Ryze On The Avenue
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 3400 South Indiana, Chicago, Illinois 60616
- CMS Provider Number
- 145337
- Inspections on file
- 66
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Ryze On The Avenue during CMS and state inspections, most recent first.
A resident with dysphagia, paraplegia, and complete dependence for eating did not receive required 1:1 feeding assistance for a lunch meal. The resident, who was cognitively intact and unable to use their arms to eat, reported waking from sleep in the afternoon hungry, with no lunch tray present and no staff having offered or provided lunch. The CNA assignment sheet identified a specific CNA as responsible for 1:1 feeding, but that CNA and all other CNAs, RNAs, and RNs on the unit stated they did not bring in or feed the lunch tray. Despite facility policies requiring hand feeding for residents unable to feed themselves and CNA duties to feed and document intake, documentation for that time reflected only supervision and setup help, with no evidence that the resident was actually fed lunch or refused the meal.
Surveyors found that several cognitively intact male residents were living in rooms with heavily stained privacy curtains, ceiling tiles with dried debris, exposed pipes, and light fixtures missing covers. Residents reported that these conditions had existed for some time and that they disliked the dirty curtains. Staff interviews showed that CNAs, housekeeping, nursing leadership, and maintenance each described expectations for daily cleaning, reporting of problems, and monthly room surveillance, but the soiled curtains, damaged or missing light covers, and stained ceiling tiles in multiple rooms were not corrected despite existing policies and assigned responsibilities.
Multiple cognitively intact residents with significant medical and functional needs, including incontinence, immobility, and fall risk, did not have functioning call lights as required by their care plans and facility policy. A bedridden resident reported her call light had not worked since admission to the room and demonstrated that pressing it produced no light or sound; she relied on her roommate to summon staff, and their shared bathroom lacked a call panel or pull cord. Another resident confirmed that staff did not consistently answer call lights and that the bathroom had no call light, while her own bed call light worked and her roommate’s did not. A third resident reported his call light did not work and depended on his roommate for help; observation confirmed the call light did not activate any signals until an LPN repeatedly unplugged and reinserted it. The DON, ADON, CNA, and Maintenance Director all described expectations that call lights be checked, kept within reach, and promptly reported for repair, and facility policies required preventive maintenance and reporting of defective call lights, yet these processes did not prevent or correct the ongoing lack of working call lights for these residents.
Two residents experienced deficiencies in pressure ulcer prevention and care, including the development and worsening of a facility-acquired unstageable pressure ulcer in a dependent, chairfast individual, and improper settings on a low air loss mattress for another resident with multiple wounds. Staff failed to follow protocols for skin assessment, repositioning, and equipment use, resulting in significant harm and hospitalization for one resident.
A resident with diabetes did not have her blood glucose checked before breakfast as ordered; instead, an LPN performed the check after the meal and documented an inaccurate result in the MAR. The DON confirmed that staff are expected to perform and document blood glucose monitoring before meals, in accordance with physician orders and facility policy.
A resident with multiple chronic conditions was found walking in the hallway holding a cup containing several tablets and capsules, which had been given by a nurse over an hour earlier. The resident could not identify the medications, and the nurse had left the medications unattended after being called away for an emergency, failing to ensure the medications were taken as required by facility policy.
A resident with hemiplegia and a history of stroke, who requires supervision for toileting, waited 11 minutes for staff to respond to a call light after activating it for assistance. Despite a CNA walking past the room without responding, the call was eventually answered by the ADON. The resident's roommate reported frequent delays in call light response, and facility policy requires prompt attention to call lights.
Multiple residents experienced physical abuse from their roommates, including incidents involving scissors, a call light, and kicking. Staff and care plans documented the risk for abuse and neglect, and residents reported feeling unsafe and helpless following these altercations.
A resident with multiple comorbidities and existing pressure ulcers did not receive timely wound assessment or care orders for over a week after admission, due to the absence of a wound care nurse and lack of staff follow-up. This lapse led to deterioration and infection of the wounds, ultimately resulting in sepsis and hospitalization, in violation of facility protocols for wound monitoring and documentation.
A resident with a history of repeated falls and a traumatic brain injury was not properly assessed or care planned for fall risk, resulting in two unwitnessed falls—one causing an epidural brain bleed and another a head laceration. Staff failed to implement fall prevention interventions, incorrectly scored fall risk assessments, and did not update the care plan until after the first fall. The facility also did not account for staff whereabouts during the incidents or obtain required statements, in violation of its own fall prevention policy.
A resident with intact cognition and multiple medical diagnoses was admitted without having their personal belongings properly inventoried by staff, as required by facility policy. The resident later reported several missing items, and the social worker confirmed that the belongings list form was not completed, resulting in the facility being unable to account for the resident's possessions.
Two residents were not protected from physical abuse by peers, resulting in one resident sustaining multiple rib fractures and a pneumothorax after slipping on water thrown by a roommate, and another resident being struck in the head with a wheelchair armrest by a peer with a history of aggression. Staff and care plans had identified behavioral risks and cognitive impairments, but interventions were insufficient to prevent these incidents.
The facility did not ensure adequate supervision for residents, including a resident with severe cognitive impairment who wandered into other residents' rooms and was involved in an altercation, and multiple residents left unsupervised in the dining room during a shift change. Staff were unclear about monitoring responsibilities, and there was no effective system to track or update care plans for residents on fall precautions, with care plans not reflecting actual incidents.
A resident with multiple medical conditions experienced vaginal bleeding and was later sent to the hospital. Although staff documented an intention to notify the physician, DON, and family, there was no evidence that the family was actually notified of the change in condition when it first occurred, as required by facility policy. Staff interviews confirmed that documentation should reflect completed notifications, not just intent.
A resident with a history of joint replacement surgery and at high risk for falls was affected by a non-functioning call light, which was not repaired despite maintenance visits. The resident had to rely on a roommate's call light, impacting their ability to request assistance, especially when unable to walk or go to the bathroom independently.
The facility failed to administer IV fluids at the correct rate for five residents, as the flow meters used had a maximum calibration of 250ml per hour, while the physician's order was for 1000ml per hour. The IV therapy company left the flow meters open, causing rapid infusion, and the facility staff did not monitor the rates. IV bags were not labeled with start and stop times, and there was no documentation of vital signs. The facility's policy requires notifying the physician if orders cannot be followed, but this was not done.
A medication cart on the 4th floor was found unlocked and unattended while an LPN was in a patient room, leaving it vulnerable to tampering. A resident was observed standing by the cart, and the LPN later acknowledged the oversight, confirming it was against facility policy to leave the cart unlocked when not in use or out of view.
The facility failed to prevent physical abuse between residents, resulting in altercations. One incident involved a resident hitting another in the head, while another involved verbal abuse followed by physical hitting. Both incidents were unwitnessed initially, but staff later confirmed the altercations. The facility's policy prohibits such abuse, yet it occurred, indicating a failure to protect residents.
A resident with a history of falls and requiring substantial assistance experienced a fall resulting in a hip fracture due to inadequate support during bed mobility. The facility failed to use side rails as per the care plan and did not complete a timely fall risk evaluation. The CNA did not request additional help and left the resident unsupported, leading to the fall.
A resident with dementia and other conditions developed a stage 3 pressure ulcer, which was not included in their care plan due to a lack of awareness by the LPN. Additionally, the facility failed to document nursing interventions for the resident's abnormal vital signs while on hospice care. The DON was uncertain about the policy for hospice residents and intended to consult externally. The care plan did not align with the facility's hospice policy and agreement.
A hospice resident with a history of dementia and brain injury experienced abnormal vital signs, including a high heart rate and low blood pressure, which were not properly addressed or documented by the nursing staff. A CNA reported the issue to an RN, who instructed the CNA to record normal vital signs to avoid delaying the shift's end. The facility's policies required notification of changes in condition, but the RN did not inform the physician or hospice services, and the DON expressed uncertainty about policy applicability to hospice residents.
A resident developed a stage 3 pressure ulcer due to the facility's failure to follow physician orders and care plan interventions for skin assessments and monitoring. The resident, initially admitted without pressure ulcers, developed a deep tissue injury on the sacrum, which progressed due to inadequate monitoring and documentation. The wound was not included in the care plan, and there was no evidence of daily skin checks as required.
A resident with hemiplegia and cognitive impairment was left without a working call light, despite informing staff of the issue. The resident, who required assistance, was unable to call for help. Staff, including RNs and a maintenance assistant, were aware of the malfunction but did not provide an alternative means for the resident to request assistance, contrary to facility policy.
A resident with severe cognitive impairment was subjected to physical abuse by another resident with mental health issues, who placed a pillow and blanket over their face. The incident was discovered by a CNA during rounds, and the resident was found in distress but unharmed. The facility's policies on abuse prevention and residents' rights were not effectively implemented, leading to this deficiency.
A facility failed to properly assess, monitor, and document pressure ulcer care for a high-risk resident, leading to the development and worsening of multiple facility-acquired pressure ulcers. The resident's care plan was not updated to reflect the status of the ulcers, and dressing changes were not documented on the Treatment Administration Record. The facility's policy for skin management was not consistently implemented, resulting in a lack of timely assessments and documentation.
