Pavilion Of Logan Square, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 2242 North Kedzie, Chicago, Illinois 60647
- CMS Provider Number
- 145792
- Inspections on file
- 34
- Latest survey
- August 26, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Pavilion Of Logan Square, The during CMS and state inspections, most recent first.
A resident with legal blindness and other conditions did not have his prescribed Latanoprost eye drops available for administration, despite a physician's order and pharmacy documentation of delivery. Nursing staff were unable to locate the medication during review, and the resident reported only receiving the drops when specifically requested. A prior family grievance also noted missed doses, indicating a failure in maintaining medication supply and administration procedures.
A resident prescribed multiple psychotropic medications experienced discrepancies in medical record documentation, including inconsistent diagnoses for Depakote, missing or delayed consent forms for Haldol and Olanzapine, and failures to upload required documents to the electronic record. An LPN confirmed that incorrect diagnoses were selected and that consent documentation was incomplete or not timely.
A resident with intellectual disabilities and Down syndrome fell in her room after being instructed to put on shoes, resulting in hospitalization. The facility failed to implement fall prevention interventions despite the resident's documented need for supervision and assistance. The incident highlights a lack of adherence to the facility's policies and the resident's care plan, contributing to the avoidable fall.
The facility failed to properly manage resident funds, charging dental insurance premiums and haircut fees without proper consent or documentation. Four residents were overcharged for dental premiums, and five residents were charged for haircuts without proper consent, especially those with cognitive impairments. The facility's auditing process for personal funds was inadequate, leading to discrepancies in charges and credits.
The facility failed to provide flu vaccinations and education to two residents, despite the importance of such measures for elderly individuals with medical comorbidities. The Infection Control RN did not document offering the vaccine or providing education, and the refusal form was inaccessible to other staff. This led to a deficiency in the facility's vaccination protocol.
A facility failed to implement care plan interventions and ensure staff followed safety protocols, resulting in injuries to three residents. One resident sustained facial lacerations after being improperly transferred by CNAs, while another suffered neck fractures due to not being secured in a facility van. A third resident also fell in the van due to a lack of seatbelt use, highlighting a pattern of non-compliance with safety protocols.
A facility failed to investigate an abuse allegation for a resident with a known fall risk. The resident sustained injuries consistent with being punched, not from a fall, during care. Two CNAs were involved in transferring the resident, and one left the room before the incident. The facility did not conduct a reportable investigation for abuse, believing it was a fall, despite the hospital's allegation of abuse.
A resident with cognitive impairments unexpectedly slapped another resident in a hallway, despite having no prior history of aggression. The incident was promptly addressed by staff, and no injuries were reported. The aggressive behavior was linked to a mental status change in the resident, possibly due to a urinary tract infection.
The facility failed to prevent employees from storing personal food in the kitchen's walk-in cooler and did not address a leaking ceiling and clogged drain in the dishwashing area, leading to unsanitary conditions. The dietary supervisor was unaware of the source of the personal food items and acknowledged the unsanitary conditions but did not take immediate corrective action.
The facility failed to monitor and maintain personal refrigerator temperature logs for several residents, with some refrigerators lacking thermometers. Staff, including CNAs and the Infection Preventionist, acknowledged the need for daily monitoring to prevent food spoilage. Conflicting statements from the Director of Nursing and Housekeeping Director about responsibility led to lapses in monitoring, posing a risk of food spoilage.
The facility failed to contain cigarette butts, which were found near a generator's fuel tank, posing a fire risk. Staff were unclear about designated smoking areas and proper disposal methods, leading to cigarette waste accumulation near the flammable tank. The maintenance director confirmed receptacles were not near the docking area, and a dietary aide was observed smoking near the fuel tank despite prohibitions.
The facility failed to conduct daily checks of the crash cart on the 3rd floor, potentially affecting 57 residents. Observations and staff interviews revealed missing daily checks on several dates, contrary to the facility's policy. An LPN and the DON emphasized the importance of these checks to ensure emergency readiness, as the cart contains essential items like oxygen tubing and IV kits.
The facility failed to secure hazardous items like razors and soap, and did not implement or update fall prevention measures for residents at risk. A resident was found with unsecured soap in their room, and the shower room had dispensers without lids, allowing staff to improperly scoop soap. Additionally, fall interventions were not followed, as a resident was observed barefoot and with an unplanned fall mat. The facility's policies on safety and fall prevention were not adhered to, posing risks to residents.
