Southpoint Nursing & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 1010 West 95th Street, Chicago, Illinois 60643
- CMS Provider Number
- 145914
- Inspections on file
- 66
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 62
Citation history
Health deficiencies cited at Southpoint Nursing & Rehab Center during CMS and state inspections, most recent first.
Surveyors found that a soiled utility room on the second floor had a broken door left partially open, overflowing trash on the floor and in the sink, a biohazard box in the sink, and visibly dirty floors, potentially affecting 72 residents on that unit. A housekeeping aide stated that housekeeping is responsible for cleaning soiled utility rooms but said he did not clean them because he believed floor technicians should do so, while the housekeeping director confirmed housekeeping must clean and organize the room daily and floor technicians are only responsible for floor care. The maintenance director reported repeatedly repairing the door after prior citations and stated that staff had been breaking the door to gain access, even though the room contains a linen chute that should remain locked for safety, and the housekeeping director’s job description assigns responsibility for cleaning schedules, supervision, and hazard recognition and removal.
A resident with severe cognitive impairment, multiple cardiovascular conditions, and on anticoagulation had a care plan requiring appropriate, stable, non-slip footwear during ambulation and transfers. While ambulating with a walker near the nurses’ station, the resident was allowed to walk wearing slide shoes, which staff later acknowledged were not appropriate. The resident lost balance, fell backward, and struck the head, leading to hospital evaluation where imaging revealed a subdural hematoma and subarachnoid hemorrhage. Staff interviews and documentation confirmed that the resident’s footwear at the time of the fall did not meet the care-planned standard for safe, traction-providing footwear.
The facility failed to maintain functional laundry equipment, leaving only one working washer and two non-functioning washers, along with an out-of-order dryer, which significantly reduced laundry capacity for linens and residents’ personal clothing. A RN and an LPN reported ongoing resident complaints about laundry after a washer broke, and the Housekeeping Director confirmed that only one machine was handling both linens and personal clothes, with frequent need to order extra linens. The Maintenance Director described long-standing, poorly maintained machines with rust, holes, and a jammed door trapping linens inside, and acknowledged that only a fraction of the normal wash capacity was available. Several residents, including one with bed sores and another with chronic diarrhea, reported not having enough clean linens, having unchanged sheets, needing to hold onto their own towels, or paying outside services to wash their clothes due to the lack of facility-provided laundry.
The facility failed to properly report an injury of unknown origin for a resident to the state surveying agency as required. When surveyors requested Facility Reported Incidents (FRIs) for the prior months, the Administrator provided a few incidents that had been emailed to an incorrect state agency address, and review showed no confirmation of receipt. The Administrator later acknowledged that her email to the agency had been returned as undeliverable and that a second email sent by the DON contained no attached FRI, with only blank emails documented. Record review confirmed that no FRI for the resident’s injury, and no other FRIs from the facility for an extended period, had been received by the state agency, while the facility’s abuse policy requires prompt reporting of incidents and injuries of unknown origin.
Surveyors found that clean linen supplies were insufficient on multiple units, with nearly empty linen carts and clean utility room shelves, while staff reported late or inadequate deliveries from laundry and acknowledged ongoing complaints about linen shortages. Several residents described having to wait for linen, keeping towels with them to ensure availability, seeing staff hide or alter towels due to lack of supplies, and wearing or storing unwashed clothing because washers were broken. One resident with paraplegia and stage 4 pressure ulcers reported not having clean sheets despite his condition, and another with chronic diarrhea stated that CNAs cited broken washers and that he had to pay for outside laundry yet still returned to dirty clothes. The housekeeping and maintenance directors confirmed that only one of three washers and two of three dryers were functional, that older machines were in disrepair, and that linen had to be frequently ordered, while only a small number of gowns and limited linens were observed in the laundry area and office.
A resident with paraplegia and multiple stage 4 pressure injuries reported that daily ordered wound care was not performed on several days, despite large, heavily draining wounds. Review of the care plan showed orders for pressure ulcer treatment per physician orders, and the wound care coordinator/LPN confirmed that staff nurses are responsible for wound care and documentation on the TAR when the wound nurse is not present. The January TAR documented multiple missed wound care treatments, contrary to facility guidelines requiring necessary treatment and services for pressure injuries to promote healing and prevent infection.
A cognitively impaired resident with multiple comorbidities, unsteady gait, and documented need for supervision experienced a decline in mobility over several days, including left leg weakness, inability to use the left leg during transfer, and ambulation with a non-baseline shuffled gait. The resident was provided a wheelchair and educated on its use, but there was no documentation of ongoing non-compliance or additional interventions despite continued gait abnormalities. The resident later reported left leg pain and was sent to the hospital, where imaging showed a left femoral neck fracture; the resident could not recall how the injury occurred, and records showed no community pass during this period. Separately, two other residents assessed as high fall risk, with care plans requiring supervision, fall precautions, and a safe environment, were observed sitting in geri-chairs in a dining room unsupervised, even though a CNA was assigned to monitor that area at set intervals. These events demonstrate failures in supervision and monitoring for residents at high risk for falls and injury.
The facility failed to provide adequate nurse and CNA staffing on one unit, resulting in delayed medication administration and untimely ADL care for multiple residents. With a census of 40 residents, only one LPN and initially two CNAs were assigned, despite internal expectations for two nurses and three to four CNAs at that census. The sole LPN managing two med carts did not begin 9AM medications until late in the morning and was still passing them after midday, while another LPN from a different floor had to assist after completing her own med pass. CNAs reported each caring for about 20 residents, prioritizing breakfast service over routine care, which delayed incontinence care, showers, and getting residents out of bed. A resident requiring substantial/maximal assistance for ADLs remained in bed well past breakfast, and another resident with quadriplegia who requested to get up mid-morning was not assisted out of bed until after lunch. The administrator confirmed there was no written staffing policy.
Two residents did not receive medications as ordered when staff failed to administer and document drugs within the facility’s required time frames. One cognitively intact resident with orthostatic hypotension and end-stage renal disease reported late and missed doses, and records showed Midodrine and other morning medications given several hours after their scheduled times, with incomplete BP documentation despite an order to hold Midodrine for elevated systolic BP. Another resident with cerebrovascular disease and hypertension received 9:00 AM medications, including Aspirin, Amlodipine, and Vitamin D3, more than two hours late while an LPN reported being the only nurse passing medications to 39 residents. The DON confirmed that facility policy requires medications to be administered within one hour before or after the scheduled time and in accordance with physician orders.
Surveyors found that the facility did not fully implement its infection control policies for two residents on special precautions. One resident with ESRD and a central venous dialysis access had physician orders and a care plan for Enhanced Barrier Precautions, but no EBP signage was posted at the room entrance despite facility policy requiring it. Another resident on contact precautions for ESBL urine had appropriate door signage, yet a visitor entered and remained in the room without any PPE, and a CNA provided lunch assistance wearing only gloves and no gown, contrary to the posted requirement for both. At the time of review, this second resident’s EHR also lacked a physician order and care plan for contact precautions, despite facility policies requiring both.
A resident with multiple chronic conditions, who was cognitively intact and able to express needs, reported that his call light remained on for more than two hours while he waited for his urinal to be emptied and for water, despite multiple calls to the receptionist. The receptionist confirmed he had called about a delayed response and notified a nurse, who later acknowledged the resident told her he had been waiting over an hour with his call light on. The CNA assigned to the resident stated she did not see or hear the call light because she was seated at the opposite end of the hallway and only responded after being informed by the nurse, at which time the resident again reported a wait of more than two hours. Another resident reported delays in call light response and showers due to lack of staff, and staff interviews, including with the DON, confirmed that call lights are expected to be answered within 15 minutes, although short staffing sometimes affects timeliness, contrary to facility policy requiring prompt response.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact actions or events that led to this finding.
A resident reported feeling exposed and violated when a male individual entered the shower room while she was showering, and the room lacked privacy curtains. Although the resident communicated her concerns to staff, including the DON and Social Service Director, no documentation of the incident or the resident's feelings was entered into her medical record, resulting in incomplete and inaccurate recordkeeping.
Two shower rooms used by 117 residents were found with holes in the ceilings and peeling paint, with one room closed for remodeling and the other still in use despite visible damage. A resident with multiple medical conditions reported discomfort due to water leaks and deteriorating conditions, and staff confirmed ongoing maintenance issues related to moisture and faulty shower valves.
A resident with behavioral issues struck another resident with a glass bottle, causing an open wound, after staff failed to provide adequate supervision in a common area. Staff admitted they could not see all residents from their positions and were distracted by phone use, leading to the incident and resulting in physical and emotional harm to the injured resident.
A resident sustained a left ankle fracture after being rammed and run over by another resident using an electric wheelchair during a verbal altercation. Staff did not immediately assess the injured resident or document pain complaints prior to a subsequent fall, and the aggressive resident continued to have access to the injured resident's area despite a history of behavioral issues.
Two residents were involved in a physical altercation due to the facility's failure to implement preventive interventions and provide adequate supervision. One resident, with severe mental impairment, displayed aggressive behavior and wandered into other residents' rooms, while the other resident, with intact cognition, reported feeling threatened. The facility's abuse prevention program was not effectively implemented, leading to injuries for both residents.
The facility failed to develop timely and comprehensive care plans for two residents. One resident, admitted with a history of falling, had a care plan addressing fall risk initiated 1.5 years late. Another resident's care plan omitted their history of alcohol and cocaine abuse, despite being admitted with these diagnoses. The facility's policy requires comprehensive assessments and care plans upon admission, which was not followed.
The facility failed to update care plans for two residents at risk for falls. One resident experienced an unwitnessed fall that was not included in their care plan, which had an outdated goal target date. Another resident's care plan was not updated due to no recorded falls, despite being at risk. The Care Plan Coordinator acknowledged the oversight, citing staffing issues and lack of fall history as reasons for the deficiencies.
The facility failed to implement fall prevention measures for three residents, leading to inadequate supervision and intervention. A resident with severe cognitive impairment and high fall risk was found with the call light out of reach, contrary to care plan instructions. Another resident experienced an unwitnessed fall and lacked required non-slip material in the wheelchair. A third resident, with severe impairment, also had the call light out of reach, violating the facility's fall prevention program.