A resident experienced verbal and emotional abuse by a CNA who used profane language and refused to perform certain duties, leading to the resident feeling hurt and inferior. The incident was witnessed by other staff members, and the facility's failure to document the incident and conduct a post-incident assessment highlights a deficiency in protecting residents from abuse.
A resident reported that a CNA used profanity and derogatory language during a request for assistance, which was witnessed by a Transportation Coordinator. The incident was reported internally but not to the state surveying agency within the required two-hour timeframe, violating the facility's abuse policy.
A resident in a long-term care facility was involved in a verbal altercation with a roommate, leading to a physical confrontation. Despite the facility's policy against abuse, the resident reported feeling scared and in pain after being hit with a walker. Staff intervened by separating the residents, but the incident highlights a failure to protect the resident from verbal abuse.
A hospice resident with prostate and bone cancer did not receive scheduled morning pain medication on time, resulting in increased pain. The delay was due to an LPN starting the shift late after being called in to cover for another nurse. The resident reported frequent delays when new nurses are on duty, and the Director of Nursing was unaware of any ongoing issues with the resident's pain management.
The facility failed to maintain the lint traps of four dryers, posing a potential fire hazard. Despite expectations for cleaning every two hours, a surveyor found lint accumulation in all dryers. A laundry personnel confirmed the oversight, and the DON acknowledged the importance of regular cleaning to prevent fire risks.
A survey identified deficiencies in a facility where call lights were not within reach for three residents, and one resident was without linen on their bed. Despite being cognitively intact, a resident was left on a bare mattress, expressing discomfort. Another resident could not locate their call light, relying on roommates for help, contrary to their care plan. Two more residents had call lights out of reach, with staff acknowledging the issue. The facility's policy requires call lights to be accessible, which was not adhered to, leading to the deficiency.
The facility failed to complete Pre-Admission Screening and Resident Reviews (PASRRs) by qualified staff before admitting residents. An Admissions Director, lacking necessary clinical qualifications, conducted PASRR Level I screenings for several residents after their admission, contrary to facility policy. One resident with schizophrenia and major depressive disorder was admitted without a prior PASRR, highlighting a lapse in the pre-admission process.
The facility failed to include residents in care plan conferences, affecting four individuals with various medical conditions. Despite policy requirements, residents were not invited to participate in developing their care plans. Interviews revealed that residents were unaware of any meetings and wished to be involved. The facility lacked documentation of invitations or conducted conferences, as confirmed by staff.
The facility failed to secure a laundry chute on the dementia unit, posing a risk to residents who wander freely. Additionally, a resident was found with a steak knife intended for self-protection, highlighting a lack of hazard policy. Staff acknowledged the risks, but the facility lacked measures to prevent such safety issues.
The facility failed to label and date respiratory equipment and ensure physician's orders for oxygen therapy for residents receiving oxygen. This affected four residents, including those with chronic respiratory conditions, as their oxygen equipment was observed without proper labeling. Staff confirmed the lack of labeling, and the facility's policy requiring weekly changes was not followed.
The facility failed to properly monitor personal refrigerators in residents' rooms, resulting in missing temperature logs, absence of thermometers, and expired food items. Observations revealed that staff did not consistently check temperatures or remove expired items, despite the facility's policy requiring daily monitoring. This oversight affected several residents, posing potential health risks.
A facility failed to assess a resident's ability to self-administer an inhaler, which was found on the resident's over-the-bed table without a medical order or proper education. The resident, diagnosed with asthma, did not have a Medication Self-Evaluation Form or an order for the inhaler in their medical record. The facility's policy requires an order and assessment for self-administration, which was not adhered to in this instance.
A facility failed to document a resident's code status in the electronic medical record, affecting the resident's medical documentation. The resident, with a history of Metabolic Encephalopathy, Sepsis, Hypocalcemia, and Acidosis, had no code status listed on their profile screen, despite having an order for Advance Directive Code Status in their Orders Summary Report. Interviews with staff confirmed that the code status should be recorded upon admission, as per facility policy.
A resident with chronic health conditions was left confined to his room due to staff inaction, despite his requests for assistance to get out of bed. The resident, who felt like he was in prison, was cognitively intact and had a care plan encouraging ambulation, but staff failed to document or consistently assist him. Interviews revealed a lack of adherence to facility policies on maintaining residents' physical and mental health, contributing to the resident's declining condition.
A resident with hepatitis C did not receive a required infectious disease consult due to the facility's failure to follow a physician's order. The resident was unaware of their diagnosis and had no documented treatment. Staff interviews confirmed the lack of consultation or treatment, despite facility policies assigning responsibility for arranging such appointments to nursing staff.
A resident with a pressure ulcer on the buttocks did not receive necessary treatment due to a lack of documentation and awareness by the wound care nurses. Despite the resident reporting the wound, it was not included in treatment orders, and the nurses were unaware of its existence until a survey. The facility's policy on regular skin assessments was not followed, leading to inadequate care.
A resident with neuromuscular dysfunction of the bladder and paraplegia reported that their indwelling catheter bag had not been changed in two months, despite being soiled. The surveyor observed the bag was undated, with cloudy urine and brownish discoloration. The DON confirmed that catheter bags should be changed when dirty or discolored, as per facility policy, but this was not done, posing a risk of infection.
A resident with a G-tube was found with an enteral feeding formula that had not been changed for three days, contrary to the facility's policy requiring daily changes. The resident has multiple diagnoses, including acute respiratory failure and dysphagia. A nurse acknowledged the error, and the DON confirmed the importance of changing the feeding every 24 hours to prevent illness.
A facility failed to securely store controlled substances, affecting a resident. An LPN observed that the refrigerator in the medication room was unlocked, with an open padlock on the counter. The LPN retrieved a vial of Lorazepam, a controlled substance, from the refrigerator, which also contained other medications without a separate lock box. The DON confirmed that controlled substances should be stored behind two locks, as per facility policy.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents with medical conditions requiring such measures. Staff were unaware of EBP requirements and did not wear appropriate PPE while providing care. The facility lacked sufficient PPE bins, and there were no documented EBP orders for the residents, putting them and staff at risk of infection transmission.
The facility did not ensure state survey records were accessible for residents, affecting all 223 residents. A resident confirmed the unavailability of inspection reports, and the administrator was initially unaware of their location. Upon checking, no records were found at the designated spot. Facility documents state residents have the right to view these reports.
A resident, severely cognitively impaired and dependent on staff for bed mobility, fell and sustained a hematoma during ADL care when one CNA left the room, leaving the other CNA to manage alone. The resident rolled out of bed, highlighting a failure in maintaining adequate supervision.
The facility failed to provide adequate staffing, affecting resident care. One resident waited 30 minutes for assistance, another was left hungry, and two others were found in soiled beds due to insufficient CNA coverage. Staff confirmed the shortage, citing call-offs and no-shows, with no agency staff used to fill gaps.
The facility failed to respond promptly to a resident's call light, leaving them in discomfort, and did not ensure call lights were accessible for three other residents needing incontinent care. Observations revealed staff resting during shifts and call lights on the floor, contrary to facility policy.
The facility failed to maintain a comfortable environment due to inadequate cooling in some rooms. Three residents experienced discomfort from either non-functional or excessively noisy air conditioners, with complaints going unaddressed. The Maintenance Director was unaware of these issues, indicating a lapse in communication and adherence to the facility's Preventive Maintenance Plan.
Failure to Provide Required 1:1 Feeding and Lunch Meal to Dependent Feeder
Penalty
Summary
The deficiency involves the facility’s failure to provide required 1:1 feeding assistance and to ensure a lunch meal was offered and provided to a dependent resident. The resident had multiple medical diagnoses including dysphagia, cervical spine fusion with paraplegia, neurogenic bladder, type 2 diabetes, hypertension, hypotension, anemia, and muscle spasms. The resident’s MDS documented a BIMS score of 15, indicating intact cognition, and coded the resident as Dependent for eating, meaning staff must perform all of the effort for the eating task. The facility’s list of 1:1 feed residents included this resident, and the care plan documented potential nutritional problems and a need for assistance with ADLs related to paraplegia. On the day in question, the resident reported receiving morning ADL care and incontinence care from a CNA around late morning, then falling asleep and waking in the afternoon feeling hungry, with no lunch tray present and no staff having awakened the resident or offered lunch. The resident stated that no one asked whether they wanted to eat and that they were not fed lunch. A family member reported receiving a call from the resident that afternoon stating the resident was hungry and had not been given lunch, and another visitor confirmed assisting the resident to call the family because staff had not provided a lunch tray. At the time of observation during survey, the resident was in bed with bilateral hand splints, stated they could not use their arms to eat or drink independently, and stated they received full care from staff. Multiple staff interviews and record reviews showed that although the Daily Assignment Sheet for that shift listed one CNA under special assignment as the 1:1 feeder for this resident, that CNA stated they did not see or feed the resident at lunch and believed the assignment entry was a mistake. The primary CNA for the resident that day confirmed providing ADL care but stated they did not bring or feed the lunch tray and believed that whoever was assigned as feeder was responsible. Other CNAs, the RNA, and the RNs working that shift each stated they did not bring in or provide the resident’s lunch meal. The CNA who created the assignment sheet stated that all CNAs were informed of their 1:1 feed responsibilities and that the CNA listed as special assignment was responsible for feeding this resident. Despite this, no staff member identified actually delivering or feeding the lunch meal, and the ADL charting by the primary CNA documented only supervision and setup help for eating at a time corresponding to the lunch period, with no indication of 1:1 physical assistance or resident refusal. Facility policies required that residents unable to feed themselves be hand-fed by qualified staff, that diets be served per physician order, and that CNAs prepare residents for meals, feed as necessary, and review care plans daily, but these expectations were not met for this resident’s lunch meal.