The facility failed to ensure proper respiratory care by not containing a nebulizer mask and not labeling or changing oxygen tubing and humidifier bottles per policy. This affected several residents with conditions like COPD and diabetes, as equipment was either undated or outdated, contrary to the facility's guidelines.
A resident with severe cognitive impairment was found with unattended medication in their room, highlighting a failure by the facility to assess the resident's ability to self-administer medications. The RN responsible admitted to leaving the medications unsupervised, contrary to facility policy, which requires a competency assessment for self-administration. The DON confirmed that the resident was not assessed for self-administration, indicating a breach in medication administration procedures.
The facility failed to ensure call lights were within reach for two residents, one with dementia and another with COPD and diabetes. Observations revealed call lights were inaccessible, contrary to care plans and facility policy. Staff confirmed the call lights should be within reach to assist residents in calling for help.
A facility failed to document a resident's code status in the EMR, affecting their treatment preferences. An LPN noted that code status should be visible on the EMR profile screen, but the resident's advance directive was blank, and no physician order was present. The DON confirmed that code status should be entered based on family verification, and until decided, residents are treated as full code. Despite this, the resident's EMR lacked the necessary order, indicating a lapse in policy adherence.
A facility failed to accurately complete a resident's MDS, reflecting inconsistencies in the resident's communication abilities. The resident, with a history of hemiplegia and dementia, was documented as having clear speech, yet observations showed unclear, strained communication. Staff interviews revealed discrepancies in the MDS coding, indicating a failure to properly assess and document the resident's status.
A resident was not referred for a Level II PASARR evaluation after being diagnosed with multiple mental disorders, including Schizoaffective Disorder and Paranoid Schizophrenia. The facility's policy requires a new PASARR with any significant change in status, but this was not done until after the deficiency was identified. The Social Service Director acknowledged the oversight, indicating a communication gap in the process.
A facility failed to complete a pre-admission screening and resident review (PASARR) for a resident with major depressive disorder and unspecified psychosis. The resident was admitted without a Level I PASARR, which was only completed after the survey began, contrary to the facility's policy requiring adherence to state and federal requirements.
A facility failed to include a resident in the development of their care plan, despite the resident's cognitive impairment and desire to participate. The resident, with multiple diagnoses including dementia and hemiparesis, was not invited to care plan meetings, contrary to facility policy. The care plan coordinator confirmed the oversight but could not explain why the resident was excluded.
Two residents who depend on staff for ADL care were not properly groomed, specifically not shaved, despite having visible facial hair. One resident has moderate cognitive impairments and requires maximum assistance, while the other has some cognitive impairments and is dependent on staff for personal hygiene. A CNA admitted to not shaving one of the residents, and the DON confirmed that shaving should be part of daily ADL care for residents with visible facial hair.
The facility failed to implement fall precautions and provide adequate supervision, resulting in multiple resident falls and injuries. Beds were not in the lowest position for two residents, and supervision was lacking during smoking times, with residents found in possession of smoking materials. Staff distractions, such as phone use, contributed to these deficiencies.
A resident's left knee injury was not properly documented or treated according to physician orders in an LTC facility. The injury occurred when an over-bed table fell on the resident's knee, and the facility failed to change the dressing as needed. The wound was inaccurately documented as healed, and the wound care nurse admitted to selecting an incorrect classification due to system limitations.
A resident with moderate cognitive impairment and a history of falls did not receive adequate supervision or effective fall prevention interventions, resulting in two unwitnessed falls and a compression fracture. Despite the facility's fall management policy, necessary updates to the care plan, including frequent monitoring, were not implemented.
Failure to Ensure Availability of Routine Medication for Resident
Penalty
Summary
The facility failed to provide and/or obtain a routine medication, Latanoprost Ophthalmic Solution eye drops, for a resident with legal blindness, Parkinson's disease with dyskinesia, major depression, and dry eye syndrome. The resident had a physician's order for the eye drops to be administered daily at 7:00 PM, one drop in both eyes. During an observation, the resident reported that he only received his eye drops if he specifically asked for them and did not receive them otherwise. When nursing staff checked the medication cart and pharmacy medication dispenser, they were unable to locate the resident's prescribed eye drops. Documentation from the pharmacy indicated that the medication had been delivered earlier in the month, and the Medication Administration Record showed daily administration, but the medication was not available at the time of the survey. A prior grievance from the resident's family member had also documented concerns that the resident was not receiving his eye drops. The facility's policies assign responsibility to nursing staff for maintaining medication supplies and to the Director of Nursing for supervising medication administration. Despite these policies, the medication was not available for administration, and the process for ensuring timely medication delivery and availability was not followed, resulting in the resident not having access to his prescribed eye drops.