The facility failed to ensure call lights were within reach for three residents, leading to a deficiency in accommodating their needs. A resident with severe cognitive impairment and requiring assistance for transfers was found with the call light on the floor, out of reach, despite staff presence. Another resident, dependent on staff for transfers, also had the call light out of reach, which was only corrected after surveyor intervention. A third resident, with moderate cognitive impairment, was left without call light access while alone in a wheelchair. The facility's policy requires call lights to be accessible, which was not followed.
A resident with a history of falls and altered mental status fell from bed, but the facility delayed notifying the physician for over 7 hours. The resident was eventually sent to the ER after family insistence and was admitted for pulmonary thrombosis. The facility's policy required immediate notification of the physician, which was not followed.
A facility failed to prevent abuse when a resident with a history of bipolar disorder entered another resident's room, leading to a physical altercation. The resident claimed to have been pushed to the floor, resulting in a hospital visit, although no acute injuries were found. The facility's abuse prevention policy was not effectively enforced, allowing the incident to occur.
A physical altercation occurred between two residents in the dining room, where one resident intervened in a verbal dispute between another resident and staff, leading to a physical confrontation. The facility failed to provide adequate supervision during mealtime, as required by their policy, resulting in a deficiency in preventing resident abuse.
An LPN in a facility was observed preparing medications for two residents simultaneously, contrary to policy, and failed to identify a pill that fell during preparation. Additionally, the LPN administered a blood pressure medication to a resident despite their blood pressure being below the physician's specified parameters. The ADON confirmed these actions were against facility policy, which mandates medications be administered as prescribed and vital signs monitored before administration.
A facility failed to develop comprehensive care plans for three dependent residents, omitting necessary interventions for ADLs such as eating, bathing, toileting, and transfers. The MDS Coordinator was unaware of their responsibility for ADL care plans, and the facility lacked a Restorative Nurse, contributing to the oversight.
The facility failed to maintain adequate staffing levels and care planning, resulting in insufficient care for residents. On the first floor, a nurse and three CNAs were responsible for 30 residents, leading to inadequate monitoring of a urinary catheter and a resident being left in a saturated brief. On the third floor, staffing was also insufficient for 52 residents, many with Alzheimer's, resulting in a resident being left in a soiled brief for over three hours. The facility lacked a formal staffing policy and proper care planning for ADLs.
The facility failed to maintain essential equipment and infrastructure, resulting in a ceiling leak on the third floor. Despite being reported months earlier, the issue persisted due to a malfunctioning actuator and unpaid HVAC services. The maintenance program was not followed, with inspections and repairs not documented or conducted timely, affecting 145 residents.
The facility failed to maintain a clean and hazard-free environment, affecting residents on the 1st and 3rd floors. A resident with Alzheimer's disease had a dirty room with food debris and a removed baseboard. Dining areas were not cleaned timely, with food debris and spills observed. Despite having six housekeepers, cleaning procedures were not followed, leading to these deficiencies.
A facility failed to transfer a resident in a timely manner and did not include discharge planning in the resident's care plan upon admission. Despite the family's requests for transfer to other facilities, the facility did not adequately document follow-ups on transfer referrals, resulting in delays. The discharge care plan was only initiated months after admission, contrary to the facility's policy.
The facility failed to provide timely ADL care to two residents, as observed by the Illinois Department of Public Health. One resident with Alzheimer's disease was found in a saturated incontinence brief, and another resident with vascular dementia was found with a soiled brief, indicating neglect in routine checks. The facility's policies on ADL and incontinence care were not followed, as staff confirmed delays in attending to the residents' needs.
A resident with chronic kidney disease and other health issues experienced a severe decline in condition due to the facility's failure to monitor changes, address critical lab results, and schedule necessary medical consultations. Despite documented weight gain and edema, the facility did not take appropriate action, leading to the resident's emergency hospitalization for severe health complications.
A facility failed to provide adequate wound care and incontinence management for three residents, leading to worsening conditions. One resident's pressure ulcer was not treated for several days due to a conflict with the wound care nurse, while another resident's sacral wound increased in size due to exposure to urine and feces. A third resident developed moisture-associated dermatitis from prolonged exposure to soiled conditions. The facility did not adhere to its policy of daily skin assessments and timely wound dressing changes.
The facility failed to provide adequate ADL care, specifically incontinence care, to residents dependent on staff assistance. One resident with paraplegia was left in urine and feces overnight, worsening a wound. Another resident with hemiplegia reported being soaked in urine for hours, leading to itching and distress. A third resident with reduced mobility was found in a soiled state, indicating neglect by the night shift. The facility's policy of two-hourly incontinence checks was not followed, as confirmed by staff observations and resident council complaints.
A facility failed to provide adequate linen and towels due to malfunctioning washing machines, leaving residents in unsanitary conditions. Residents reported being left in soiled states for extended periods, and CNAs confirmed the shortage of clean laundry. The facility's laundry operations were hindered by broken equipment, impacting all 150 residents.
The facility failed to properly contain and cover waste containers, potentially affecting all 156 residents. A surveyor and the Maintenance Director observed an uncovered dumpster and an overflowing trash can in the facility's dumpster area and back parking lot. The Maintenance Director acknowledged the issue, noting that the containers were for construction waste and should have been picked up by the city. The facility's policy requires that trash not accumulate to the point where lids cannot fit tightly and that dumpster lids remain closed.
A facility failed to follow proper hand hygiene and PPE protocols, leading to potential infection risks. An LPN did not sanitize hands before and after glove use during a blood glucose test, and a CNA did not perform hand hygiene between assisting residents during meal service. Additionally, a resident's room lacked an Enhanced Barrier Precautions sign and PPE bin, which was later corrected. The involved residents had severe cognitive impairments and multiple health issues, necessitating strict infection control measures.
The facility failed to monitor and maintain personal refrigerators for residents, affecting four individuals. Deficiencies included missing temperature logs and thermometers, and inadequate cleaning. Observations showed confusion among staff about responsibilities, leading to improper maintenance. Residents' refrigerators were found dirty, with doors ajar, and lacking temperature checks, contrary to facility policy.
The facility failed to prevent a resident with a history of alcohol abuse from accessing and consuming alcohol, despite being on narcotic pain medication with a warning against alcohol use. Additionally, another resident was found with razors in their possession, posing a safety risk, and the facility lacked a policy for razor disposal.
The facility failed to manage and document respiratory care equipment properly for several residents. One resident's nebulizer mask and tubing were not dated or contained, and there was no oxygen order documented. Another resident received oxygen without a physician's order, and a third resident's respiratory devices were uncontained, risking infection. Additionally, a resident's oxygen tubing and humidifier bottle were not dated, contrary to facility policy.
The facility did not post the daily nursing staffing information, potentially affecting all 156 residents. The outdated staffing information was observed at the receptionist desk, and the new receptionist was unaware of the posting requirement. The Staffing Coordinator mentioned that either the Transportation Coordinator or the DON is responsible for posting the staffing information in her absence.
A facility failed to ensure proper documentation and accountability of controlled medications, affecting three residents. An RN admitted to not signing the controlled substance accountability record due to being busy and a pen running out of ink. Discrepancies were found between the actual count of medications and the recorded amounts on the Controlled Drug Receipt/Record/Disposition Forms. The DON confirmed that narcotics should be signed out immediately after administration and that accountability sheets should be signed at shift changes.
The facility failed to maintain resident dignity by not covering a resident's urinary bag and not providing proper one-to-one feeding assistance. A resident's urinary drainage bag was exposed, and despite requests, a privacy bag was not provided. Additionally, a CNA was observed feeding a resident while standing and engaging with others, contrary to the facility's policy for one-to-one feeding. The residents involved had conditions like dementia and dysphagia, requiring specific care interventions.
The facility failed to ensure call devices were within reach for three residents, affecting their ability to call for assistance. One resident's call device was on the floor, obstructed by floor mats, while another's was wrapped around a bed rail, and a third's was hanging from the wall. Staff acknowledged these issues, which contravened the facility's policy requiring accessible call lights.
The facility failed to support the rights of two residents to engage in consensual sexual activities, despite having care plans in place. Staff repeatedly intervened, citing privacy concerns in shared rooms, and there was a lack of clear communication and understanding among staff regarding the residents' rights to intimacy.
A resident's code status was not documented in the electronic medical record, despite being indicated in the care plan as FULL CODE. The facility's policy requires code status documentation, but it was missing from the resident's profile and orders, leading to a deficiency noted by surveyors.
The facility failed to provide adequate nail care for two residents, who were observed with long fingernails and a brownish-gray substance underneath. Both residents require assistance with ADLs, including personal hygiene, as per their care plans. Despite facility policies and staff responsibilities, the deficiency was noted due to a lapse in executing these duties.
A resident with contractures in both hands did not receive proper care as the facility failed to apply a hand splint consistently and correctly. The resident's left hand, which was more contracted, required a splint, but it was incorrectly applied to the right hand. The occupational therapist had recommended specific exercises and splint application for the left hand, but these were not followed, and the facility lacked policies for restorative care and splint application.
A CNA failed to follow proper infection control practices by not wearing a gown and using the same washcloth for different body areas of a resident on enhanced barrier precautions. The resident had multiple wounds, and the CNA was unaware of the need to change gloves between cleaning different areas. The missing signage due to construction contributed to the oversight.
A facility failed to develop a care plan for a resident with a Foley catheter, despite documentation of the catheter in the resident's MDS and CAA worksheet. The DON acknowledged the oversight, and the CMS manual highlights the need for individualized care plans for residents with indwelling catheters due to potential complications.
Failure to Maintain Safe and Sanitary Soiled Utility Room Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary functional environment in the second-floor soiled utility room, potentially affecting all 72 residents on that unit. During a tour of the second floor, the surveyor observed that the soiled utility room door was broken, could not be closed, and was standing partially open. Inside the room, there was overflowing garbage on the floor, garbage in the sink, a biohazard box placed in the sink, and floors with visible black debris and dirt. The room also contained access to the second-floor linen chute, which the Maintenance Director stated should be locked at all times for safety. When interviewed, a housekeeping aide stated that housekeeping is responsible for cleaning the soiled utility rooms but reported that he personally did not clean them because he believed floor technicians should be responsible for ensuring the soiled utility rooms are clean. He also acknowledged that it is unsafe and unsanitary for the soiled utility room to go without being cleaned. The Housekeeping Director confirmed that the housekeeping department is responsible for daily cleaning of the soiled utility room, including removing trash, sweeping, and organizing, while floor technicians are responsible for waxing and keeping floors free of dirt and debris. The Maintenance Director reported that he had repaired the second-floor soiled utility door several times after citations from the state agency for the door not being locked, and that staff continued to break down the door when they could not access the room. The facility’s job description for the Director of Housekeeping documented responsibility for ensuring cleaning schedules are followed, supervising housekeeping personnel, and recognizing, removing, and reporting potential hazards, as well as ensuring housekeeping personnel follow established safety regulations.