Failure to Maintain Clean Curtains and Intact Room Fixtures for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike physical environment for multiple cognitively intact residents. During a tour, surveyors observed that two male residents’ rooms had privacy curtains with large stains and dried debris. Both residents reported that the curtains had been dirty and unchanged for some time and that they disliked their appearance. In one of these rooms, surveyors also observed a stained ceiling tile, exposed pipes, and a bathroom light fixture missing its cover, and the resident stated that these conditions had been present and unchanged. In another room shared by two additional male residents, surveyors observed ceiling tiles with dried debris and privacy curtains hanging off their hooks. One of these residents reported that the curtains and ceiling stains had been in that condition for some time. All four residents involved had BIMS scores of 15, indicating they were cognitively intact and able to make their needs known. The environmental issues identified included dirty and damaged privacy curtains, missing light covers, stained ceiling tiles, and exposed pipes. Staff interviews revealed inconsistent understanding and implementation of responsibilities for identifying and addressing these environmental problems. A CNA stated housekeeping was responsible for ensuring curtains and rooms were clean. The housekeeper reported that rooms were cleaned daily but was unsure whether they should notify anyone when curtains needed changing, while acknowledging that several residents’ curtains were visibly soiled. The ADON and assistant administrator stated that curtains should be clean, changed when dirty, and checked regularly, and that lights should have covers. The maintenance director and other staff described processes for daily checks and monthly surveillance of rooms, as well as policies and job descriptions requiring regular inspections and maintenance of resident rooms, but the observed conditions showed these processes were not effectively carried out for the affected residents’ rooms.
Failure to Ensure Working Call Lights for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents had working call lights to reasonably accommodate their needs and preferences, as required by their care plans and facility policy. One resident, a cognitively intact female with multiple diagnoses including bilateral lower leg fractures, COPD, malnutrition, incontinence, and high fall risk, was admitted to her current room on 12/29/2025. Her care plan included multiple interventions requiring that the call light be placed within reach and that staff assess her ability to use it, particularly due to her functional deficits, incontinence, and fall risk. On observation, she was bedridden, unable to bear weight on her legs, and dependent on staff for all assistance, yet she reported that her call light had not worked since admission to the room. When she pressed the call light during the survey, there was no light at the panel, no light outside the room, and no audible sound. The same resident stated that when her roommate was present, the roommate would either press her own call light or walk to the nurses’ station to get help, but when the roommate was not present, the resident had to wait and became scared that no one would come when she needed help. The bathroom shared by these two residents had no call panel or pull switch. The roommate, also cognitively intact and with multiple medical and psychiatric diagnoses, confirmed that staff did not answer call lights consistently and that the other resident’s call light did not work. She demonstrated that her own call light functioned, while the bedridden resident’s did not, and she stated that if she needed help in the bathroom, there was no call light to pull. The Director of Nursing observed that the bedridden resident’s call light did not activate any lights and acknowledged that the resident was dependent on staff and required a working call light. The DON stated that if a call light was not working, the resident should have been given a bell, and that clinical staff do not check call lights, even though call lights should be working. A third cognitively intact male resident with a history of stroke, hemiplegia, incontinence, and high fall risk also reported that his call light did not work and that he relied on his roommate to get staff when he needed assistance. His care plan required that the call light be placed within easy reach to maintain his dignity related to incontinence and that he be educated to use the call light for assistance with ADLs as part of his fall prevention interventions. During observation, when he pressed his call light, there was no light at the wall panel, no light above the room, and no audible sound. The call light was not answered, and when an LPN entered to give medications, she did not acknowledge the call light because it was not functioning. When the LPN later tested the call light, it did not work until she unplugged and reinserted it several times, after which it began to function. She stated that nurses and CNAs are supposed to ensure call lights are working, keep them within reach, and submit work tickets for nonfunctioning call lights so they can be fixed immediately. Interviews with staff revealed inconsistencies between stated procedures and actual practice. The Assistant DON stated that call lights are checked every day and that frequent rounds are made to ensure residents are checked, while the Maintenance Director stated that rooms are checked daily by housekeeping and CNAs, that any nonworking equipment should be entered into the system to alert maintenance, and that every bed should have a functioning call light. The Maintenance Director acknowledged that the bedridden resident’s call light had been a “constant issue,” that management knew in morning meetings that the call light was not working, and that someone should have provided the resident with some type of communication device. The facility’s Preventive Maintenance Policy required monthly surveillance of all resident rooms for proper operation of equipment, and the Call Light Response policy required prompt reporting of defective call lights. The Maintenance Director’s job description required periodic rounds to check equipment and ensure it was working properly. Despite these policies and stated expectations, multiple residents had nonfunctioning call lights and lacked bathroom call devices, and staff either were unaware of the problems or did not ensure timely reporting and resolution, resulting in residents’ needs not being reasonably accommodated through access to working call lights.
Failure to Prevent and Manage Pressure Ulcers and Inappropriate Use of Pressure-Relieving Equipment
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development and worsening of pressure ulcers for two residents. One resident, who was chairfast, incontinent, and totally dependent for activities of daily living, was admitted with intact skin but developed a facility-acquired unstageable pressure ulcer on the sacral area. Documentation and interviews confirmed that the resident did not have a wound upon admission, and the wound was first identified by staff, who noted moisture-associated skin dermatitis. The resident later required hospitalization due to wound infection, with hospital records indicating the presence of osteomyelitis and exposed bone. There was no documentation indicating that the wound was unavoidable, and the resident reported that staff did not clean or reposition her as needed. Another resident, who had multiple pressure ulcers and was severely cognitively impaired, was observed lying on a low air loss mattress that was set at a weight significantly higher than the resident's actual weight. Both the RN and the wound care nurse confirmed that the mattress should be set according to the resident's weight, and that an incorrect setting could result in a hard surface, impairing wound healing. The resident's care plan and physician orders specified the use of a pressure redistribution mattress, but the mattress was not set appropriately, contrary to manufacturer instructions and facility policy. Facility policies required that all residents at risk for skin breakdown receive appropriate care, including regular skin assessments, timely reporting of changes, and repositioning at least every two hours for those unable to reposition themselves. The facility's failure to follow these protocols and ensure proper use of pressure-relieving equipment resulted in the development and worsening of pressure ulcers for two residents, one of whom required hospitalization and surgical intervention.
Failure to Monitor and Document Blood Glucose per Physician Order
Penalty
Summary
Staff failed to monitor and document a resident's blood glucose according to the physician's order. On the morning in question, a Licensed Practical Nurse (LPN) checked the resident's blood glucose after the resident had already eaten most of her breakfast, rather than before the meal as ordered. The glucometer reading at that time was 309. The Medication Administration Record (MAR) for that day inaccurately documented the blood glucose as 144 at 7:30am, despite the actual check occurring later and yielding a much higher result. The LPN acknowledged that the blood glucose should have been checked before breakfast, and the Director of Nursing confirmed that staff are expected to perform the check prior to meal service to ensure accurate readings. The resident involved had diagnoses including hypertension, chronic pain, and Type 2 Diabetes Mellitus, with active orders for blood glucose monitoring before meals and at bedtime. Facility policy also required blood glucose monitoring to be performed and documented per physician's orders. Interviews with staff and review of records confirmed that the blood glucose was not checked at the correct time and that the result was not accurately documented, which could impact the management of the resident's diabetes.
Medications Left Unattended and Unlabeled with Resident
Penalty
Summary
A deficiency occurred when a cognitively intact resident, admitted with multiple chronic conditions including COPD, diabetes, chronic pancreatitis, chronic kidney disease, hypertension, and atherosclerotic heart disease, was observed ambulating in the hallway holding a souffle cup containing seven tablets and capsules. The resident reported that the nurse had given the medications over an hour prior but was unable to identify the medications when asked. The resident subsequently left the medications with the surveyor and walked away. Interviews with facility staff revealed that the nurse had prepared and delivered the medications to the resident, but left the room due to an emergency involving another resident. The nurse did not return to ensure the medications were taken, contrary to facility policy, which requires staff to remain with the resident to ensure medications are swallowed. The DON confirmed that staff should not leave medications at the bedside and should explain the medications to the resident.