Failure to Maintain Accurate Medical Records and Obtain Proper Consents for Psychotropic Medications
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Summary
The facility failed to maintain accurate and accessible medical records for a resident who was prescribed multiple psychotropic medications. Discrepancies were found in the physician orders for Depakote, with different diagnoses listed on separate dates, including mood affective disorder and depression, despite the resident's face sheet not listing depression as a diagnosis. The Medication Administration Record (MAR) documented administration of Depakote for depression, which did not align with the resident's documented diagnoses. Additionally, the psychotropic nurse acknowledged that the wrong diagnosis was selected and that there are differences in side effects between the two diagnoses. Further deficiencies were identified in the management of consent forms for psychotropic medications. Only one consent form was present for two different Haldol orders (tablet and injection), and the consent form was uploaded to the electronic record significantly after it was signed. There was also a lack of consent documentation for Olanzapine, and the consent form for Haldol was not uploaded in a timely manner. The psychotropic nurse confirmed these documentation lapses and noted that medical records staff failed to upload the necessary documents as required.
Failure to Implement Fall Prevention Leads to Resident's Fall
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Summary
The facility failed to implement fall prevention interventions for a resident, resulting in a fall and subsequent hospitalization. The resident, who has a history of intellectual disabilities, Down syndrome, and other medical conditions, was found to have severely impaired cognition. On the morning of the incident, the resident was walking barefoot in her room when a CNA instructed her to put on her shoes. As the resident turned, she lost her balance and fell, hitting her head on the bathroom door. The CNA reported the incident to a registered nurse, who found the resident sitting on the floor without visible injuries, although the resident later required hospitalization. The resident's care plan indicated a risk of falls due to her medical history and required supervision or assistance for activities such as walking and putting on footwear. Despite these documented needs, the resident was not adequately supervised or assisted at the time of the fall. The facility's policies, including the Falling Star Program and Accidents and Incidents policy, emphasize the importance of monitoring residents at risk of falls and implementing individualized care plans to prevent avoidable accidents. However, these protocols were not effectively followed in this case. Interviews with facility staff revealed that the resident had been exhibiting increased confusion and required more redirection and assistance with daily activities. The primary physician acknowledged the difficulty in preventing falls but emphasized the need for close monitoring. The failure to implement the resident's fall prevention care plan interventions placed her at a higher risk for an avoidable fall, as confirmed by the physician. The facility's lack of adherence to its own policies and the resident's care plan contributed to the incident.
Improper Management of Resident Funds
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Summary
The facility failed to safeguard resident rights by improperly accounting for and charging resident funds for seven out of nine residents. Specifically, four residents were charged dental insurance premiums that should have been included in the care cost, resulting in significant discrepancies between the amounts deducted and credited back to their accounts. The Assistant Administrator acknowledged that dental insurance premiums should be part of the care cost and not charged separately, yet the residents' accounts showed substantial charges that were not fully credited back. Additionally, five residents were charged for haircuts from their personal funds without proper documentation of consent. Some residents, due to impaired cognition, were unable to give consent, and there were discrepancies in the service dates recorded. The Activity Director signed as a witness for these charges, but the residents' signatures were missing, and the dates of service did not match the dates on the resident fund statements. This lack of proper documentation and consent highlights a failure in the facility's process for managing resident funds. The Business Manager and Assistant Administrator were informed of these discrepancies, and it was noted that the facility's auditing process for personal funds needed improvement. The Director of Nursing acknowledged the issue, particularly for residents with severe cognitive impairment who could not provide consent. The facility's policy mandates the safeguarding and proper management of resident funds, which was not adhered to in these instances.
Failure to Document and Provide Flu Vaccinations
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Summary
The facility failed to provide flu vaccinations and education to two residents, R1 and R11, as required. R11, a resident with a history of influenza and other significant health conditions, was admitted to the facility and later diagnosed with the flu after being sent to the hospital. Despite the importance of flu vaccinations for elderly residents with medical comorbidities, the facility's Infection Control RN, V6, did not document offering the flu vaccine or providing education to R1. Additionally, although V6 stated that R11 was offered the vaccine, this was not documented in R11's medical records, and the refusal form was kept in a binder inaccessible to other medical staff. The facility's policy requires that flu vaccines be administered by the end of October and continue to be offered as long as influenza viruses are circulating. However, V6 admitted to not documenting the offer or refusal of the vaccine for R1 and R11, nor did she follow up to ensure they understood the importance of the vaccination. This lack of documentation and follow-up led to a deficiency in the facility's vaccination protocol, as the residents' immunization records did not reflect any consent, refusal, or education regarding flu immunizations.