Failure to Ensure Appropriate Footwear Resulting in Fall and Intracranial Hemorrhage
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident at risk for falls wore appropriate footwear to prevent accidents. The resident was an older adult with diagnoses including pulmonary embolism with acute cor pulmonale, essential hypertension, coronary artery disease with stent, dementia, and other conditions. The resident’s MDS documented a BIMS score of 3, indicating severe cognitive impairment. The resident’s care plan, initiated in January 2026 and revised in February 2026, specifically included an intervention to ensure the resident wore appropriate footwear that provided stability and good traction when ambulating, mobilizing in a wheelchair, and during transfers. On the day of the incident, the resident was ambulating with a walker in a supervised area near the nurses’ station, walking toward the dining room. Staff statements and nursing documentation indicate that the resident abruptly stood up or was walking with the walker, lost balance, and fell backwards. The LPN on duty reported hearing the walker, then seeing the resident on the floor, and documented that the resident appeared to have hit her head. The LPN and other staff confirmed that the resident was wearing slide shoes at the time of the fall, described as open-toed, backless footwear with a strap across the top of the foot. The LPN acknowledged that slides were the resident’s preferred footwear but stated that, honestly, this was not appropriate footwear for the resident. Following the fall, the resident, who was on blood thinners (Eliquis), was sent to the hospital for evaluation. Hospital records document that the resident presented after a mechanical fall with head impact, reporting headache, neck pain, and wrist bruising. Imaging studies, including CT and MRI of the brain, identified a tiny left frontal, parietal, temporal, and occipital subdural hematoma and a small focus of subarachnoid hemorrhage in the left posterior frontal lobe. The nurse practitioner and restorative nurse both indicated that proper footwear for a resident of this age and condition should include closed-toe/heel shoes or non-skid socks with grip, and that slide footwear was not appropriate. The facility’s fall guidelines required incidents and accidents to be identified, reported, investigated, and used for QAPI trending, but the failure to ensure the resident wore appropriate, care-planned footwear directly preceded the fall and resulting intracranial bleeding.
Failure to Maintain Functional Laundry Equipment Resulting in Linen Shortages
Penalty
Summary
The facility failed to maintain laundry equipment in good working condition, resulting in inadequate availability of clean linens and personal clothing for residents. Staff interviews revealed that the facility’s washing machines had been malfunctioning over several months. A RN reported that residents had been complaining about their laundry after a washing machine broke approximately two weeks prior to the survey. An LPN stated that a new washing machine had recently been installed and was being used for both linens and residents’ clothing, and that during this period residents voiced concerns about their clothing not being washed and returned. The Ombudsman Residents’ Rights document cited in the record notes that residents have the right to keep and wear their own clothing. The Housekeeping Director stated that both linens and residents’ personal clothes are washed in the facility and that, when the machines needed repair, clothes and linens were sent to another facility. She reported that three months earlier only one washer was working while another was being repaired, and that one washer was designated for personal clothes and the other for facility linens. She also stated that she frequently had to order additional linens from an outside vendor because there were not enough linens available, and that some residents were hoarding linens in their rooms. At the time of the survey, she reported that a single washing machine was being used for both linens and personal clothing, and that there was a significant difference in capacity and workflow when all machines were functioning. The Maintenance Director reported that there were three washing machines, but two were not working. One washer had been newly installed after it broke three months earlier, and after that installation the other two washers failed and required repair. The two non-functioning washers were observed in poor condition with rust-like structures and holes, and one contained linens that could not be removed because the door would not open. The facility therefore had only 60 pounds of washing capacity in use instead of the 200 pounds available when all three machines were operational. One of three dryers was also out of order. Multiple residents reported a lack of linens: one resident with bed sores stated that his fitted sheet had not been changed and that he had informed the Administrator he had no linen; another newly admitted resident reported hearing concerns about linen shortages and having to wait for linen; another resident kept a clean towel on her chest to ensure she would have one for care; and a resident with daily diarrhea reported that CNAs often said they had no linen because the washers were broken, leading him to pay an outside service to wash his clothes. Invoices and orders showed that parts for washers and dryers had been ordered over preceding months, and the facility’s laundry policy stated that laundry equipment would be inspected and serviced by Maintenance per preventive maintenance procedures.
Failure to Properly Report Injury of Unknown Origin to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely and properly report an injury of unknown origin for one resident (R7) to the state surveying agency, as required by regulation and the facility’s Abuse Prevention Program policy. Surveyors requested Facility Reported Incidents (FRIs) for the prior three months and were provided only three incidents dated 12/02/25, 12/16/25, and 01/14/26. During review, surveyors observed that these incidents had not been submitted to the correct state agency email address. The Administrator (V1) stated she became aware of R7’s incident from the DON (V2) and believed she had reported it to the state agency via email on 12/16/25, the same day it was reported to her. When asked to provide confirmation of successful submission, V1 was unable to access her email initially and later reported she had not received confirmation because the email was returned as undeliverable. Further review showed that V1 also asserted that V2 had emailed R7’s incident to the state agency, but the only documentation produced to the surveyor were scanned emails showing time stamps of blank emails (one undeliverable and one sent to the correct address) with no FRI attached. When the surveyor requested that V1 forward the original email with the attached reportable incident, this was not provided. Record review confirmed that no FRI for R7 had been received by the state agency and that no FRIs from the facility had been received since 12/03/25. V1, who had been Administrator since 08/2024, stated she was unaware she had been using an incorrect email address and acknowledged that she never received confirmation of successful submissions. V1 also reported using an incorrect fax number for the state agency. The facility’s Abuse Prevention Program policy requires all personnel to promptly report any incident or suspected incident of abuse, mistreatment, neglect, including injuries of unknown origin, but this did not occur for R7’s injury of unknown origin.
Inadequate Clean Linen Supply Due to Laundry Equipment Failures and Poor Linen Management
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate clean linens for multiple residents, resulting in limited access to necessary bedding and personal care items. During observations on several floors, surveyors noted that linen carts and clean utility room shelves were sparsely stocked or empty, particularly on the first and second floors. On the first floor, only a small number of gowns, wash cloths, sheets, underpads, and towels were available on a single linen cart, and the clean utility room cart had no linen. A registered nurse reported that laundry usually delivers linen late in the morning and that residents had been complaining about not having enough linen. On the second floor, one linen cart was completely empty and the others had minimal linen, and the clean utility room cart was also empty, despite staff stating that laundry had delivered linen. Residents reported direct impact from the linen shortage. One recently admitted resident stated she had heard concerns about lack of linen and sometimes had to wait for linen to be provided. Another resident was observed keeping a clean towel folded on her chest in bed, explaining that if she did not keep it with her, she would not have a towel for her care; this resident also reported witnessing staff hide linen for later use and cut larger towels into smaller wash cloths due to insufficient supplies. A resident with paraplegia and documented pressure ulcers of the sacral region and right hip (stage 4) stated there was no linen available, that staff cited washer problems, and that his fitted sheet had not yet been changed while he was washing himself up. He reported telling the administrator he had no linen despite having bed sores and being told linen was coming from another company, but no linen arrived. Additional information from staff and another resident further described ongoing linen and laundry capacity issues. Resident council minutes noted concerns about residents and staff hoarding linen. The housekeeping director stated that both linens and personal clothes are washed in-house, that washers had been down and clothes and linens had been sent to another facility, and that linen had to be ordered frequently because there was not enough. She also reported that currently a single working washer was being used for both linens and personal clothes. The maintenance director confirmed that of three washers, only one 60‑lb capacity machine was operational, with the other two older machines out of order and in poor condition, and one dryer also out of order. In the laundry area, only five gowns were observed on shelves, and additional wrapped linens in the housekeeping director’s office did not include gowns. Another resident with irritable bowel syndrome and frequent diarrhea reported that CNAs told him they had no linen because the washers were broken, that he had resorted to paying for outside laundry due to backed‑up dirty clothes, and that he continued to wear dirty clothes upon return because his clothing remained unwashed.
Failure to Consistently Provide Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to consistently implement physician-ordered pressure ulcer treatments for a cognitively intact resident with multiple stage 4 pressure injuries. The resident, who has paraplegia and pressure ulcers of the sacral region and right hip, reported that on several days the ordered wound care was not performed, despite orders for daily dressing changes due to large, heavily draining stage 4 wounds. The resident stated that he waited for staff to come at any time during the day, did not call to remind the nurse, and sometimes fell asleep while waiting, resulting in days passing without the treatment being done. Record review confirmed that the resident’s comprehensive care plan and current care plan included pressure ulcer treatments per physician orders, with goals for the wounds to remain free of signs and symptoms of infection and to continue healing without complications. The wound care coordinator/LPN stated that wound care is documented on the Treatment Administration Record (TAR) and that staff nurses are responsible for completing wound care when the wound care nurse is not working. The January TAR showed multiple dates on which the resident’s wound care treatments were not administered as ordered. Facility guidelines state that residents with pressure ulcers are to receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing.