Delayed Call Light Response for Resident Requiring Assistance
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral vascular accident, right-sided hemiplegia, and speech and language deficits, who requires supervision with toileting and uses a walker, activated the call light for staff assistance. The resident waited a total of 11 minutes before the call light was answered by the Assistant Director of Nursing, despite a certified nursing assistant in a purple uniform walking past the room without responding to the call light. The resident's care plan and medical records indicate intact cognition and a need for staff support with toileting due to physical limitations. The resident's roommate confirmed that delays in call light response are frequent, sometimes lasting hours, and that the resident often requires help with toileting and dressing. Facility policy states that call lights should be answered as soon as possible, and both the Director of Nursing and Administrator acknowledged that it is not acceptable for staff to ignore call lights or delay responses. The observed delay and staff inaction directly contributed to the deficiency in timely response to resident needs.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect three residents from physical abuse by their roommates, resulting in multiple incidents of resident-to-resident altercations. In one case, a cognitively intact resident with paraplegia and other significant diagnoses was attacked by her roommate, who attempted to use scissors as a weapon and struck her with a call light. The incident was witnessed by a restorative aide, who intervened and removed the scissors, but the aggressor produced a second pair of scissors after the initial intervention. The victim expressed ongoing feelings of being unsafe following the event. Another incident involved two residents with cognitive and behavioral health diagnoses who engaged in a physical altercation, described as wrestling on a bed. The altercation was reported by a roommate and confirmed by an LPN who intervened. A body check revealed redness, and a police report was filed for simple battery. The care plan for one of the residents documented a potential for abuse or neglect. A third incident involved a resident with legal blindness and multiple comorbidities who was kicked by his cognitively intact roommate. The victim reported feeling upset and helpless due to his inability to defend himself. Staff were notified, and the aggressor admitted to the action, stating it was due to having a bad day. The facility's documentation and interviews confirm that these resident-to-resident altercations occurred, and the affected residents were identified as being at risk for abuse and neglect in their care plans.
Failure to Provide Timely Pressure Ulcer Care Resulting in Wound Infection and Hospitalization
Penalty
Summary
A resident with multiple medical conditions, including a displaced femur fracture, muscle weakness, diabetes, and existing pressure ulcers, was admitted to the facility with documented wounds on the coccyx and both heels. Despite being identified as at risk for further skin breakdown, the resident did not receive a wound assessment or wound care orders from admission until eight days later. During this period, there was no wound care nurse available for approximately one week, and the resident's wounds were not assessed or treated. Facility staff confirmed that the resident did not have wound care orders until the delayed assessment, and the Director of Nursing was unaware of this lapse. Following the delayed intervention, the resident's wounds deteriorated, with the sacral wound becoming infected, as evidenced by wound cultures and physician assessments. The resident subsequently developed sepsis, was transferred to the hospital, and was diagnosed with acute metabolic encephalopathy likely due to sepsis from the sacral wound infection. Facility policy required consistent monitoring and documentation of wounds, but this protocol was not followed, resulting in a decline in the resident's condition.
Failure to Assess, Care Plan, and Supervise High Fall Risk Resident
Penalty
Summary
The facility failed to accurately assess and evaluate a resident who was at high risk for falls, and did not provide an appropriate plan of care or implement fall prevention interventions. Despite the resident's history of repeated falls, traumatic subdural hemorrhage, and a coagulation defect, the facility did not include any fall prevention interventions in the care plan upon admission or readmission. The fall risk assessments were incorrectly scored, indicating the resident was not at high risk, even though the actual scores were well above the threshold for high risk. No baseline care plan interventions were provided, and the care plan for falls was only created after the resident experienced a fall. The resident experienced two unwitnessed falls while in the facility. The first fall resulted in an epidural brain bleed and required hospital admission, while the second fall caused a laceration to the back of the head, also necessitating hospital transfer. Staff interviews revealed that the resident was left alone in the room during times when assistance was needed, and staff were unsure if alternative supervision or transfer to a wheelchair would have prevented the falls. The resident was not included on the 'get up' list, and staff cited being too busy to provide additional supervision or assistance during critical times. Further review of the facility's investigation process showed that staff whereabouts at the time of the falls were not accounted for, and written statements from assigned CNAs were missing. The facility's fall prevention policy required fall risk evaluations on admission, readmission, quarterly, and after each fall, with care plans to be updated accordingly. However, these procedures were not followed, and the lack of timely assessment and intervention contributed to the resident's repeated falls and injuries.
Failure to Inventory Resident's Personal Belongings Upon Admission
Penalty
Summary
A deficiency occurred when the facility failed to properly inventory the personal belongings of one resident upon admission, as required by facility policy. The resident, who had an intact cognitive status and diagnoses including amyloidosis, insomnia, and anxiety disorder, reported missing several personal items, including headphones, a mini wrench with screwdriver, a State ID, an orange extension cord with USB, and a titanium phone charging cord. The resident stated that he provided a list of these items to the social worker, who confirmed being informed of the missing belongings and completed a concern form on the resident's behalf. The facility's social worker acknowledged that the proper procedure for inventorying personal belongings was not followed, as the resident did not bring his belongings to the receptionist upon arrival and no belongings list form was completed. The administrator confirmed that staff are responsible for completing the belongings list to account for residents' personal items, in accordance with the facility's policy. The policy requires that an inventory be completed upon admission and updated as items are brought in or removed. The failure to follow this procedure resulted in the inability to account for the resident's personal belongings.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to prevent and protect residents from resident-to-resident abuse, resulting in two separate incidents involving four residents. In the first incident, a resident with moderate cognitive impairment and a high risk for falls was involved in an altercation with her roommate. The altercation escalated when the roommate threw water on her, causing the resident to slip, fall, and sustain multiple rib fractures and a pneumothorax. The incident was not immediately reported to staff, and initial assessments did not reveal the involvement of another resident until further investigation. The resident required hospitalization for her injuries, and it was later confirmed that the fall was directly related to the altercation with her roommate. In the second incident, a resident with severe cognitive impairment and a history of wandering entered another resident's room. The resident in the room, who had a history of verbal and physical aggression and intact cognition, became agitated and struck the wandering resident with a wheelchair armrest. Staff responded to the commotion, separated the residents, and both were sent to the hospital for evaluation. The wandering resident sustained redness and an abrasion on the forehead, while the aggressive resident was sent for psychiatric evaluation. The aggressive resident did not return to the facility following the incident. Both incidents demonstrate a failure to adequately supervise and protect residents from physical abuse by peers, particularly those with known behavioral risks and cognitive impairments. The facility's own assessments and care plans documented the residents' vulnerabilities and behavioral histories, yet these measures were insufficient to prevent the altercations and resulting injuries. The events were reported to the appropriate authorities, but the deficiencies stemmed from the lack of effective interventions to prevent resident-to-resident abuse.
Failure to Provide Adequate Supervision and Monitoring for At-Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision and monitoring for residents in key areas, specifically the dining room and among residents with known risks such as wandering and falls. One resident with severe cognitive impairment and a diagnosis of Alzheimer's disease was observed wandering into other residents' rooms without staff accompaniment or electronic monitoring. This resident entered another resident's room and was struck by the other resident, who was in a wheelchair. Multiple staff interviews confirmed that the resident frequently wanders and enters peers' rooms, and that staff typically redirect the resident but do not consistently accompany or closely monitor them. Additionally, residents were observed sitting in the dining room without any staff present to monitor them during a shift change. Staff acknowledged that there should always be someone monitoring the dining room to prevent falls, altercations, or other incidents, but at the time of observation, no clear assignment had been made for this responsibility. Staff expressed uncertainty about who was responsible for monitoring, and only after being alerted by the surveyor did a CNA enter the dining room to supervise the residents. The facility also failed to properly monitor and track residents on fall precautions. One resident who experienced a fall was not care planned for the actual fall event, and the fall coordinator did not maintain a current list or binder of residents on fall precautions for staff reference. The care plan for the resident was updated only after the surveyor began investigating, and the facility was unable to provide relevant policies on supervision, monitoring, or accident prevention when requested. These failures affected residents on the second floor, where 73 residents reside.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in condition for one of three residents reviewed for notification of change, out of a total sample of fourteen. The resident, who had a history of benign neoplasm of the right breast, hemiplegia and hemiparesis, abnormal uterine and vaginal bleeding, and unspecified dementia, experienced vaginal bleeding and the passage of large clots. This change in condition was first observed and reported by a CNA to an LPN, who documented the intention to notify the medical doctor, Director of Nursing (DON), family, and the next shift nurse. However, the documentation only indicated that these notifications 'will' be made, rather than confirming that they had actually occurred. Further review of the resident's progress notes revealed that while an attempt to contact the family was documented on the day the resident was sent to the hospital, there was no documentation of any attempt to notify the family on the days when the change in condition was first identified. Interviews with nursing staff and the DON confirmed that proper notification procedures were not followed, as documentation should reflect actual notification rather than intent. The facility's policy requires alerting the resident, physician, and resident party of a change in condition, except in a medical emergency, but this was not adhered to in this case.
Non-Functioning Call Light Affects Resident's Ability to Request Assistance
Penalty
Summary
The facility failed to ensure that a resident's call light device was functioning properly, affecting one resident out of three reviewed for call lights. The resident, who is alert and responsive, reported that their call light has never worked since admission. Despite maintenance staff visiting twice, the issue was not resolved, and the resident was instructed to use their roommate's call light. This situation was confirmed through observation, as pressing the call light did not activate any notification at the nurse's station or outside the resident's room. The resident, who has a history of joint replacement surgery and is at high risk for falls, expressed that the non-functioning call light significantly impacted their ability to call for assistance, especially when they were unable to walk or go to the bathroom independently. The resident's care plan emphasized the importance of having the call light within reach and assessing the resident's ability to use it. However, the facility's failure to address the defective call light was evident, as the resident had to rely on their roommate's call light, causing inconvenience and frustration.