Failure to Implement Care Plan and Safety Protocols Leads to Resident Injuries
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Summary
The facility failed to implement care plan interventions for a resident, resulting in the resident sustaining facial lacerations. The incident occurred when two Certified Nursing Assistants (CNAs) transferred the resident from a shower chair to a bed using a gait belt. One CNA left the room, and the remaining CNA attempted to reposition the resident, who then rolled off the bed and hit his head on the nightstand. The resident's care plan required substantial/maximal assistance from two staff members for repositioning and turning in bed, which was not followed, leading to the fall and subsequent injuries. Additionally, the facility failed to ensure staff followed their job description and Driver Safety Rules, resulting in another resident sustaining neck fractures. The resident, who had a history of falls involving the facility van, was not properly secured in the van by the bus driver. During transport, the resident fell out of the wheelchair due to the seatbelt not being fastened, leading to a neck fracture. The bus driver admitted to not fastening the seatbelt and failing to reposition the resident properly, which contributed to the fall. A third resident also experienced a fall in the facility van due to the seatbelt not being fastened. The resident slid from the wheelchair onto the van floor when the driver abruptly stopped. The incident highlights a pattern of non-compliance with safety protocols during resident transport, as evidenced by the repeated failure to secure residents properly in the van, leading to multiple falls and injuries.
Failure to Investigate Allegation of Abuse
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Summary
The facility failed to follow its policy to investigate an allegation of abuse for a resident who was reviewed for abuse. The incident involved a resident with a known fall risk history who allegedly rolled out of bed onto the floor during care. However, the Emergency Department Physician noted that the resident's injuries were consistent with being punched in the face rather than a fall from a low bed. The resident sustained a complex eyelid laceration that required transfer to another hospital for repair. Despite the hospital's allegation of abuse, the facility did not conduct a reportable investigation for abuse, as they believed it was a fall. The incident occurred when two Certified Nursing Assistants (CNAs) were involved in transferring the resident from a shower chair to bed. One CNA left the room, and the other CNA attempted to adjust the resident's diaper, during which the resident rolled off the bed and hit their head on the nightstand. The bed was raised to waist height for care, contrary to the claim that the resident was in a low bed. The facility's administrator acknowledged the incident and spoke with the involved staff but did not follow the facility's abuse prevention policy to investigate the allegation of abuse, as they concluded it was a fall incident.
Resident-to-Resident Physical Abuse Incident
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Summary
The facility failed to protect a resident, identified as R2, from physical abuse by another resident, R1. R1, who was admitted with a medical history including bipolar disorder, Parkinson's Disease, and cognitive impairment, became physically aggressive towards R2. The incident occurred when R1, sitting in the hallway, slapped R2 as she was walking by. This behavior was unexpected as R1 had no prior history of aggression and was generally calm and required no close monitoring. R2, who also has cognitive impairments, reported the incident to staff, stating that R1 accused her of talking about her and then slapped her. Despite the physical contact, R2 did not sustain any injuries or pain and expressed understanding of R1's confusion. Staff members, including a housekeeper and a nurse, witnessed the incident and intervened promptly to separate the residents and assess them for injuries. The facility's administrator and medical personnel were informed, and R1 was sent for a psychiatric evaluation and medication adjustment. Interviews with staff and other residents confirmed that R1's behavior was out of character and attributed to a mental status change, possibly linked to a urinary tract infection. The facility's abuse prevention policy was reviewed, and it was noted that R1's aggression was non-intentional due to her confusion. The incident was reported to the appropriate authorities, and both residents and their families agreed to maintain their living arrangements, indicating no fear or discomfort from the incident.