Failure to Adequately Supervise High-Risk Residents Resulting in Unwitnessed Femur Fracture and Unattended High-Fall-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and monitoring to prevent accidents for three residents, including one who sustained a left femoral fracture. One resident had multiple diagnoses including essential hypertension, type 2 diabetes with neuropathy, cerebrovascular disease, muscle weakness, abnormalities of gait and mobility, muscle wasting, weakness, unsteadiness on feet, and unspecified convulsions. This resident’s MDS showed significant cognitive impairment with a BIMS score of 6/15 and documented need for supervision with ADLs and mobility. The resident’s care plan stated that a safe environment was to be maintained and that staff should anticipate and meet needs and provide a safe environment. A community survival skills assessment documented that the resident did not appear capable of unsupervised outside pass privileges. On 12/11/2025, staff identified a change in this resident’s condition related to mobility and gait. The restorative nurse received a report that the resident was experiencing increased unsteadiness in gait. Upon assessment, the resident reported that his left knee sometimes gave out. A wheelchair and urinal were provided, and the resident was educated on safe wheelchair use and encouraged to request staff assistance. A change in condition note by an LPN the same day documented that the resident needed two-person assistance to bed due to left leg weakness, later proceeded to walk without staff after resting, and that his gait was not at baseline, though it showed some improvement. Another note documented that the resident was later seen leaning on the bathroom door, unable to use his left leg during transfer, and that he walked into the dining area for dinner with a shuffled gait that was not baseline. The care plan and progress notes from 12/11/2025 to 12/16/2025 did not document any ongoing non-compliance with wheelchair use or additional interventions related to his increased unsteadiness. On 12/16/2025, the LPN documented that the resident complained of left leg pain starting at the groin and radiating down the thigh, with pain on movement but not on light touch, and the resident was sent to the hospital for evaluation. Hospital records showed a left basicervical femoral neck fracture, and the resident was described as a very poor historian, alert and oriented x1, unable to explain why he was brought to the ED, and unable to recall the mechanism or timing of injury. The hospital record noted that no information was provided from the nursing home and that family could not be reached. The social services director stated that the resident did not go into the community independently and that any community pass would be documented; review of progress notes and the Resident Community Access Tracking Tool for December 2025 showed no documentation that the resident went out on community pass. Despite the resident’s impaired cognition, unsteady gait, and documented change in condition, there was no clear documentation of how the fracture occurred while the resident was in the facility. The deficiency also includes inadequate supervision of two additional residents who were both assessed as high fall risk. On observation, two residents were seen sitting in geri-chairs in the second-floor dining room unsupervised and unattended. Their fall risk assessments documented high fall risk scores (13 and 12), and their care plans included impaired cognition, history of falls, muscle weakness, dementia, impaired decision-making, and the need for cueing, reorientation, supervision, fall precautions, and maintenance of a safe environment with fall interventions in place. An LPN stated that CNAs take turns monitoring residents in the dining room at 30-minute intervals to ensure residents do not fall, injure themselves, choke, or get into physical altercations, and that a specific CNA was assigned to monitor the dining room during the time of observation. Despite this assignment and the facility’s policies on standard supervision and incidents/accidents/falls, the two high-risk residents were left in the dining room without staff present, demonstrating a failure to provide the supervision and monitoring required by their assessed needs and care plans.
Insufficient Nursing and CNA Staffing Leading to Delayed Medications and ADL Care
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on the first floor to meet residents’ ADL needs in a timely manner and to administer medications as ordered. On the day of survey, the staffing coordinator stated that the first floor should be staffed with two nurses when there are 32 or more residents and three to four CNAs when the census is 40. The daily census for the first floor showed 40 residents, yet the daily assignment sheet listed only one nurse assigned to the unit. Observations confirmed that only one LPN was working on the first floor, and initially only two CNAs were present due to a CNA call-out, with a third CNA brought in later in the morning. The LPN assigned to the first floor reported that she was the only nurse scheduled for the 7AM–7PM shift and that she had to manage two medication carts. She stated she had not started passing 9AM medications by 10:50 AM and was still passing 9AM medications after noon, acknowledging that the medications were late due to staffing. Another LPN from the second floor came down after completing her own 9AM medication pass to assist with remaining medications and Accu-Chek readings for diabetic residents on the first floor. The Director of Nursing confirmed that medications are expected to be administered within one hour before or after the scheduled time and that insufficient staffing could cause delays in care, including medication administration. CNAs on the first floor described having to care for 40 residents with only two CNAs at the start of the shift, each responsible for about 20 residents, which they stated was not realistic compared to the usual 11–12 residents per CNA. They reported prioritizing breakfast service, including passing trays, feeding dependent residents, and collecting dirty trays, which delayed routine care such as two-hour checks, incontinence care, and showers. One CNA stated she still needed to provide a shower that would have been completed earlier if fully staffed. Residents corroborated delays in ADL care: one resident, with diagnoses including hemiplegia following cerebral infarction, cerebral palsy, neuromuscular bladder dysfunction, and documented need for substantial/maximal assistance with ADLs, reported that she was usually gotten out of bed before breakfast but remained in bed late in the day and attributed this to having only two CNAs instead of three. Another resident, with quadriplegia, extensive mobility and self-care limitations, and substantial/maximal assistance needs, stated he requested to get out of bed at 9:30 AM but was told staff could not assist due to only two CNAs working; he was not gotten out of bed until after lunch around 12:30 PM. The facility administrator reported there was no written staffing policy.
Failure to Administer Medications Within Ordered Time Frames
Penalty
Summary
The deficiency involves the facility’s failure to administer medications in accordance with physician orders and facility policy for two residents. One resident, cognitively intact with a BIMS score of 15 and diagnoses including orthostatic hypotension, end-stage renal disease, and polyosteoarthritis, reported not receiving scheduled morning medications at 6:00 AM on one day, instead receiving them at 8:00 AM, and also reported not receiving Eliquis, a multivitamin, and Midodrine on a prior date. Record review showed that Midodrine 10 mg ordered every eight hours with a 10:00 PM scheduled dose was not documented as administered until 5:19 AM the following day, more than seven hours late. The same resident’s Medication Administration Audit Report showed that on another day, Midodrine, Protonix, and Ferrous Sulfate ordered for 6:00 AM were documented as administered at approximately 8:00 AM. Nursing staff interviews revealed inconsistencies and issues related to medication availability and administration timing. One RN who worked the night shift denied giving Midodrine late and suggested that medications might not be administered if they were unavailable or not ordered. Another RN assigned to the resident on the evening shift documented that Midodrine was “on order” and stated it was not administered because the resident’s blood pressure was high, although there was no documentation of blood pressure readings in the progress notes for that date other than a single reading at 6:17 AM of 110/68. The facility’s blood pressure summary for that resident showed no additional readings for that day, and the progress note documented the Midodrine as on order without further clarification. A second resident, with diagnoses including cerebrovascular disease and essential hypertension and a BIMS score of 6 indicating cognitive impairment, also received medications outside the facility’s required time frame. During a medication pass observation, an LPN reported being alone to pass medications to 39 residents and stated she was not finished with the 9:00 AM medications. The LPN took this resident’s blood pressure at 11:14 AM and then prepared and administered the resident’s 9:00 AM medications (Aspirin, Amlodipine, and Vitamin D3) between 11:16 AM and 11:21 AM. The Medication Administration Audit Report showed these medications, ordered for 9:00 AM, were documented as administered at 11:18 AM, more than two hours late. The DON stated that medications are to be administered within one hour before or after the scheduled time and that nurses are expected to follow physician orders and facility policy, which requires medications to be given within 60 minutes of the scheduled time.
Failure to Post EBP Signage and Enforce PPE Use for Residents on Precautions
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not posting required Enhanced Barrier Precautions (EBP) signage and not ensuring proper use of personal protective equipment (PPE) for a resident on contact precautions. One resident with chronic conditions including COPD, end stage renal disease (ESRD), dependence on hemodialysis, and a central venous dialysis access in the right chest had physician orders and a care plan indicating the need for EBP due to the invasive dialysis access site. During observation, this resident was found resting in bed with a visible dialysis catheter dressing, but there was no EBP signage posted at the room entrance, contrary to the resident’s care plan and the facility’s EBP policy, which require door signage and PPE guidance for staff and visitors. A second resident, admitted with multiple diagnoses including ESRD, diabetes, liver disease, transplant-related conditions, MRSA infection, and C. difficile enterocolitis, was on contact precautions for ESBL in the urine, as later confirmed by the infection preventionist (IP) nurse. At the time of surveyor observation, there was contact precautions signage on the door instructing everyone to don gloves and gown before room entry. However, a visitor was observed inside the room sitting and talking with the resident without wearing any PPE, and a CNA was later observed entering the room and assisting the resident with lunch while wearing gloves but no gown, despite the posted requirement for both gloves and gown upon entry. Interviews with the IP nurse and the DON confirmed that residents on EBP should have door signage and accessible PPE, and that residents on contact precautions require a physician order, care plan, and use of gloves and gowns by staff and visitors when entering the room. Review of the second resident’s electronic health record with the IP nurse initially showed no physician order or care plan for contact precautions at the time of the observations. The facility’s written policies for EBP and infection control/isolation guidelines specify that appropriate PPE must be used, proper signage must be posted on resident room doors, and that contact precautions require gloves and gowns upon room entry and must be ordered by a physician and care planned, all of which were not fully implemented for the residents observed.
Failure to Respond Promptly to Resident Call Lights
Penalty
Summary
The deficiency involves the facility’s failure to ensure call lights were answered in a timely manner, as required by its own policy and expectations. One resident with diagnoses including orthostatic hypotension, end-stage renal disease, and polyosteoarthritis, and who was cognitively intact, reported that his call light remained on for more than two hours one afternoon while he waited for his urinal to be emptied and for water. He stated that no one responded to his call light from approximately 4:20 PM until 6:45 PM, despite his calling the reception desk four times to request assistance. The receptionist confirmed that residents sometimes call the front desk when call lights are not answered timely and recalled that this resident had called her, reporting he had been waiting “a while” for his call light to be answered; she then went to the floor and informed the nurse, who said she would send someone. The nurse assigned to the resident that evening stated that when she entered the room to administer pain medication, the resident told her he had been waiting over an hour with his call light on and that no one had emptied his urinal. The CNA assigned to the resident that evening reported that she only became aware of the call light after being informed by the nurse; when she entered the room, the resident told her he had been waiting more than two hours for someone to answer his call light and needed water and his urinal emptied. The CNA stated she did not hear or see the call light because she was sitting at the end of the hallway on the opposite side of the resident’s room. Another resident reported that staff were sometimes delayed in answering call lights and providing showers due to lack of staff. The DON and staff interviews confirmed that anyone can and should answer call lights, that they are expected to be answered within 15 minutes, and that short staffing sometimes affects timeliness of care, contrary to the facility’s written policy requiring prompt response to activated call lights.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor a resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Document Resident Privacy Concern During Shower Incident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident, resulting in a lack of documentation regarding a reported privacy violation during a shower. The resident, who was cognitively intact and able to clearly express her concerns, reported that while taking a shower, a male individual entered the shower room, leaving her feeling exposed and violated. The resident stated that she had previously complained about privacy issues, including staff not knocking before entering rooms, and specifically reported this incident to the nurse on duty and to the Social Service Director. The shower room in question did not have privacy curtains, and the resident expressed feeling unprotected and vulnerable as a result. Despite the resident's report and the acknowledgment by staff that the incident occurred and that the shower room lacked privacy curtains, there was no documentation of the incident or the resident's concerns in her medical record. The Social Service Director and the DON both indicated that they did not consider the event an incident requiring documentation, and only a general concern form and an in-service related to shower room safety were completed, neither of which addressed the specific privacy concerns raised by the resident. The lack of documentation and failure to record the resident's expressed feelings and the details of the event constituted a deficiency in maintaining accurate and complete resident records in accordance with professional standards.
