of any abuse allegations or injuries of unknown origin since July 2024 and would have initiated an investigation had he been aware. The facility's policy requires injuries of unknown origin to be reported to the abuse coordinator, but this protocol was not followed in R1's case, leading to a failure in addressing a potential abuse situation.
Failure to Assess and Obtain Treatment Orders for Surgical Wound
Penalty
Summary
The facility failed to assess and obtain treatment orders for a resident with a known surgical wound. The resident, who was readmitted with multiple diagnoses including a left gluteal abscess, did not have her wound assessed or treatment orders obtained upon readmission. The wound care nurse was notified of the resident's condition but did not assess the wound until several days later. The wound was initially covered with a dressing that was not removed or evaluated, and the resident's electronic medical record did not show any treatment orders for the wound until several days after readmission. The facility's staff, including the Nursing Unit Manager and the Director of Nursing, acknowledged that the wound was not assessed and treatment orders were not obtained in a timely manner. The facility's policies on skin assessment and pressure injury risk assessment were not followed, as the resident's wound was not documented or addressed according to the established procedures. The lack of timely assessment and treatment orders for the resident's surgical wound represents a deficiency in the quality of care provided by the facility.
Failure to Report Allegation of Mistreatment and Potential Sexual Abuse
Penalty
Summary
The facility staff, including a Registered Nurse (V3) and a Certified Nursing Assistant (V16), failed to report an allegation of mistreatment and potential sexual abuse to the administrator. This incident involved a resident (R1), who was cognitively intact and required moderate to extensive assistance with ADLs. R1 reported to V3 that another aide (V4) was rough during incontinence care and had inserted her finger into R1's vagina, causing pain. Despite documenting the incident in the progress notes, V3 did not report the allegation to the facility administrator. Similarly, V16 did not report R1's complaint about V4's rough handling during incontinence care to anyone, including the administrator. The facility's undated abuse policy mandates that employees report any incident, allegation, or suspicion of potential abuse, neglect, exploitation, or mistreatment to the administrator immediately or to an immediate supervisor who must then report it to the administrator. Both V3 and V16 failed to adhere to this policy, resulting in a deficiency in reporting suspected abuse. The failure to report the incident promptly and appropriately was identified during an interview and record review, highlighting a significant lapse in the facility's internal reporting and identification of allegations process.
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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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