Deficiencies in Kitchen Sanitation and Food Storage
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Summary
The facility failed to ensure that employees' personal food items were not stored in the kitchen's walk-in cooler, which is against the facility's policy. During an observation, it was noted that four small food baskets belonging to kitchen staff were stored inside the walk-in cooler. The dietary supervisor, V8, was unaware of where the staff obtained their food items and believed it was acceptable if the items were labeled, despite the facility's policy prohibiting personal food storage in the dietary department refrigerators or freezers. Additionally, the facility failed to address a leaking ceiling and a clogged drainage pipe in the dishwashing area, which could lead to unsanitary conditions. Observations revealed a puddle of water by the dishwashing area due to a clogged drain, and a leak from the ceiling was noted, with water being collected in buckets. The dietary supervisor acknowledged the unsanitary and unsafe conditions but did not take immediate corrective action. These issues have the potential to affect all residents taking oral nutrition at the facility.
Failure to Monitor Personal Refrigerator Temperatures
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Summary
The facility failed to monitor and maintain personal refrigerator temperature logs for five residents and did not ensure that three residents' personal refrigerators had thermometers. This deficiency was identified through observations, interviews, and record reviews. Specifically, residents' personal refrigerators were found without thermometers and temperature logs, which are necessary to prevent food spoilage and potential health risks. Staff members, including CNAs and the Infection Preventionist, acknowledged the requirement for daily monitoring and logging of refrigerator temperatures to ensure food safety. The facility's policy mandates monthly tracking sheets for refrigerator temperatures and assigns responsibility to designated employees for checking and recording these temperatures. However, there was a lack of clarity and consistency in the roles of nursing and housekeeping staff regarding this responsibility. The Director of Nursing and the Housekeeping Director provided conflicting statements about who should check and log the refrigerator temperatures, leading to lapses in monitoring. This inconsistency contributed to the failure to maintain proper temperature logs and thermometers in residents' personal refrigerators, posing a risk of food spoilage.
Improper Disposal of Cigarette Butts Near Fuel Tank
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Summary
The facility failed to ensure that cigarette butts were properly contained and not blown towards the generator's fuel tank, posing a potential fire hazard. During an observation at the facility's docking area, cigarette butts were found inside a trash can adjacent to the fuel tank, under the fuel tank, on the drain cover, and around the docking area. The cook, maintenance staff, and other personnel were unaware of the specific smoking areas and the proper disposal of cigarette butts, leading to the accumulation of cigarette waste near the flammable fuel tank. The maintenance director confirmed that the receptacles for cigarette butts were located upstairs, away from the docking area. Interviews with various staff members revealed a lack of clarity regarding designated smoking areas and the disposal of cigarette butts. The activity director stated that staff were not allowed to smoke on the patio, while the maintenance director and regional maintenance director were unaware of the staff smoking area. Additionally, a dietary aide was observed smoking near the dumpster, which is adjacent to the fuel tank, despite being informed that smoking was prohibited in that area. The assistant administrator confirmed that there was no specific policy regarding smoking near the fuel tank, and staff were expected to dispose of cigarette butts in metal ashtrays provided by the facility.
Failure to Conduct Daily Crash Cart Checks
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Summary
The facility failed to ensure that emergency medical equipment stored for use in basic life support was checked daily, as required by their policy. This deficiency was observed on the 3rd floor, potentially affecting all 57 residents residing there. The crash cart checklist showed daily checks were only completed on three specific dates, with several other dates missing. This lack of daily checks was confirmed through observation and interviews with staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON). The LPN acknowledged that the crash cart should be checked every day to ensure supplies are available in case of an emergency, emphasizing the potential danger to residents if the cart is not checked. The DON explained that the crash cart contains essential items for emergencies, such as oxygen tubing, IV starter kits, and a suction machine, and highlighted the importance of daily checks to ensure readiness. The facility's policy mandates that the crash cart be checked daily to confirm it is locked and has not been opened, but this procedure was not consistently followed.
Safety Hazards and Fall Prevention Failures
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Summary
The facility failed to maintain a safe environment by leaving unsecured shaving razors in an unlocked shower room, unsecured liquid body soap in a drinking cup in a resident's room, and an unlocked laundry chute accessible to residents. These oversights were observed during a survey, where a resident was found with a drinking cup containing blue liquid soap in their bathroom, which was confirmed by a registered nurse to be a hazard. Additionally, the shower room on the 4th floor had soap dispensers without lids, allowing staff to scoop soap into cups, which could be left in residents' rooms, posing a safety risk. The facility also failed to implement and update care-planned fall precaution interventions for residents at risk of falls. One resident, identified as a fall risk due to dementia and other health conditions, was observed walking barefoot in their room, which was not their assigned bed, and with a folded-up fall mat not care-planned for them. The resident's care plan included interventions such as wearing shoes or gripper socks and using a low bed, but these were not adequately followed or updated after observed falls. Furthermore, the facility's policies on fall management and accident prevention were not adhered to, as evidenced by the improper storage of hazardous items and inadequate supervision of residents. The Director of Nursing acknowledged the need for proper documentation and adherence to care plans to prevent falls and ensure resident safety. The survey also highlighted the risk posed by an unlocked laundry chute, which could lead to severe accidents if accessed by residents.