Failure to Maintain Safe and Homelike Shower Room Environment
Penalty
Summary
The facility failed to provide a homelike environment by not maintaining the physical condition of two shower rooms, resulting in visible holes in the ceilings and peeling paint. During the survey, it was observed that one shower room on the third floor was closed for remodeling, while the other in the 3 North hallway, still in use, had a hole in the ceiling. On the second floor, a resident reported holes in the wall, peeling paint, and water dripping from the ceiling in the shower room, expressing discomfort with using the facility. The surveyor confirmed the presence of a hole and peeling paint in the 2-North shower room, which was actively being used for resident showers. A resident affected by these conditions was cognitively intact and had multiple medical diagnoses, including polyosteoarthritis, inguinal hernia, localized swelling, hyperlipidemia, and GERD. The Maintenance Director explained that ongoing issues with shower valves led to water leaks, steam, and moisture accumulation, causing the drywall to become soggy and buckle, resulting in holes and peeling paint. Facility records indicated that 117 residents were scheduled to use these shower rooms, and facility policies required immediate attention to areas needing repair, as well as maintaining a clean and attractive environment.
Failure to Prevent Resident-to-Resident Physical Abuse Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when the facility failed to follow its policy to protect a resident from physical abuse by another resident. One resident, who had a history of behavioral issues including aggression and manipulative behavior, struck another resident in the face with a glass bottle, resulting in an open wound above the left eyebrow. The incident took place near the dining room, and staff were not positioned to adequately supervise all residents in the area, as confirmed by their own statements that they could not see all residents from where they were seated. The resident who was struck had significant medical conditions, including hemiplegia and severe cognitive impairment, and reported feeling scared and experiencing headaches after the incident. Multiple staff members, including CNAs and LPNs, acknowledged that residents are not supposed to hit each other and that such altercations are considered abuse. The staff also admitted to being distracted or not optimally positioned for supervision at the time of the incident, with some using their phones for charting or personal use, which further limited their ability to monitor resident interactions and prevent altercations. Documentation and interviews revealed that the facility's policies on supervision and abuse prevention were not effectively implemented. The incident was reported to the police, and the aggressor was sent to the hospital for psychiatric evaluation. However, the failure to provide adequate supervision and to prevent the altercation directly led to the physical abuse and injury of a resident, as well as emotional distress.
Failure to Prevent and Protect Resident from Abuse Resulting in Injury
Penalty
Summary
A deficiency occurred when the facility failed to prevent and protect a resident from resident-to-resident abuse, resulting in the resident sustaining a left ankle fracture. The incident began when the resident refused to lend a Bluetooth speaker to another resident, leading to a verbal altercation with a second resident who then used his electric wheelchair to ram into the first resident, knocking him to the floor and running over his leg. Staff intervened only after the second resident attempted to run over the resident again. The initial staff response was limited to asking if the resident was okay, and no immediate assessment or vital signs were taken at that time. The resident later reported pain in his foot to a nurse, but there was no documentation of a thorough assessment or physician notification prior to the resident experiencing a fall in his room due to increased pain. After the fall, emergency services were called, and the resident was diagnosed with a closed bimalleolar fracture of the left ankle. The documentation failed to show that the nurse recorded the resident's complaint of pain, the assessment performed, or the notification to the physician before the fall occurred. The resident's care plan indicated a low risk for aggression, while the second resident had a documented history of behavioral issues and aggression towards peers and staff. Despite this, the second resident continued to have access to the area where the injured resident was relocated, and there was no evidence of effective interventions to prevent further contact or abuse. The facility's policies and residents' rights documents emphasize the prohibition of abuse and the requirement to protect residents from harm, which was not upheld in this case.
Failure to Prevent Resident Altercation
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in a physical altercation between them. Resident 1 (R1) and Resident 2 (R2) were involved in an incident where R1 sustained a displaced fracture of the left 5th metacarpal, right shoulder deformity, and right eye discoloration, while R2 had a scratched forehead. Prior to the altercation, R1 had reported feeling threatened by R2, who had been displaying aggressive behavior and wandering into other residents' rooms. Despite these warning signs, the facility did not implement adequate preventive interventions or provide sufficient supervision to prevent the altercation. R2 had a history of severe mental impairment, as indicated by a BIMS score of 3, and was diagnosed with dementia, metabolic encephalopathy, and psychoactive substance abuse. R2's care plan noted behavioral symptoms related to severe mental illness, with interventions including psychiatric evaluation as needed. However, R2 continued to exhibit aggressive and disruptive behavior, including an incident where R2 was verbally aggressive and refused to leave another resident's room. Despite these behaviors, the facility did not take effective measures to prevent the altercation with R1. R1, who had a BIMS score of 13 indicating intact cognition, reported being assaulted by R2, who was his roommate at the time. R1's care plan highlighted his increased susceptibility to abuse and neglect, yet the facility failed to observe and address signs of fear and insecurity. The facility's abuse prevention program was not effectively implemented, as resident and family concerns were not adequately recorded, reviewed, or addressed, and random rounds to assess safety were not conducted. This lack of action and oversight contributed to the failure to protect R1 and R2 from the altercation.
Failure to Develop Timely and Comprehensive Care Plans
Penalty
Summary
The facility failed to develop timely and comprehensive care plans for two residents, R4 and R6, as required by their care planning policy. R4, who was admitted with a history of falling, was identified as high risk for falls on 6/13/23, yet the comprehensive care plan addressing this risk was not initiated until 1/21/25, approximately 1.5 years after admission. This delay in care planning indicates a significant oversight in addressing the resident's fall risk in a timely manner. Similarly, R6 was admitted with a history of alcohol and cocaine abuse, but the comprehensive care plan received on 1/28/25 did not include these diagnoses under the Focus section, despite the Care Plan Coordinator acknowledging the need for such information to be included. The facility's care planning policy mandates that comprehensive assessments and individualized care plans be completed upon admission and updated as needed, which was not adhered to in these cases.
Failure to Update Care Plans for Fall Risk Residents
Penalty
Summary
The facility failed to follow its policy procedures regarding the review and revision of comprehensive care plans for two residents who were at risk for falls. Resident R3 experienced an unwitnessed fall on 11/26/24, but this incident was not included in their care plan, which had an outdated goal target date of 8/11/24. Similarly, Resident R7's care plan, which identified them as at risk for falls, had an outdated goal target date of 11/12/24 and was not updated due to a lack of recorded falls. The Care Plan Coordinator, V15, acknowledged that the care plans were not updated as required, citing that R3's care plan was assigned to someone who had quit and that R7's care plan was not updated due to no history of falls. The facility's care planning policy mandates that care plans be reviewed and updated as needed with re-admissions, quarterly, annually, and with changes in condition, while the fall prevention program requires that care plans address each fall with appropriate interventions.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to follow its fall prevention policy and procedures, resulting in inadequate supervision and implementation of fall prevention interventions for three residents. Resident R4, who is at high risk for falls due to severe cognitive impairment and mobility issues, experienced a fall that was witnessed by a roommate but not by staff. Despite being identified as requiring partial/moderate assistance for transfers and bed mobility, R4's call light was found on the floor and out of reach, contrary to the care plan's intervention to keep it within reach. Resident R3, also at high risk for falls, had an unwitnessed fall while attempting to cover her daughter, who was not present. R3 requires assistance for transfers and is supposed to have a non-slip material in her wheelchair, but this was not in use during the surveyor's observation. Additionally, R3 was left unattended without access to a call light, and the CNA assigned to her was unaware of all required fall prevention interventions. Resident R7, with severe cognitive impairment and moderate fall risk, was found with the call light on the floor and out of reach. The facility's fall prevention program mandates that call lights be within reach at all times, but this was not adhered to. The facility's failure to ensure staff awareness and implementation of fall prevention interventions contributed to the deficiencies observed during the survey.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents, leading to a deficiency in accommodating the needs and preferences of each resident. Resident R4, with a severely impaired mental status and requiring moderate assistance for transfers, was observed with the call light on the floor and out of reach. Despite the presence of a Licensed Practical Nurse (LPN) at the bedside, the call light was not placed within reach, and the LPN did not initially acknowledge this as part of the fall prevention interventions. Similarly, Resident R7, who is dependent on staff for transfers and has a severe cognitive impairment, was found with the call light on the floor and out of reach. The Director of Nursing (DON) confirmed the call light's location and had to place it within reach after being prompted by the surveyor. Resident R3, with moderate cognitive impairment and requiring assistance for transfers, was found alone in her room without access to a call light while seated in a wheelchair. The Certified Nursing Assistant (CNA) assigned to R3 was unaware of the fall prevention interventions beyond the use of floor mats and did not provide the call light within reach before leaving the room. The facility's call light policy mandates that the call system be available and accessible to residents, which was not adhered to in these instances, resulting in a failure to accommodate the residents' needs and preferences effectively.
Delayed Notification of Physician After Resident Fall
Penalty
Summary
The facility failed to timely notify the Physician, Nurse Practitioner, and/or Medical Director of a change in condition for a resident who was reviewed for falls. The resident, who has a history of altered mental status and falls, experienced a fall from bed. The incident was witnessed by the roommate, and the resident was found on the floor by a CNA. Despite the fall, the resident denied pain and showed no signs of distress or injury at the time. The staff transferred the resident back to bed and educated her on using the call light for assistance. However, the facility did not immediately notify the physician as required by their policy. The progress notes indicate that the staff contacted the Medical Doctor but awaited a callback. It was not until approximately 7.75 hours later, when the resident's family insisted, that the Nurse Practitioner was contacted, and the resident was sent to the emergency room. The hospital later admitted the resident for pulmonary thrombosis. Interviews with the facility's physician and staff revealed that the physician expected to be notified immediately of such incidents, and the facility's policy required immediate notification of the physician, family, and nursing leadership after a fall. The delay in notification and subsequent actions led to the deficiency identified by the surveyors.