Failure to Administer IV Fluids at Correct Rate
Penalty
Summary
The facility failed to adhere to the physician's orders for the administration of IV fluids to five residents, resulting in a deficiency. The IV fluids were ordered to be infused at a rate of 1000ml per hour, but the flow meters used had a maximum calibration of 250ml per hour. This discrepancy led to the IV fluids being administered at an incorrect rate, as the flow meters were left open, causing the fluids to infuse too rapidly. The registered nurses and licensed practical nurses at the facility were not actively monitoring the infusion rates, as the responsibility was delegated to an external IV therapy company. During observations, it was noted that the IV bags were not labeled with start and stop times, and there was no documentation of vital signs before and after the infusion. The nurses from the IV therapy company admitted to leaving the flow meters open and speeding up the infusion if there was any fluid left, which was not in accordance with the physician's orders. The facility's Director of Nursing and Nurse Consultant acknowledged that the drip rate was too fast and that the IV infusion should be administered per the physician's order to prevent potential complications such as fluid overload. The facility's policy on medication administration requires that all medications be administered safely and appropriately, and if a physician's order cannot be followed, the physician should be notified. However, this protocol was not followed, as there was no communication with the physician regarding the inability to infuse the IV fluids at the ordered rate. The educational in-service provided by the facility on calculating drip rates was not effectively implemented, as the correct flow rate was not maintained for the residents receiving IV therapy.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that the medication cart was locked when not in visual proximity of the nurse and not in use, which could lead to tampering and accidental hazards. On January 27, 2025, at 1:30 pm, a medication cart on the 4th floor was observed unlocked and unattended in the hallway while a resident stood nearby. The Licensed Practical Nurse (LPN) responsible for the cart was inside a patient room, leaving the cart vulnerable. When questioned, the resident indicated they were waiting for the LPN to return. Upon being informed of the situation, the LPN acknowledged the oversight and confirmed that the facility's policy requires the medication cart to be locked when not in use or when the nurse is not in direct view of it. The Assistant Director of Nurses (ADON) reiterated that the expectation is for nurses to lock the cart if they must walk away or turn their back on it. The facility's policy on medication administration clearly states that medication carts should never be left open and unattended.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect four residents from physical abuse, resulting in altercations between them. Resident 2 (R2) and Resident 3 (R3) were involved in a physical altercation where R3 allegedly followed R2 to their room and struck them. R2 retaliated by swinging their arms and making contact with R3. The incident was unwitnessed, but a Licensed Practical Nurse (LPN) later observed R2 swinging their arms at R3. R3 was sent to the hospital for neck pain but returned without injury. Both residents had care plans indicating they should be free from mistreatment, yet the altercation occurred. Another incident involved Resident 5 (R5) and Resident 6 (R6), where R6 verbally abused R5 using racial slurs and then physically hit R5 in the face. R5 retaliated, and both residents were found by staff in a state suggesting a physical altercation had occurred. R6 had a small scratch on their face, and R5 reported being in pain but declined medication. R6 was known for verbal aggression and was sent to the hospital for evaluation but did not return to the facility. The facility's policy prohibits abuse, including physical and verbal mistreatment, yet these incidents occurred. Staff interviews confirmed that physical hitting is considered abuse, and the facility's investigation documented the altercations. Despite the presence of care plans and policies aimed at preventing abuse, the facility failed to prevent these resident-to-resident altercations, resulting in physical abuse.
Failure to Provide Adequate ADL Assistance and Fall Risk Assessment
Penalty
Summary
The facility failed to provide appropriate assistance during activities of daily living (ADL) care and did not adhere to the ADL care plan intervention regarding the use of side rails. This deficiency was evident in the case of a resident who experienced a fall resulting in a left hip fracture. The resident, who had a history of falling and required substantial assistance with toileting and personal hygiene, was not adequately supported during bed mobility, leading to the fall incident. The resident's care plan indicated the use of side rails to assist with bed mobility, but on the day of the incident, the side rails were not in use. The Certified Nursing Assistant (CNA) providing care did not request additional help, despite the resident's need for substantial assistance. The CNA momentarily left the resident unsupported while reaching for a moisture barrier cream, during which time the resident slipped and fell from the bed. Additionally, the facility did not complete a timely fall risk evaluation for the resident, with the last assessment conducted in July and no evaluation found for October. This lapse in assessment meant that the resident's fall risk was not adequately monitored or addressed, contributing to the incident. The facility's policies on bed rails and fall prevention were not followed, as the necessary assessments and interventions were not implemented to ensure the resident's safety.
Failure to Provide Individualized Care Plan for Pressure Ulcer and Hospice Care
Penalty
Summary
The facility failed to provide an individualized and person-centered care plan for a resident who acquired a pressure ulcer and was receiving hospice care. The resident, who has dementia, traumatic brain injury, and subdural hemorrhage, developed a stage 3 pressure ulcer on the sacrum, which was not included in the care plan. The Wound Coordinator, a Licensed Practical Nurse, was unaware that a new care plan was required for new pressure ulcers. The Minimum Data Set Director acknowledged the need for a person-centered care plan but deferred responsibility to the wound care department. Additionally, the facility did not document nursing interventions for the resident's abnormal vital signs while on hospice care. The Director of Nursing stated that abnormal vital signs are expected for hospice residents and did not believe the physician needed to be notified. However, the Director of Nursing was uncertain about the applicability of the change of condition policy to hospice residents and intended to consult with an external consultant. The resident's care plan for hospice did not align with the facility's hospice policy and agreement, which required a comprehensive and collaborative plan of care.
Failure to Address Abnormal Vital Signs in Hospice Resident
Penalty
Summary
The facility failed to provide appropriate comfort measures and document the response to abnormal vital signs for a hospice resident. The resident, who was on hospice care, exhibited a heart rate of 147 beats per minute and low blood pressure, which were not properly addressed or documented by the nursing staff. A Certified Nursing Assistant (CNA) reported these abnormal vital signs to a Registered Nurse (RN), who instructed the CNA not to record them accurately to avoid delaying the end of the shift. Instead, the RN recorded a normal heart rate, and no further nursing interventions or documentation were made regarding the resident's condition. The resident, who had a medical history of dementia, traumatic brain injury, and subdural hemorrhage, was admitted to hospice care. Despite the facility's policy requiring notification of changes in a resident's condition, the RN did not notify the physician or hospice services about the abnormal vital signs. The Director of Nursing (DON) acknowledged that abnormal vital signs should be reassessed and reported, but also expressed uncertainty about the applicability of the change of condition policy to hospice residents. The facility's hospice policy and agreement with the hospice provider outlined the need for communication and documentation of any significant changes in a resident's condition. However, the facility staff failed to adhere to these guidelines, resulting in a lack of appropriate care and documentation for the hospice resident. The DON's reliance on a consultant for clarification further highlighted the facility's failure to address the resident's needs in accordance with established policies.
Failure to Follow Skin Assessment and Monitoring Protocols
Penalty
Summary
The facility failed to adhere to physician orders and care plan interventions for a resident, leading to the development of a pressure ulcer. The resident, who was admitted without any pressure ulcers, developed a deep tissue injury on the sacrum, which later progressed to a stage 3 pressure injury. The facility did not conduct weekly skin assessments as ordered by the physician, nor did they perform daily skin checks as outlined in the resident's care plan. The wound was not included in the care plan, and there was a lack of documentation regarding daily skin monitoring. The wound coordinator, a Licensed Practical Nurse, acknowledged the oversight and stated that the nursing staff, including the wound care team, were responsible for daily skin checks. However, there was no evidence of documentation to support that these checks were being performed. The facility's policy on skin management emphasized the importance of consistent monitoring and documentation, which was not followed in this case. The resident's pressure ulcer increased in size after surgical debridement, indicating a lack of effective monitoring and intervention by the facility staff.
Failure to Provide Working Call Light for Resident
Penalty
Summary
The facility failed to provide a working call light for one resident, identified as R9, who was part of a sample of six residents reviewed. R9, a [AGE] year-old individual with a medical history including hemiplegia and hemiparesis following cerebral infarction, was observed on 12/10/2024 sitting in a wheelchair between beds, unable to call for assistance due to a non-functioning call light. R9 reported the issue to staff earlier in the day, but no action was taken to resolve it, leaving R9 without a means to request help. Staff members, including two registered nurses and a maintenance assistant, were aware of the malfunctioning call light. The registered nurse, V14, acknowledged being informed by R9 about the issue at 8:30 AM but failed to ensure a follow-up. V15, another RN, admitted that an alternative, such as a bell, could have been provided to R9 but was not considered until the surveyor's interview. V16, the maintenance assistant, was aware of the problem but prioritized other plant issues over fixing the call light. The facility's policy mandates that call lights be within residents' reach and that defective call lights be promptly reported, which was not adhered to in this case.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment from abuse, violating their abuse prevention and residents' rights policies. The incident involved a resident with severe cognitive impairment, who was subjected to an act of physical abuse by another resident. The abusive resident, who also had cognitive impairments and a history of mental health issues, placed a pillow and blanket over the face of the vulnerable resident, leading to a situation that could have caused harm. The incident was discovered by a Certified Nursing Assistant (CNA) during routine rounds. The CNA found the resident with a pillow and blanket covering their face and immediately removed them, alerting the nursing staff. The resident was found to be in distress, although no physical harm was reported. The staff separated the residents and notified the family of the affected resident, who expressed concern and intended to file a police report. The facility's investigation revealed that the abusive resident believed the other resident was deceased, which led to the inappropriate action. Despite the facility's policies affirming residents' rights to safety and freedom from abuse, the incident highlighted a failure to ensure a secure environment for all residents, particularly those with severe cognitive impairments.