Deficiencies in Respiratory Care and Equipment Management
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Summary
The facility failed to provide safe and appropriate respiratory care for several residents by not adhering to its own policies regarding the containment and labeling of respiratory equipment. Specifically, a nebulizer mask for a resident with chronic obstructive pulmonary disease (COPD) and acute respiratory failure was observed to be left on a nightstand without being contained in a plastic container, as required to prevent cross-contamination. This oversight was acknowledged by the Director of Nursing as an infection control issue. Additionally, the resident's care plan indicated the need for optimal breathing patterns and medication administration, which was not consistently followed. Furthermore, the facility did not ensure that oxygen tubing and humidifier bottles were labeled with the dates they were changed, nor were they changed according to the facility's policy. Observations revealed that several residents had undated or outdated oxygen tubing and humidifier bottles, contrary to the policy that requires weekly changes and proper labeling. The Director of Nursing confirmed that the policy mandates dating the equipment at the time of change, which was not adhered to, affecting residents with various diagnoses including COPD, hypertension, and diabetes.
Failure to Assess Resident's Ability to Self-Administer Medications
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Summary
The facility failed to assess a resident's ability to safely self-administer medications, which led to a deficiency affecting one resident and potentially impacting all residents on the 4th floor. During an observation, a surveyor found a clear medicine cup containing five medication pills on a nightstand in a resident's room. The resident, who has severe cognitive impairment due to dementia and other conditions, was not assessed for self-administration of medications. The Registered Nurse (RN) responsible for administering the medications admitted to preparing and leaving the medications unattended in the resident's room, which is against the facility's policy. The resident in question, identified as having severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 6, was not assessed for the ability to self-administer medications. The RN acknowledged that the medications were left in the room unsupervised, which could lead to the resident forgetting to take them or someone else accessing them. The facility's Director of Nursing (DON) confirmed that a medication self-administration assessment is necessary to ensure a resident's cognitive competence to manage their medications independently. The facility's policy requires that medications be administered safely and only by licensed personnel, with residents allowed to self-administer only if deemed competent by the Attending Physician and Interdisciplinary Care Planning Team. The RN's actions of leaving the medications unattended violated this policy, as the resident was not assessed for self-administration competency. The facility's documentation confirmed that the resident was not capable of self-administering medications, highlighting a lapse in adherence to established procedures for medication administration.
Failure to Ensure Call Lights Within Reach for Residents
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Summary
The facility failed to maintain residents' call lights within reach, affecting two residents. One resident, diagnosed with dementia and other conditions, was observed with their call light string hanging out of reach behind a nightstand. A Certified Nursing Assistant (CNA) confirmed the call light should be within reach and adjusted it accordingly. The resident's care plan emphasized the importance of having the call light accessible due to their risk of falls and need for assistance with personal care. Another resident, with a diagnosis including Chronic Obstructive Pulmonary Disease and Type 2 Diabetes Mellitus, was observed unable to reach their call light, which was attached to a pillow behind their head. Both a Licensed Practical Nurse (LPN) and a CNA acknowledged the call light was out of reach. The resident's care plan also highlighted the necessity of having the call light within reach to prevent falls. The facility's call light policy mandates that call lights be easily accessible to residents in bed or confined to a chair.
Failure to Document Code Status in EMR
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Summary
The facility failed to ensure that a resident had a physician's order for a code status in the electronic medical record (EMR), affecting one resident out of a sample of 76 reviewed for advanced directives. During an interview, an LPN indicated that the code status, whether full code or DNR, should be visible on the profile screen of the EMR. However, the resident's advance directive category was found to be blank, and there was no physician order for the resident's code status in the EMR. The resident in question, identified as having severe cognitive impairment, did not have a documented code status, which is essential for determining the appropriate emergency resuscitation measures. The Director of Nursing confirmed that the code status should be entered into the EMR based on the resident's or family's wishes and verified by the family. The facility's policy requires that each resident's plan of care be consistent with their documented treatment preferences and advance directives. The policy also states that until a decision is made about the code status, the resident should be treated as full code, and an order for full code should be in the EMR. Despite these procedures, the resident's EMR lacked the necessary physician order for code status, indicating a lapse in following the facility's policy and ensuring the resident's treatment preferences were documented and accessible to the nursing staff.