Failure to Prevent Resident Abuse
Penalty
Summary
The facility failed to adhere to its policy and procedure to prevent abuse, resulting in a physical altercation between two residents. Resident 1, a male with multiple diagnoses including cerebral infarction and mood disorder, reported being pushed to the floor by Resident 2, who has a history of bipolar disorder and alcohol dependence. The incident occurred when Resident 2 entered Resident 1's room, allegedly to speak with Resident 1's roommate. A commotion ensued, leading to Resident 1 being on the floor and later complaining of back pain. Despite conflicting accounts from the involved residents, the facility's initial incident report confirmed a dispute, and both residents were sent to the hospital for evaluation. The hospital records indicated that Resident 1 did not sustain any fractures or acute injuries, contradicting his initial claim of a fractured back and ribs. The facility's abuse prevention policy explicitly states that abuse, including physical abuse by other residents, will not be tolerated. However, the incident report and interviews reveal that the facility did not effectively prevent the altercation or ensure the safety of Resident 1. The facility's failure to prevent this incident highlights a deficiency in their abuse prevention measures, as Resident 2 was able to enter Resident 1's room and engage in a physical confrontation.
Failure to Prevent Resident Abuse During Dining Room Altercation
Penalty
Summary
The facility failed to prevent an incident of physical abuse between two residents, R1 and R2, which occurred in the dining room. R2, who has a history of unspecified convulsions, bipolar disorder, and major depressive disorder, reported that R1 pushed her and scratched her face after she intervened in a verbal altercation between R1 and the staff. R1, who has diagnoses including conversion disorder with seizures and major depressive disorder, claimed that R2 grabbed his face, prompting him to push her away. Witnesses, including other residents and staff, provided varying accounts of the incident, with some noting that R1 was cursing at staff and R2 intervened, leading to a physical altercation. The facility's staff, including CNAs and the Director of Nursing, were not present during the entire incident, and their accounts were based on second-hand information. The staff failed to adequately supervise the residents during mealtime, as required by the facility's policy and procedure for standard supervision and monitoring. The incident was not immediately witnessed by staff, and there were discrepancies in the accounts regarding whether there were visible injuries on R1 and R2 following the altercation. The facility's abuse prevention program policy mandates the prevention of resident abuse, neglect, and mistreatment, but the staff's inaction in adequately supervising the residents and intervening in a timely manner contributed to the incident. The facility's incident report concluded that R1 was frustrated with staff and R2's intervention led to the physical altercation. Despite the facility's policy to prevent abuse, the lack of immediate staff intervention and supervision during the incident resulted in a failure to protect R2 from physical abuse by R1.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure medications were administered as ordered by the residents' physician, leading to significant medication errors. During a survey, an LPN was observed preparing medications for two residents simultaneously, which is against the facility's policy. The LPN placed the medications for one resident aside and began preparing medications for another resident without administering the first set. When questioned, the LPN admitted to preparing medications for both residents at the same time and acknowledged the importance of following the rights of medication administration. Further observations revealed that the LPN was unable to identify a pill that fell onto the medication cart while preparing medications for a resident, indicating a lack of adherence to proper medication administration procedures. Additionally, the LPN administered a blood pressure medication to a resident whose blood pressure reading was below the physician's specified parameters for administration. The LPN did not follow the physician's order to hold the medication if the resident's systolic blood pressure was less than 110, which was documented in the resident's medication administration record. The Assistant Director of Nursing confirmed that it is unacceptable for nurses to prepare medications for more than one resident at a time, as it could lead to residents receiving the wrong medication and experiencing adverse reactions. The facility's policy mandates that medications be administered as prescribed and in accordance with good nursing principles. The policy also requires that vital signs be monitored before administering medications dependent on such measures, which was not adhered to in this instance.
Deficient Care Planning for Dependent Residents
Penalty
Summary
The facility failed to ensure that staff were aware of and followed facility policies, resulting in the lack of comprehensive care plans for three dependent residents. These residents required various levels of assistance with activities of daily living (ADLs), such as eating, bathing, toileting, and transfers, but their care plans did not include the necessary interventions. For instance, one resident with Alzheimer's disease and severe cognitive impairment required extensive assistance with most ADLs, yet their care plan omitted specific interventions for eating, bathing, toileting, and transfers. Another resident with paraplegia required supervision for eating and substantial assistance for toileting and transfers, but their care plan also lacked these details. A third resident, dependent on staff for eating, transfers, and toileting, had a care plan that excluded ADL care entirely. The surveyor's investigation revealed that the facility's interdisciplinary team, including the MDS Coordinator and Restorative Nurse, was responsible for developing and updating comprehensive care plans. However, the MDS Coordinator was unaware of their responsibility for ADL care plans until the surveyor's inquiry. Additionally, the facility did not have a Restorative Nurse at the time of the survey, which may have contributed to the oversight. The Director of Nursing confirmed the absence of a Restorative Nurse, highlighting a gap in the facility's staffing and care planning processes.
Inadequate Staffing and Care Planning in LTC Facility
Penalty
Summary
The facility failed to ensure adequate staffing levels and a written staffing policy, which led to insufficient care for residents. On the first floor, an agency registered nurse and three CNAs were responsible for 30 residents, with more than half requiring assistance. This staffing level was deemed inadequate, as evidenced by the failure to monitor a resident's indwelling urinary catheter, which resulted in sediment buildup and a confirmed urinary tract infection. Another resident, who required substantial assistance, was found with a moderately saturated incontinence brief, indicating a lack of timely care. On the third floor, the staffing was also insufficient, with four to five CNAs and two nurses for 52 residents, many of whom had Alzheimer's and required assistance. The CNAs reported that the staffing was not adequate to meet the residents' needs, as demonstrated by a resident being left in a soiled incontinence brief for over three hours. The facility's staffing coordinator confirmed that there were call-offs and late arrivals, which further exacerbated the staffing issues. Additionally, the facility lacked proper care planning for residents' activities of daily living (ADL). The MDS Coordinator was unaware of their responsibility for ADL care plans, resulting in incomplete care plans for residents requiring assistance with transfers, toileting, and eating. The facility also did not have a restorative nurse, and the administrator admitted that there was no formal staffing policy, relying instead on census and needs assessments.
Facility Maintenance Failures Lead to Ceiling Leak
Penalty
Summary
The facility failed to maintain essential equipment and infrastructure, leading to a deficiency that affected the safety and comfort of its residents. The Illinois Department of Public Health received an allegation regarding falling ceiling tiles on the third floor of the facility. Upon investigation, it was observed that ceiling tiles were missing, and water was leaking profusely from the ceiling, with a large trash can and wet towels placed to manage the water. The Director of Nursing acknowledged the issue, but it was not adequately addressed. The Maintenance Director confirmed that the problem was reported months earlier, and although the roof was sealed, the issue persisted due to a malfunctioning actuator tied to the air handling system. The facility's maintenance program was not followed as required, with inspections and repairs not documented or conducted timely. The HVAC contractor, responsible for checking the air handling systems, had not been paid for services since July, and invoices for necessary repairs were missing. The preventive maintenance program required daily inspections and immediate attention to repairs, but these protocols were not adhered to, resulting in unresolved issues and potential risks to the 145 residents in the facility.
Failure to Maintain Clean and Hazard-Free Environment
Penalty
Summary
The facility failed to maintain a clean and hazard-free environment for its residents, as observed during a survey conducted by the Illinois Department of Public Health. The survey revealed that the facility did not ensure timely cleaning of resident rooms and dining areas, which posed potential risks to the residents. Specifically, a resident on the 1st floor, who has Alzheimer's disease and requires assistance for daily activities, was found to have a dirty room with food debris and a removed baseboard lying on the floor. The housekeeping staff claimed that rooms are cleaned daily, but the presence of smashed food and other debris indicated otherwise. Additionally, the dining room on the 1st floor had food debris and dried spills on the floor, suggesting inadequate cleaning after meals. On the 3rd floor, similar issues were noted, with the dining room tables not cleared and the floor littered with trash and food debris, including large orange juice spills. A resident's room on the 3rd floor was also found to have dried spots of gastrostomy tube feeding and scattered debris on the floor. Despite having six housekeepers on duty, the facility's housekeeping director confirmed that the cleaning procedures were not followed as required. The general cleaning policies and procedures of the facility mandate thorough cleaning of resident rooms and dining areas, but these were not adhered to, leading to the observed deficiencies.
Failure to Timely Transfer Resident and Document Discharge Planning
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding the transfer and discharge of residents, specifically in the case of a resident who was not transferred in a timely manner. The resident's comprehensive care plan did not include discharge planning upon admission, which is a requirement. Despite the family's repeated requests for the resident to be transferred to another facility, the facility did not document follow-ups on the transfer referrals adequately. The resident's family expressed a desire for the resident to be transferred to several different facilities, but the facility either did not document the follow-up or failed to secure a transfer due to issues such as insurance or bed availability. The facility's social services staff acknowledged that every resident should have a discharge care plan upon admission, yet the resident's discharge care plan was only initiated over three months after admission, following a surveyor's request. The facility's transfer and discharge policy emphasizes the resident's right to receive necessary care and participate in the development of their comprehensive care plan. However, the facility did not ensure that the resident's discharge care plan included an actual discharge plan, nor did it adequately follow up on transfer referrals, leading to a delay in the resident's transfer to another facility.
Failure to Provide Timely ADL Care
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADL) for two dependent residents, R1 and R3, as observed by the Illinois Department of Public Health. R1, diagnosed with Alzheimer's disease and requiring substantial assistance for toileting and transfers, had a care plan that did not include these necessary supports. On observation, R1 was found in a moderately saturated incontinence brief, indicating a lack of timely care. Similarly, R3, who is dependent on staff for eating, transfers, and toileting, also had a care plan that excluded ADL care. R3 was found with a soiled incontinence brief, suggesting neglect in routine checks and changes. The facility's policies on ADL and incontinence care were not adhered to, as evidenced by the observations and staff interviews. The policy mandates that ADL care should be provided throughout the day and as needed, with incontinence checks every two hours. However, both R1 and R3 were not checked or changed for over three hours, contrary to the facility's stated procedures. Staff interviews confirmed the lapses in care, with CNAs acknowledging the delay in attending to the residents' needs.