Failure to Document and Monitor Pressure Ulcer Care
Penalty
Summary
The facility failed to properly assess, monitor, and document pressure ulcer care for a resident identified as high risk, leading to the development and worsening of multiple facility-acquired pressure ulcers. The resident, who was admitted with several medical conditions including hemiplegia, dementia, and epilepsy, developed several pressure ulcers during their stay. These included ulcers on the left ankle, left shoulder, left trochanter, left heel, right lower leg, and right shoulder, which were not properly assessed or documented in a timely manner. The Wound Care Nurse, who had been working at the facility for about two months, stated that assessments should be conducted immediately upon the identification of a new pressure ulcer, with the care plan revised accordingly. However, the facility failed to document dressing changes on the Treatment Administration Record (TAR) and did not update the individualized care plan to reflect the status of the pressure ulcers. The Director of Nursing confirmed that if treatments are not documented, it is assumed they were not done, which could lead to the worsening of the wounds. The facility's policy for skin management requires consistent implementation of protocols for monitoring and documenting wounds, including assessments with each dressing change or at least weekly. Despite this, the facility was unable to provide documentation of assessments for several identified pressure ulcers, and the care plan did not reflect the necessary updates. This lack of documentation and timely assessment hindered the ability to monitor the progress of the wounds and potentially contributed to their deterioration.
Verbal Abuse Incident Involving Resident and CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, resulting in verbal and emotional abuse by a staff member. The resident, who has a history of emotional abuse and is cognitively intact, reported feeling hurt and inferior after a Certified Nursing Assistant (CNA) used profane language and refused to perform certain duties. The incident occurred when the resident requested assistance to go to the bathroom, and the CNA responded with profanity and derogatory remarks. The facility's records and interviews reveal that the CNA had a history of complaints from both residents and staff regarding their attitude and communication skills. On the day of the incident, multiple staff members, including another CNA and the Transportation Coordinator, witnessed or heard the CNA using profanity towards the resident. Despite the facility's policy prohibiting such behavior, the CNA continued the abusive conversation in the presence of the resident. The facility's documentation shows that the incident was not properly recorded in the resident's progress notes, and a post-incident nursing assessment was not conducted. The facility's abuse policy clearly defines verbal abuse and emphasizes the importance of protecting residents from such mistreatment. However, the failure to adhere to these guidelines resulted in the resident experiencing psychosocial harm.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, R3, within the required two-hour timeframe to the state surveying agency. On the morning of the incident, R3, who was alert and oriented, requested assistance from a Certified Nursing Assistant (CNA), V5, to go to the bathroom. R3 reported that V5 responded with profanity and derogatory language, which made R3 feel demeaned and hurt. A Transportation Coordinator, V14, witnessed the incident and reported hearing V5 using loud and profane language directed at R3. V14 reported the incident to the former Administrator, V6, who was not on-site at the time. V6 instructed the Assistant Administrator, V2, to ask V5 to leave the facility pending an investigation. V6 later confirmed the incident with R3. Despite these actions, the facility did not report the incident to the state surveying agency until the following day, exceeding the two-hour reporting requirement. The facility's abuse policy mandates that any allegation of abuse be reported immediately, but not more than two hours after the allegation. The delay in reporting constitutes a failure to comply with the facility's abuse policy and state regulations.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse, as evidenced by an incident involving two residents, R2 and R3. The incident report and interviews reveal that R2 and R3, both cognitively intact, engaged in a verbal altercation. R2, who has a self-care deficit and cannot walk independently, reported that R3 became agitated and hit him with a walker after being told to sit down. R3 was reportedly anxious due to being unable to smoke, which led to the altercation. The facility's investigation concluded that there was no intention of harm, but the incident was not substantiated as abuse. The facility's staff, including a nurse, intervened by separating the residents and conducting assessments. The nurse's statement and progress notes indicate that R3 was moved to another room, and no physical injuries were noted on R2. However, R2 reported feeling scared and in pain after the incident. The facility's abuse policy emphasizes the residents' right to be free from abuse, including verbal abuse, which involves the use of disparaging language or threats. The facility's administrator, who started after the incident, stated that all employees are informed about the types of abuse and the importance of reporting any incidents. Despite these measures, the incident between R2 and R3 highlights a failure to prevent verbal abuse, as R2 felt threatened and unsafe during the altercation. The facility's response included separating the residents and notifying relevant parties, but the deficiency in protecting R2 from verbal abuse remains evident.
Delayed Pain Medication Administration for Hospice Resident
Penalty
Summary
The facility failed to administer scheduled pain medication on time for a hospice resident with prostate and bone cancer. The resident, who is on a palliative care program, reported not receiving his scheduled morning pain medication, resulting in a pain level of 7 out of 10. The resident expressed that delays often occur when new nurses are on duty. On the day of the survey, the resident's 9:00 AM morphine and PRN Norco were administered late by an LPN who started the shift late due to being called in to cover for another nurse attending a certification class. The Director of Nursing was unaware of any issues with the resident's pain medication administration and mentioned that the resident typically contacts the hospice nurse for PRN medication needs. The facility's pain management policy emphasizes timely administration to promote comfort and dignity. However, the delay in administering the resident's pain medication was attributed to the LPN's late start, which was a result of staffing adjustments. The resident's physician orders specified the administration of morphine twice daily and Norco as needed every four hours for pain management.
Failure to Maintain Dryer Lint Traps
Penalty
Summary
The facility failed to ensure the safety of its environment by not maintaining the lint traps of four dryers in the laundry room, which could potentially affect all residents. On September 22, 2024, a surveyor observed that the lint traps of dryers labeled 1, 2, 3, and 4 had accumulations of lint, despite the expectation that they should be cleaned every two hours to prevent fire hazards. V17, a laundry personnel, indicated that the last recorded cleaning was at 7 am by another staff member, V50, but upon inspection, it was evident that the lint traps were not cleaned as claimed. V17 acknowledged the risk of fire due to the uncleaned lint traps. The Director of Nursing, V2, confirmed the expectation for regular cleaning to prevent fire or damage to the dryers. The facility's undated policy on lint screen cleaning emphasized the importance of regular maintenance to avoid fire hazards.
Deficiency in Call Light Accessibility and Linen Provision
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents and did not provide linen for one resident, which was identified during a survey. One resident was observed lying on a bare mattress without any linen or blanket, and when questioned, the resident stated that the staff mentioned they did not have any available. This resident, who is cognitively intact, expressed discomfort due to the lack of linen and a blanket, which was not addressed despite the resident's clear preference and need. Another resident was found unable to locate their call light, relying on roommates to call for assistance. This resident, also cognitively intact, had a care plan that emphasized the importance of having commonly used items within reach due to their medical conditions, which include chronic obstructive pulmonary disease and morbid obesity. Despite this, the call light was not accessible, indicating a failure to adhere to the care plan. Two additional residents were observed with their call lights out of reach, one of whom had a severely impaired cognitive status. The call lights were found under their beds, and staff acknowledged the issue, noting that the call lights should be attached to the pillows for easy access. The facility's policy requires call lights to be within reach, yet this was not followed, leading to the deficiency noted by the surveyors.
Failure to Complete PASRRs by Qualified Staff
Penalty
Summary
The facility failed to ensure that Pre-Admission Screening and Resident Reviews (PASRRs) were completed prior to the admission of residents, affecting four residents in a sample of 65. The PASRR Level I screenings for these residents were completed by the Admissions Director, who was not qualified to perform these assessments as they lacked a nursing license, physician license, or a social work degree. The PASRRs for residents R38, R75, R110, and R124 were all completed on the same day, 9/23/24, after their admissions, indicating a lapse in the pre-admission screening process. Resident R124, who was admitted with diagnoses of schizophrenia and major depressive disorder, did not have a PASRR completed prior to admission. The resident's care plan and medication orders indicated ongoing treatment for these conditions. The facility's policy requires PASRR assessments to be completed by qualified clinical staff, but the Admissions Director, who completed the assessments, did not meet these qualifications. The Social Services Director confirmed the importance of clinical knowledge in completing PASRRs and acknowledged that the assessments were not done prior to the residents' admissions.