Inaccurate MDS Documentation for Resident's Communication Abilities
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Summary
The facility failed to accurately complete sections of a resident's Minimum Data Set (MDS) to reflect the resident's health status. The resident, identified as R153, has a medical history that includes hemiplegia and hemiparesis following a cerebral infarction, dementia, and unspecified psychosis. The MDS inaccurately documented that R153 has clear speech and is able to be understood, while also indicating that the Brief Interview for Mental Status (BIMS) should not be completed because the resident is rarely/never understood. This inconsistency was noted during a surveyor's review of the MDS and through interviews with facility staff. Observations and interviews revealed that R153's speech was not clear, and the resident communicated in a quiet, strained, raspy whisper, making it difficult for staff to understand. Despite this, the MDS nurse, V44, affirmed that R153 has clear speech and can be understood, which contradicts the observations. The Social Services Director, V38, who was responsible for completing the BIMS, stated that R153 refused the interview, leading to the coding of the resident as rarely/never understood. However, V38 acknowledged that R153 is sometimes able to be understood, and the BIMS should have been conducted. This discrepancy in the MDS documentation highlights a failure to accurately assess and document the resident's communication abilities.
Failure to Conduct Level II PASARR for Resident with New Mental Disorder
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Summary
The facility failed to refer a resident, identified as R170, for a Level II PASARR evaluation after the resident was diagnosed with a new mental disorder. Initially, R170's PASARR, dated 03/03/23, indicated that no Level II evaluation was required as there was no serious mental illness or intellectual disability. However, after admission on 03/04/23, R170 was diagnosed with several mental disorders, including Schizoaffective Disorder, Paranoid Schizophrenia, Bipolar Disorder, Major Depressive Disorder, and Anxiety Disorder, among others. Despite these significant changes in mental health status, the facility did not complete a new PASARR evaluation as required by their policy. The facility's policy mandates that a new PASARR Level I screen should be completed with any significant change in a resident's status, and any changes should be reported to the state mental health authority. The Social Service Director (SSD), identified as V38, acknowledged that a new PASARR should have been initiated for R170 following the new diagnoses. The SSD stated that they would only initiate a new PASARR if informed of the need, indicating a communication gap in the process. R170's care plan and physician orders documented various mental health issues and behaviors, yet no new PASARR was conducted until the SSD submitted a new Level I PASARR after the deficiency was identified.
Failure to Complete PASARR for Resident
Penalty
Summary
The facility failed to obtain a pre-admission screening and resident review (PASARR) for a resident diagnosed with major depressive disorder and unspecified psychosis. The resident was admitted to the facility without a completed Level I PASARR, as confirmed by the Assistant Administrator. The PASARR was only submitted and determined after the survey had begun, indicating a lapse in the required pre-admission process. The facility's policy mandates the completion of a Level I screen per state and federal requirements, which was not adhered to in this instance.
Failure to Include Resident in Care Plan Development
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Summary
The facility failed to invite and conduct care plan conferences to include a resident in the development of their plan of care. This deficiency was identified for one resident in a sample of 76. The resident, who has a diagnosis of hemiplegia and hemiparesis following cerebral infarction, unspecified dementia, protein calorie malnutrition, and osteoarthritis, was found to be cognitively impaired with a mental status score of 11. Despite this, the resident reported never being invited to participate in the development of their care plan and expressed a desire to be involved in such meetings. The facility's care plan coordinator, a Licensed Practical Nurse, confirmed that care conferences are held quarterly and as needed, but acknowledged that the resident had not been invited to a care conference. The coordinator was unable to provide a reason for this oversight. The facility's policy on comprehensive person-centered care plans emphasizes the involvement of the resident and their representative in the care planning process, which was not adhered to in this case.