Failure to Monitor and Address Resident's Deteriorating Condition
Penalty
Summary
The facility failed to monitor and recognize a change in condition for a resident with a known history of chronic kidney disease, chronic obstructive pulmonary disease, type II diabetes, chronic congestive heart failure, cardiomegaly, essential hypertension, and other health issues. The resident was admitted with these conditions and had specific care plan interventions, including monitoring and documenting edema and weight changes, and reporting these to a physician. Despite these interventions, the facility did not adequately monitor the resident's condition, as evidenced by the lack of action on significant weight gain and edema, which were not addressed by the nursing staff or physicians. The facility also failed to review and address diagnostic test results in a timely manner. Critical lab values indicating deteriorating renal function were not reviewed or acted upon promptly by the nurse practitioner or other medical staff. Additionally, an abdominal ultrasound showing a large amount of ascites was not communicated to the physician, and the resident's significant weight gain was not addressed by the medical staff, despite being documented in progress notes. This lack of communication and follow-up on critical test results contributed to the resident's worsening condition. Furthermore, the facility did not follow physician orders to schedule necessary nephrology, cardiology, and pulmonary consultant appointments. The appointment scheduler was aware of the orders but did not schedule the appointments, citing uncertainty about insurance as a possible reason. This failure to schedule essential consultations and tests delayed the resident's access to necessary medical care, ultimately resulting in the resident being sent to the emergency department with severe health issues, including massive volume overload, worsening kidney function, and respiratory failure.
Inadequate Wound Care and Incontinence Management
Penalty
Summary
The facility failed to adhere to its skin condition assessment policy, resulting in inadequate wound care for three residents. One resident, who was admitted with multiple medical conditions including heart failure and reduced mobility, developed a stage II pressure ulcer on the left rear thigh. The wound care nurse attempted to treat the wound but was met with resistance from the resident, leading to a lapse in treatment from September 4 to September 9. During this period, the resident's wound care was not completed as prescribed, and the resident reported the issue to the facility's ombudsman, expressing concerns about a potential infection. Another resident, who was admitted with a stage four sacral wound, experienced an increase in wound size due to inadequate care. The resident reported being left in soiled conditions overnight, which led to the wound being exposed to urine and feces. This lack of timely incontinence care contributed to the deterioration of the wound, as observed by the surveyor and confirmed by the wound nurse practitioner. The resident's wound dressing was not maintained, and the staff failed to replace it promptly, exacerbating the resident's condition. A third resident developed moisture-associated dermatitis due to prolonged exposure to urine and feces. The resident was found in a soiled state, with the incontinence pad saturated and the skin showing signs of excoriation. The facility's staff did not provide timely incontinence care, leading to the development of skin issues. The facility's policy requires daily observation and documentation of skin conditions, but this was not consistently followed, resulting in the residents' wounds worsening or not healing as expected.
Failure to Provide Adequate Incontinence Care
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care to residents who are dependent on staff assistance, specifically incontinence care and personal hygiene. This deficiency affected three residents, resulting in significant discomfort and potential health risks. One resident, with a medical history of muscle wasting, paraplegia, and major depressive disorder, reported being left in urine and feces overnight, which aggravated a wound on their buttocks. The resident's care plan indicated a need for total assistance with ADLs, yet they experienced prolonged exposure to incontinence, leading to the wound not healing properly. Another resident, admitted with hemiplegia and hypertension, also reported being left in urine for an extended period, leading to itching and scratching. This resident expressed feelings of neglect and a lack of personal hygiene care, as they had not received a shower despite repeated requests. The resident's care plan similarly required total assistance with ADLs, highlighting a consistent failure in providing necessary care. A third resident, with a diagnosis of weakness and reduced mobility, was found in a similar state of neglect, with their incontinence care not being addressed throughout the night. The resident was left in a soiled state, causing discomfort and distress. Staff observations confirmed that the night shift failed to provide the necessary care, and the facility's policy on incontinence care, which mandates checks every two hours, was not adhered to. This pattern of neglect was further corroborated by previous resident council complaints about inadequate incontinence care and delayed response to call lights.
Laundry Deficiency Leads to Unsanitary Conditions
Penalty
Summary
The facility failed to provide adequate bed linen and bath towels for four residents, leading to unsanitary conditions and discomfort. Residents reported not having clean towels and linens, resulting in prolonged periods without being changed or cleaned. This issue was exacerbated by the facility's malfunctioning washing machines, which hindered the timely provision of clean laundry. The deficiency was observed through interviews and record reviews, revealing that residents were left in soiled conditions for extended periods. One resident reported being soaked with urine and feces overnight, while another expressed frustration over not receiving a shower due to the lack of clean linen. Certified Nurse Assistants confirmed the shortage of towels and linens, indicating that they often had to wait for laundry deliveries, which were insufficient to meet the needs of all residents. The facility's laundry operations were severely impacted by equipment failures, with only one small washer functioning. The laundry aide and supervisor highlighted the challenges in maintaining adequate linen supplies due to broken washing machines and clogged drains. Despite being aware of these issues, the facility had not taken timely action to repair the equipment or secure additional resources, leading to a widespread deficiency affecting all 150 residents.
Improper Waste Container Management
Penalty
Summary
The facility failed to ensure that waste containers were properly contained and covered, which has the potential to affect all 156 residents residing in the facility. During an observation, a surveyor and the Maintenance Director noted that one of the dumpsters in the facility's dumpster area was uncovered. Although the dumpster was designated for recyclable items, it was acknowledged by the Maintenance Director that it should still be covered, and he proceeded to cover it with the lid. Further observation revealed an additional dumpster and garbage can in the back parking lot, both of which were not properly covered. The dumpster was uncovered, and the trash can lid could not be closed due to the amount of trash inside, which included food and drink waste. The Maintenance Director explained that these containers were for construction waste and suggested that the city had forgotten to pick them up. He affirmed that trash is picked up weekly and acknowledged that not covering trash containers can attract pests and rodents. The facility's waste disposal policy mandates that trash should not accumulate to the point where the lid cannot fit tightly and that dumpster lids should remain closed at all times.
Infection Control Deficiencies in Hand Hygiene and PPE Protocols
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols, as observed during a blood glucose test on a resident. An LPN applied gloves without using hand sanitizer and subsequently touched the medication cart without sanitizing hands. The LPN acknowledged the oversight, citing infrequent attendance at infection control in-services as a possible reason for the lapse. The facility's hand hygiene policy mandates the use of a waterless alcohol-based agent before glove application and interaction with residents, which was not followed in this instance. Additionally, the facility did not initially post an Enhanced Barrier Precautions (EBP) isolation sign or place a PPE bin outside a resident's room, who was on EBP due to a wound. The oversight was corrected the following day, but the initial failure to provide clear instructions and necessary PPE outside the room posed a risk of infection spread. The resident in question had multiple diagnoses, including dementia and a stage 3 pressure injury, necessitating strict adherence to EBP protocols. The facility's policy requires signage and PPE availability to prevent the spread of multidrug-resistant organisms. During meal service, a CNA failed to perform hand hygiene between assisting multiple residents, increasing the risk of cross-contamination. The CNA moved between residents without sanitizing hands, despite the facility's policy requiring hand hygiene after assisting each resident. The DON confirmed that hand hygiene is essential to prevent contamination, especially when handling food and utensils for different residents. The residents involved had severe cognitive impairments, making them particularly vulnerable to infection risks.
Failure to Monitor and Maintain Resident Refrigerators
Penalty
Summary
The facility failed to ensure proper monitoring and maintenance of personal refrigerators for residents, affecting four residents in the sample. The deficiencies included the absence of temperature logs and thermometers in personal refrigerators, as well as inadequate cleaning. For instance, a resident's refrigerator was observed to be dirty and missing a temperature log for July, with the resident stating that they clean it themselves and staff do not check it. Another resident's refrigerator had no temperature entries recorded for nearly two weeks, despite the facility's policy requiring daily temperature checks. The facility's policy mandates that all refrigerators have internal thermometers and that temperatures are recorded daily to prevent food spoilage. However, observations revealed that several residents' refrigerators lacked these essential components. Staff interviews indicated confusion about responsibilities, with some staff members believing that nurses or administrative staff were responsible for monitoring the refrigerators, while others thought it was the housekeeping staff's duty. This lack of clarity contributed to the failure in maintaining the refrigerators properly. Additionally, one resident's refrigerator was found with the door ajar and no temperature log or thermometer present. The resident mentioned that they adjust the temperature manually when it gets too warm, indicating a lack of staff oversight. Staff members were unsure about who was responsible for checking the refrigerator temperatures, further highlighting the facility's failure to adhere to its own policies regarding food safety and refrigerator maintenance.
Failure to Prevent Alcohol Access and Ensure Razor Safety
Penalty
Summary
The facility failed to prevent a resident with a history of alcohol abuse from obtaining and consuming alcohol, which is prohibited within the facility. The resident, who is cognitively intact and has a diagnosis of alcohol abuse, was observed with an open half-empty bottle of beer in their personal refrigerator, which also contained more full bottles of beer. Despite the facility's policy prohibiting alcohol, the resident was able to access and consume it, and the staff did not take immediate corrective action to prevent further consumption. The resident was also on narcotic pain medication, which has a black box warning against the concomitant use of alcohol due to the risk of severe adverse effects. Additionally, the facility failed to ensure the safe storage and disposal of razors, which were found in another resident's basin. This resident, who is also cognitively intact, had two razors in their possession, posing a risk of self-harm or harm to others. The facility lacked a specific policy for the disposal of razors, and the resident did not have a care plan addressing shaving or razor use. The Director of Nursing acknowledged the expectation for razors to be disposed of in sharps containers but confirmed the absence of a formal hazard policy regarding razors.