Failure to Include Residents in Care Plan Conferences
Penalty
Summary
The facility failed to conduct care plan conferences that included the residents or their responsible parties in the development of their care plans. This deficiency affected four residents, each with various medical conditions such as hemiplegia, heart failure, Alzheimer's disease, and epilepsy. Despite the facility's policy requiring interdisciplinary care conferences to include residents and their significant others, the residents reported not being invited to participate in these meetings. Interviews with the residents revealed that they were unaware of any care plan meetings and expressed a desire to be involved in the development of their care plans. The facility's policy, dated January 2024, mandates that residents and their representatives be notified of care plan conferences, which should occur within 14 days of admission and quarterly thereafter. However, the facility lacked documentation of invitations or conducted care plan conferences for the affected residents. The Registered Nurse Consultant and the Director of Nursing confirmed the absence of such meetings and acknowledged the residents' right to participate in their care planning. This oversight indicates a failure to adhere to the facility's policy and to ensure resident involvement in care planning.
Safety Hazards and Unauthorized Weapon Possession in Dementia Unit
Penalty
Summary
The facility failed to maintain a safe environment on the 3rd floor dementia unit by leaving a laundry chute unlocked and accessible to residents. Observations revealed that the soiled utility room, containing the laundry chute, was not secured, allowing residents to wander freely in the area. Staff, including a Licensed Practical Nurse and the Director of Nursing, acknowledged the risk posed by the unlocked chute, especially given the confusion and wandering tendencies of dementia residents. The Director of Nursing confirmed that the facility lacked a policy on safety and hazards, which contributed to the oversight. Additionally, the facility failed to prevent a resident from possessing a potentially dangerous item. A resident was found with a steak knife on their bedside table, which they claimed was for self-protection due to distrust of others. The resident, who was cognitively intact according to their mental status assessment, expressed intentions to use the knife as a weapon. The Licensed Practical Nurse and Director of Nursing both recognized the potential harm the knife could cause, yet the facility did not have a hazard policy in place to address such situations. The facility's expectation was that residents would not possess items like steak knives, but this expectation was not effectively communicated or enforced.
Failure to Label and Date Respiratory Equipment and Ensure Physician's Orders for Oxygen Therapy
Penalty
Summary
The facility failed to properly label and date respiratory equipment, such as nasal cannulas and humidifier bottles, and did not ensure there were physician's orders for oxygen therapy for certain residents. This deficiency affected four residents who were receiving oxygen therapy. For instance, one resident with a diagnosis of Chronic Obstructive Pulmonary Disease and dependence on supplemental oxygen did not have a documented physician's order for oxygen, and their oxygen equipment was observed without a date. Another resident with acute respiratory failure had a care plan that included oxygen therapy, but the equipment was not labeled with a date. Additionally, a resident with chronic respiratory failure was observed with undated oxygen tubing and humidifier bottles, and staff confirmed the lack of labeling. The Director of Nursing acknowledged that oxygen equipment should be dated and changed weekly. Another resident with chronic obstructive pulmonary disease was observed using oxygen equipment that was not labeled with a date, and the staff was unable to determine when it was last changed. The facility's policy requires oxygen equipment to be changed weekly and as needed, but this was not adhered to, leading to the deficiency.
Deficiencies in Monitoring Personal Refrigerators
Penalty
Summary
The facility failed to ensure proper monitoring and maintenance of personal refrigerators in residents' rooms, leading to several deficiencies. Observations revealed missing temperature logs, absence of thermometers, and expired food items in the refrigerators of six residents. For instance, a small refrigerator in a resident's room had missing temperature records for seven days, and expired milk cartons were found inside. The Licensed Practice Nurse acknowledged the lapse in daily checks, which are crucial to prevent food spoilage and potential harm to residents. Another resident's refrigerator also had missing temperature logs on multiple days, and the Director of Nursing emphasized the importance of maintaining temperatures within the safe range of 36F-41F to prevent food spoilage. The facility's policy mandates daily temperature recordings to ensure safe and sanitary storage of food brought by family and visitors. However, the surveyor found that these guidelines were not consistently followed, as evidenced by incomplete logs and expired food items. Additional observations included a refrigerator without a thermometer and no temperature log, as well as another resident's refrigerator with expired milk cartons. Staff members, including CNAs and the Director of Nursing, acknowledged the importance of checking temperatures and removing expired items to prevent residents from consuming spoiled food. Despite the facility's policy, the surveyor noted that staff did not consistently monitor the refrigerators, leading to potential health risks for the residents.
Failure to Assess Resident's Ability to Self-Administer Medication
Penalty
Summary
The facility failed to assess a resident's ability to safely self-administer medications, specifically an inhaler, which affected one resident. The resident, who has a diagnosis of Multiple Subsegmental Thrombotic Pulmonary Emboli, Type 2 Diabetes Mellitus with other Circulatory Complications, and Asthma, was observed with a red inhaler on their over-the-bed table. The resident mentioned having asthma but stated they did not use the inhaler. The Director of Nursing (DON) acknowledged that leaving an inhaler at the bedside without a medical order or proper education could lead to potential harms and risks, including incorrect usage and possible transmission of infections if used by another resident. Upon review of the resident's electronic medical record, there was no documentation of a Medication Self-Evaluation Form, nor was there an order for an Albuterol Asthma Inhaler. A progress note indicated that the resident had the inhaler because a surgeon advised them to bring it, and it was returned to the nurse. The facility's policy requires an order and a determination of the resident's ability to self-administer medications, which was not followed in this case.
Failure to Document Resident's Code Status
Penalty
Summary
The facility failed to document the code status for one resident, identified as R213, which affected the resident's medical records. R213 has a medical history that includes Metabolic Encephalopathy, Sepsis, Hypocalcemia, and Acidosis. During a survey, it was observed that R213's profile screen did not list a code status, and there was no order for an Advance Directive (code status) in the electronic medical record. However, an order for Advance Directive Code Status was documented in R213's Orders Summary Report, and the POLST Form indicated an order for Attempt Resuscitation/CPR. Interviews with facility staff revealed that the code status should be visible on the face sheet and profile screen in the electronic medical record. The Director of Nursing confirmed that the code status is supposed to be entered into the electronic medical record upon admission. The facility's policy on Advance Directives and DNR states that a Full Code order should be noted in the resident's medical record, which was not adhered to in this case.
Resident Confined to Room Due to Lack of Assistance
Penalty
Summary
The facility failed to ensure that a resident, identified as R72, was not confined to his room, as evidenced by observations and interviews. R72, who has chronic obstructive pulmonary disease, chronic embolism, thrombosis of deep veins, seizures, and morbid obesity, expressed feeling like he was in prison due to being left in his room without assistance to get out. Despite R72's cognitive intactness, as indicated by a BIMS score of 13, he reported that staff often ignored his requests to be helped out of bed, claiming they were too busy or would return later but never did. The care plan for R72 included interventions for psychosocial wellbeing and encouragement for ambulation, yet these were not consistently implemented. Staff, including a registered nurse and a nurse practitioner, acknowledged that R72 was often in his room and did not have restrictions preventing him from leaving. However, there was a lack of documentation to support that R72 was regularly assisted out of bed, and the restorative nursing program primarily conducted activities in his room, with limited instances of him being taken to the dining room. Interviews with various staff members, including the Director of Nursing and the Restorative Aide, revealed a lack of consistent documentation and follow-through on R72's mobility and activity needs. The facility's policies on abuse prevention and activities of daily living emphasize the importance of maintaining residents' physical and mental health, yet these were not adhered to in R72's case. The failure to assist R72 in getting out of bed and engaging in activities outside his room contributed to his declining physical and mental health, as noted by the nurse practitioners.
Failure to Follow Physician's Order for Infectious Disease Consult
Penalty
Summary
The facility failed to follow a physician's order for an infectious disease consult to treat a resident diagnosed with hepatitis C. The resident, identified as R110, was admitted with a diagnosis of hepatitis C, and a physician's order dated June 15, 2020, required an infectious disease consult. However, there is no documentation indicating that R110 received the necessary consultation or treatment. Interviews with the resident revealed that they were unaware of their hepatitis C diagnosis and could not recall receiving any treatment. The care plan for R110 also lacked information on any follow-up or treatment by an infectious disease provider. Further interviews with facility staff, including a Nurse Practitioner and the Director of Nursing, confirmed the absence of documentation for an infectious disease consultation or treatment for R110. The Nurse Practitioner acknowledged the active diagnosis of hepatitis C and the need for treatment by an infectious disease specialist but was unaware of any consultation or treatment provided. The Director of Nursing affirmed that the facility had no records of an appointment being made or treatment being administered, despite the expectation that such orders should be followed up. The facility's policy on appointments and transportation outlines the responsibility of nursing staff to arrange appointments, but it appears this was not executed for R110.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with a pressure ulcer, leading to a deficiency in wound care. A resident, identified as R29, was observed to have an open wound on the buttocks, which was not being treated or monitored appropriately. Despite the resident reporting pain and the presence of a wound to the nursing staff weeks prior, the wound was not documented or included in the treatment orders. During a survey, it was discovered that the wound was a stage 2 pressure ulcer, and the wound care nurses were unaware of its existence. The wound was found to be 100% granular with scant serous drainage, and there were no specific treatment orders for this wound in the resident's Treatment Administration Record (TAR) or Physician's Order Sheet (POS). The Licensed Practical Nurse (LPN) responsible for wound care admitted to overlooking the treatment order due to the lack of a specified site, which led to the neglect of the buttocks wound. The Director of Nursing acknowledged that without a specific site indicated in the treatment order, staff would not know where to apply the treatment, potentially worsening the wound. The facility's policy on skin care prevention mandates regular skin assessments and reporting of any changes, which were not adhered to in this case. The resident's TAR and POS did not reflect the necessary care for the buttocks wound, and the weekly skin checks were not conducted as required, contributing to the oversight and inadequate care provided to the resident.