Failure to Provide Grooming Assistance to Residents
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Summary
The facility failed to ensure that two residents, R40 and R199, who depend on staff assistance for their Activities of Daily Living (ADL) care, received proper grooming, specifically shaving. R40, with a BIMS score of 08 indicating moderate cognitive impairments, was observed ungroomed with visible facial hair on multiple occasions. R40 has diagnoses including unspecified dementia, major depressive disorder, and bipolar disorder, and requires maximum assistance with personal hygiene. Similarly, R199, with a BIMS score of 6 indicating some cognitive impairments, was also observed ungroomed with facial hair. R199 has diagnoses including the need for assistance with personal care, muscle weakness, and dementia, and is dependent on staff for personal hygiene. The surveyor's interviews with staff revealed a lack of adherence to the facility's policy on grooming and hygiene. A Certified Nursing Assistant (CNA), V34, admitted to not shaving R199 despite being responsible for their care. The Director of Nursing (DON), V2, confirmed that shaving is part of ADL care and should be offered daily if visible facial hair is present, emphasizing its importance for the dignity and hygiene of residents. The facility's policy and job description for CNAs outline the expectation to meet grooming needs with dignity and privacy, yet this was not followed, resulting in the deficiency.
Inadequate Supervision Leads to Falls and Unsafe Smoking Practices
Penalty
Summary
The facility failed to implement fall precaution interventions and provide adequate supervision for several residents, leading to multiple falls and injuries. Two residents, identified as R1 and R3, were observed with their beds in high positions, contrary to their care plans which required beds to be in the lowest position to prevent falls. R1 experienced two falls within the facility, resulting in a facial laceration and a head contusion. R2 also fell in the dining room, sustaining a fracture of the iliac crest. Despite being monitored by CNAs, these incidents occurred, indicating a lack of effective supervision and adherence to fall prevention protocols. Additionally, the facility failed to provide adequate supervision during designated smoking times, compromising resident safety. Residents R4, R5, R6, and R7 were observed smoking without proper supervision, and some were found in possession of smoking materials, which is against the facility's smoking policy. The smoking bin containing lighters and cigarettes was left unlocked and unattended, posing a significant fire hazard. The facility's policy mandates that all smoking materials be kept by the facility and that residents be supervised while smoking, yet these protocols were not followed. The report highlights the facility's inadequate monitoring and supervision practices, both in preventing falls and ensuring safe smoking practices. Staff members were observed using personal phones while on duty, which may have contributed to the lack of attention and supervision. The facility's failure to adhere to its own policies and procedures regarding fall prevention and smoking safety resulted in multiple incidents that could have been prevented with proper oversight and adherence to established protocols.
Failure to Follow Wound Care Procedures and Documentation
Penalty
Summary
The facility failed to follow its policy procedures and physician orders regarding the treatment and documentation of a resident's skin integrity impairment. The resident, who had a BIMS score indicating intact cognition, had physician orders to cover a left knee injury with a foam silicone dressing to be changed every three days or as needed. However, the facility did not document the injury in a timely manner, and the dressing was not changed according to the physician's orders. The resident reported that the injury occurred when an over-bed table was mishandled by staff, causing it to fall on the knee. During the survey, the resident's left knee was observed to have a large, scabbed abrasion with drainage, contradicting the facility's documentation that the wound was healed. The wound care nurse and the Director of Nursing provided inconsistent information regarding the status and classification of the wound. The wound was inaccurately documented as a blister and healed, despite evidence to the contrary. The wound care nurse admitted to selecting an incorrect classification due to limitations in the documentation system. The facility's failure to accurately assess and document the resident's wound, as well as to follow physician orders, was evident. The wound care nurse was unsure when the injury was first assessed, and the Director of Nursing acknowledged that risk management should have been conducted when the injury was first reported. The facility's wound assessment policy was not followed, as the injury was not documented in the electronic medical records or wound rounds as required.
Inadequate Fall Prevention and Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for a resident identified as R1. R1, who had a moderate cognitive impairment and required assistance for transfers and toileting, experienced two unwitnessed falls within a short period. Despite being at risk for falls due to conditions such as encephalopathy and opioid dependence, the facility did not implement effective fall prevention interventions or provide necessary supervision. After the first fall, the staff primarily relied on redirecting the resident and encouraging the use of a call light, without incorporating frequent monitoring or supervision into the care plan. Following the second fall, which resulted in a compression fracture, the facility's interventions remained inadequate, as supervision or frequent monitoring was still not included in the care plan. The Director of Nursing acknowledged the lack of documented supervision and frequent monitoring in the resident's care plan, despite the resident's impulsive behavior and history of unwitnessed falls. The facility's fall management policy requires new interventions and care plan updates after a fall, but these were not effectively implemented for R1, leading to repeated incidents.
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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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