Deficiencies in Respiratory Care Equipment Management
Penalty
Summary
The facility failed to ensure proper management and documentation of respiratory care equipment for several residents. For one resident with acute and chronic respiratory failure, the nebulizer mask and tubing were not dated or contained, and there was no oxygen order documented. The Director of Nursing confirmed that such equipment should be dated and contained to prevent infection. Another resident with chronic obstructive pulmonary disease and other respiratory conditions was observed receiving oxygen without a documented physician's order, which is required to guide the administration of oxygen therapy. Additionally, a resident with lung issues was found with an incentive spirometer and peak flow meter uncontained, with mouthpieces touching potentially contaminated surfaces. The Licensed Practical Nurse acknowledged that these devices should be contained to prevent infection. The Director of Nursing also stated that respiratory equipment should be kept at the bedside and covered to avoid dust and infection. Another resident was observed using oxygen with tubing and a humidifier bottle that were not dated, contrary to the facility's policy that requires such equipment to be labeled with the date, time, and staff initials. The Licensed Practical Nurse admitted to not changing the equipment due to the presence of water in the bottle, despite the lack of a date. These deficiencies highlight lapses in the facility's adherence to its own policies regarding respiratory care equipment management.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the daily nursing staffing information, which has the potential to affect all 156 residents residing in the facility. On July 14, 2024, the Director of Nursing confirmed the facility's census of 156 residents. Upon entrance to the facility at 9:00 am, the daily staff posting was observed at the receptionist desk, dated July 4, 2024, indicating it was not updated. The receptionist, who had just started the position a few days prior, acknowledged that she did not post the updated Daily Nurse Staffing Form. On July 15, 2024, the Staffing Coordinator stated that the Nurse Staffing is posted daily, and in her absence, either the Transportation Coordinator or the Director of Nursing is responsible for posting it.
Failure to Document and Account for Controlled Medications
Penalty
Summary
The facility failed to ensure proper documentation and accountability of controlled medications, affecting three residents. During observations, it was noted that the Controlled Substances Check form for a medication cart had missing signatures on multiple dates. A registered nurse (RN) from an agency admitted to not signing the controlled substance accountability record due to being busy and a pen running out of ink. This lack of documentation was observed during the controlled medication count for three residents, where discrepancies were found between the actual count of medications and the recorded amounts on the Controlled Drug Receipt/Record/Disposition Forms. The Director of Nursing (DON) confirmed that narcotics should be signed out by the nurse immediately after administration and that the accountability sheet should be signed at the beginning and end of each shift by both the incoming and outgoing nurses. The facility's policies require that controlled substances be accounted for on individual control substance records and that both nurses verify and sign the count sheet during shift changes. The RN's failure to document the administration of controlled medications and to sign the accountability sheets as required by facility policy led to inaccuracies in the narcotics records.
Failure to Maintain Resident Dignity and Proper Feeding Assistance
Penalty
Summary
The facility failed to maintain the dignity of residents by not adequately covering a resident's indwelling catheter urinary bag and by not providing proper one-to-one feeding assistance. During observations, a resident's urinary drainage bag was visibly exposed, and the resident expressed a desire for a privacy bag, which had not been provided despite requests. This lack of privacy was confirmed by a Licensed Practical Nurse (LPN), who acknowledged that all urinary drainage bags should be kept in privacy bags to ensure the resident's dignity. Additionally, the facility did not uphold the dignity of a resident during meal times. A Certified Nursing Assistant (CNA) was observed feeding a resident while standing, not maintaining eye contact, and engaging with other residents, which is against the facility's policy for one-to-one feeding. The CNA was seen moving between residents, feeding multiple individuals, and not focusing solely on the resident requiring one-to-one assistance. This behavior was contrary to the expectations set by the Director of Nursing (DON), who stated that staff should be seated at eye level with the resident and fully attentive during feeding. The residents involved had various medical conditions, including dementia, dysphagia, and reduced mobility, which necessitated specific care interventions. The facility's failure to adhere to its policies and procedures regarding resident dignity and feeding assistance was evident in the observations and interviews conducted. The facility's policies clearly state the importance of treating residents with dignity and respect, yet these incidents demonstrate a lapse in compliance with those standards.
Inaccessible Call Devices for Residents
Penalty
Summary
The facility failed to ensure that call devices were within reach for residents to use to call for staff assistance, affecting three residents. On July 14, 2024, a surveyor observed a resident seated in a wheelchair by the window with the call device on the floor between two beds, making it inaccessible due to floor mats. The resident confirmed the inability to reach the call device. A Licensed Practice Nurse acknowledged the issue and repositioned the call device within reach. The resident's care plan emphasized the need for the call light to be within reach, but the facility did not conduct a call light assessment. Additionally, two other residents were affected by similar issues. One resident's call light was wrapped around a bed rail, making it unreachable, and a Licensed Practical Nurse confirmed this. Another resident's call light was hanging from the wall, out of reach, and a Certified Nursing Assistant acknowledged the resident's inability to reach it. The facility's call light policy requires that call lights be accessible to residents at all times, but this was not adhered to in these cases.
Failure to Support Resident Intimacy Rights
Penalty
Summary
The facility failed to adhere to the care plans of two residents, R8 and R65, who were assessed and documented as having the right to engage in an intimate sexual relationship. Despite both residents having intact cognition and expressing their desire to exercise this right, staff repeatedly intervened and stopped them from engaging in consensual sexual activities. R65 reported that the staff stopped them approximately 15 times, even though the facility provided condoms and had care plans in place supporting their right to intimacy. Interviews with staff revealed inconsistencies in understanding and implementing the residents' rights to intimacy. While some staff members acknowledged the provision of condoms and the need for privacy, others expressed personal discomfort or lack of clarity on the policy, leading to the interruption of the residents' consensual activities. The Director of Nursing was unsure about how communication regarding residents' sexual activities was handled among staff, indicating a lack of clear guidance and education on the matter.
Failure to Document Resident's Code Status
Penalty
Summary
The facility failed to document the code status for a resident, identified as R133, in the electronic medical record. This oversight was discovered during a survey, which included observation, interview, and record review. R133 has multiple diagnoses, including Nontraumatic Intracerebral Hemorrhage, Epilepsy, and Schizoaffective Disorder, and is rarely or never understood according to the Minimum Data Set (MDS). Despite the care plan indicating that R133 elected to be a FULL CODE, the electronic medical record and the Order Summary Report did not reflect any physician's order for advance directives, such as full code or DNR status. Additionally, the Admission Record Form for Advance Directive was left blank. The Director of Nursing acknowledged that the code status should be documented for every resident in the facility, both on the resident's profile screen and in the orders. The facility's policy on Advance Directives, dated January 17, 2017, outlines the procedure for advising residents or their legal representatives about their rights to establish an advance directive and ensuring these choices are incorporated into the resident's plan of care. However, this policy was not followed in the case of R133, leading to the deficiency noted by the surveyors.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to provide adequate nail care for two residents, R18 and R41, as observed by surveyors. R18, who has diagnoses including hemiplegia, type 2 diabetes mellitus, dementia, and a contracture in the right hand, was found with long fingernails and a brownish-gray substance underneath them. R41, diagnosed with cerebrovascular disease, hemiplegia, and a contracture in the left elbow, was also observed with a similar substance under their fingernails. Both residents require assistance with activities of daily living (ADLs), including personal hygiene, as documented in their care plans. The facility's policy on ADLs, dated January 25, 2023, states that residents should receive routine daily care to promote hygiene and comfort. The job description for Certified Nursing Assistants (CNAs) includes providing nail hygiene. However, interviews with staff, including an LPN and the Director of Nursing, revealed that nail care is supposed to be provided on shower days and as needed, with nurses responsible for diabetic residents. Despite these protocols, the observations indicated a lapse in the execution of these duties, leading to the deficiency noted by the surveyors.
Failure to Apply Hand Splint Correctly for Resident with Contractures
Penalty
Summary
The facility failed to provide appropriate care for a resident with contractures by not applying a hand splint as required, applying the splint to the incorrect hand, and not ensuring the resident was properly care planned for the use of a hand splint. The resident, who had suffered a stroke, had contractures in both hands, with the left hand being more affected. The resident reported that the splint was not consistently applied, depending on staff availability, and during the survey, it was observed that the splint was not in place. The surveyor noted that the restorative aide applied the splint to the resident's right hand, which was incorrect as the splint was supposed to be on the left hand. The resident confirmed that the splint should be on the left hand, as the right hand was still functional. The occupational therapist had recommended active range of motion exercises for the right hand and passive range of motion for the left hand, with the splint to be applied to the left hand to prevent further contracture. The facility's documentation indicated that the resident was to have a bilateral resting hand splint applied to the left hand during morning care and removed during evening care. However, the care plan and restorative nursing program were not properly followed, leading to the incorrect application of the splint. Additionally, the facility lacked specific policies for restorative care and splint application, contributing to the oversight.
Inadequate Infection Control Practices Observed
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, specifically in the handling of personal protective equipment (PPE) and the use of washcloths during resident care. A Certified Nursing Assistant (CNA) was observed entering a resident's room without wearing a gown, despite the requirement for enhanced barrier precautions due to the resident's wounds. The CNA used a single washcloth to clean different parts of the resident's body without changing gloves or the washcloth between dirty and clean areas, which is against infection control protocols. The resident involved, identified as R3, had multiple wounds requiring daily care and was on enhanced barrier precautions to prevent the spread of multidrug-resistant organisms (MDROs). The CNA was not aware of the need to change gloves between cleaning different body areas and was not following the correct sequence for donning and doffing PPE. The Director of Nursing acknowledged that the enhanced barrier precautions sign was missing due to construction, which contributed to the CNA's oversight. The facility's policies require the use of gowns and gloves during high-contact care activities for residents at risk of MDROs, such as those with wounds. However, the CNA's actions did not align with these policies, as they were not adequately trained or informed about the proper procedures for infection control. This deficiency in infection control practices has the potential to affect all residents on the first floor, as it increases the risk of spreading infections.
Failure to Develop Care Plan for Foley Catheter Use
Penalty
Summary
The facility failed to develop a care plan for a resident with a Foley catheter, affecting one resident sampled for Foley catheter care. The resident, who has been using a Foley catheter since before entering the facility, has diagnoses including acute on chronic heart failure, urine retention, and the presence of urogenital implants. Despite the resident's cognitive intactness and the presence of an indwelling catheter being documented in the Minimum Data Set (MDS) and Care Area Assessment (CAA) worksheet, the care plan did not address the catheter use. The Director of Nursing acknowledged that the care planning for the resident's Foley catheter was overlooked. The CMS Minimum Data Set 3.0 Resident Assessment Instrument User's Manual emphasizes the importance of developing an individualized care plan for residents with indwelling catheters due to the risk of substantial complications. The manual suggests that the assessment should consider the risks and benefits of catheter use, potential for removal, and possible complications, which were not reflected in the resident's care plan.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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