Failure to Change Indwelling Catheter Bag
Penalty
Summary
The facility failed to ensure the timely change of an indwelling catheter bag for a resident diagnosed with neuromuscular dysfunction of the bladder and paraplegia. The resident, who is cognitively intact, reported that their catheter bag had not been changed in two months despite informing the staff that it was soiled. The surveyor observed the catheter bag attached to the resident's wheelchair, noting it was undated, contained cloudy urine, and had a brownish discoloration. The Director of Nursing acknowledged that catheter bags should be changed according to physician orders and when they become dirty or discolored to prevent infections. The facility's policy states that catheter bags should be changed if they become cloudy, leak, or have an odor, and catheter care should be provided every shift and as needed. However, the resident's catheter bag was not changed as required, leading to a potential risk of infection.
Failure to Timely Change Enteral Feeding Formula
Penalty
Summary
The facility failed to ensure that an enteral feeding formula was changed in a timely manner for a resident with a gastrostomy tube (G-tube). The resident, who has a diagnosis of acute respiratory failure, dysphagia, and esophageal obstruction, among other conditions, was observed with a G-tube feeding bottle that had been opened and dated three days prior. The facility's policy requires that G-tube feedings be changed every 24 hours, but the feeding bottle for this resident was not replaced within the required timeframe. During the survey, a registered nurse acknowledged the oversight, noting that the feeding should be changed daily. The Director of Nursing confirmed that G-tube feedings are only good for 24 hours and should be discarded after that period to prevent potential illness. The facility's policy on tube feeding and equipment change schedule also supports this requirement, indicating that the enteral feeding solution and bag/bottle should be changed every 48 hours or as needed, which was not adhered to in this case.
Failure to Securely Store Controlled Substances
Penalty
Summary
The facility failed to ensure that controlled substances were stored appropriately, affecting one resident in a sample of 65. During an observation, a Licensed Practical Nurse (LPN) noted that the refrigerator in the 3rd floor medication room, which should have been locked, was not secured. An open padlock was found on the counter above the refrigerator. The LPN retrieved a vial of Lorazepam, a controlled substance, from the refrigerator, confirming that it should have been kept locked. The refrigerator also contained other medications such as insulin pens, bisacodyl suppositories, acetaminophen suppositories, and a vial of haloperidol lactate, but no additional lock box or device was present to separate the controlled substance from non-controlled medications. The Director of Nursing (DON) confirmed that all controlled substances should be stored behind a system of two locks, which includes a lock on the medication room door and a lock on the refrigerator. The facility's policy on medication storage, reviewed in January 2024, mandates that Schedule II-V medications must be maintained in a separately locked, permanently affixed compartment and cannot be stored with non-scheduled medications. This policy was not adhered to, as evidenced by the unsecured storage of Lorazepam in the refrigerator.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement proper Enhanced Barrier Precautions (EBP) for two residents, R29 and R129, who required such measures due to their medical conditions. R29, diagnosed with a stage 3 pressure ulcer on the left buttock, and R129, with a neuromuscular dysfunction of the bladder and paraplegia, were not provided with the necessary Personal Protective Equipment (PPE) bins or supplies. During a survey, it was observed that there were no PPE bins or supplies available on the first-floor unit where these residents were located. Staff members, including a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA), were unaware of the EBP requirements and failed to wear appropriate PPE while providing high-contact care to R29. The LPN admitted to not knowing what EBP was, and the CNA acknowledged not paying attention to the EBP sign on R29's door. Additionally, the Wound Care Nurse did not wear a gown while performing wound care on R29, despite the presence of an EBP sign indicating the need for such precautions. The Infection Preventionist confirmed that the facility's policy required the use of gowns and gloves for residents with wounds and indwelling medical devices, such as those of R29 and R129. However, the facility lacked sufficient PPE bins, and there were no documented EBP orders for either resident in their Physician Order Sheets. This oversight in implementing EBP measures put both residents and staff at risk of infection transmission.
Failure to Provide Access to State Survey Records
Penalty
Summary
The facility failed to ensure that state survey records were accessible for residents to review, which could potentially affect all 223 residents residing in the facility. During a resident council meeting, the resident council president confirmed that state inspection reports were not available for residents to read. The facility administrator was initially unaware of the location of the survey findings and had to consult the assistant administrator/social worker. Upon checking, the administrator found that the survey records were not on the table by the entrance, where they were supposed to be kept. This was further confirmed by a surveyor's observation the following day, where no survey records were found at the designated location. The facility's document on residents' rights states that residents have the right to see reports of all inspections by the Illinois Department of Public Health from the last five years, along with the most recent review and any corrective plans submitted by the facility.
Inadequate Supervision During ADL Care Leads to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision during Activities of Daily Living (ADL) care for a resident, resulting in a fall and injury. The resident, who was severely cognitively impaired and dependent on staff for bed mobility, rolled out of bed while being cared for by two Certified Nursing Assistants (CNAs). The incident occurred when one CNA left the room to get a towel, leaving the other CNA to manage the resident alone. During this time, the resident rolled out of bed and sustained a hematoma on the forehead. The resident's medical record indicates a history of conditions such as Metabolic Encephalopathy, Muscle Weakness, and a need for assistance with personal care. The resident was dependent on two or more helpers for bed mobility, as documented in the Minimum Data Set (MDS). Despite this, the CNAs did not maintain the required level of supervision, leading to the fall. The incident was documented in a nursing note, which confirmed the fall was witnessed and that the resident was assisted back to bed with a mechanical lift.
Inadequate Staffing Leads to Resident Care Deficiencies
Penalty
Summary
The facility failed to ensure adequate staffing to meet the needs of its residents, affecting at least four specific individuals and potentially all 210 residents. One resident, who required assistance due to conditions such as cerebral infarction and muscle weakness, was observed slumped in bed and waited 30 minutes for assistance after pressing the call device. Another resident, needing help with personal care and feeding, reported being left hungry as the CNA had to attend to another patient. A third resident, suffering from adult failure to thrive and other conditions, was found in a wet bed with a strong urine odor, indicating a lack of timely care. The fourth resident, requiring maximal assistance, was also found in a soiled bed, with staff acknowledging the difficulty in providing adequate care due to insufficient staffing. The report highlights that the facility's staffing policy was not effectively implemented, as evidenced by the shortage of CNAs during the overnight shift. Staff interviews revealed that only two CNAs were available on certain floors, which was insufficient given the high number of residents needing total care. The nurse supervisor confirmed that staffing was inadequate due to call-offs and no-shows, and the facility did not use agency staff to supplement the workforce. This staffing issue was corroborated by a resident council document indicating a need for more staff on weekends and holidays.
Failure to Respond to Call Lights and Ensure Accessibility
Penalty
Summary
The facility failed to respond to a dependent resident's call light within a reasonable amount of time, resulting in the resident remaining in an uncomfortable position for an extended period. The resident, who requires maximal assistance with activities of daily living and toileting due to conditions such as cerebral infarction and hemiplegia, pressed the call device for assistance but waited 30 minutes before a CNA entered the room. The CNA mentioned that the resident's assigned CNA was on break and that she needed to find someone to help reposition the resident. Additionally, the facility did not ensure that call lights were within reach for three other dependent residents who required incontinent care. These residents, who have various medical conditions including adult failure to thrive, cerebral infarction, and dementia, were found with their call lights on the floor, unable to call for assistance. Observations included a strong urine odor in one resident's room and another resident sitting in feces and urine. Staff members were observed resting with their eyes closed during the night shift, and the facility's policy on call light response was not adhered to, as call lights were not answered within the stipulated time frame.
Inadequate Cooling and Maintenance Oversight
Penalty
Summary
The facility failed to provide a functional and comfortable environment for residents, specifically regarding inadequate cooling in certain rooms. Three residents, identified as R9, R10, and R17, were affected by this deficiency. R9 and R10 reported that their room was hot and that the air conditioner was too noisy, which disturbed their sleep. Despite their complaints, no action was taken to address the noise issue. R17's air conditioner was not functioning at all, and despite her complaints, no repairs were made. The outside temperature was 95 degrees, exacerbating the discomfort for these residents. The Maintenance Director, identified as V6, was initially unaware of any issues with the air conditioners and stated that no staff had informed him of the problems. The facility's Preventive Maintenance Plan requires regular inspections of residents' rooms to ensure proper operation of equipment, which was not adhered to in this case. The Maintenance Director's job description emphasizes the importance of maintaining the facility in a safe and comfortable manner, which was not achieved due to the lack of communication and failure to address the residents' complaints about the air conditioning units.
Latest citations in Illinois
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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