Wentworth Rehab & Hcc
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 201 West 69th Street, Chicago, Illinois 60621
- CMS Provider Number
- 145429
- Inspections on file
- 33
- Latest survey
- December 6, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Wentworth Rehab & Hcc during CMS and state inspections, most recent first.
A resident at moderate risk for pressure ulcers, with significant mobility and incontinence issues, developed a new sacral pressure ulcer that was not identified, reported, or treated by staff as required. CNAs observed the wound but failed to notify nursing staff, and there was no documentation or intervention until the issue was discovered by a surveyor. Facility policies for skin assessment and reporting were not followed, resulting in delayed care.
Three residents with cognitive impairments were not properly informed of their monthly personal fund amounts and did not consistently receive their trust fund disbursements. Facility staff were unclear about representative payee responsibilities and failed to notify residents about the management of their funds, resulting in confusion and lack of access to entitled monies.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The report notes that the environment was not maintained safely and supervision was lacking, but does not provide further specifics.
A resident with multiple medical conditions, including a stage 4 pressure ulcer and severe malnutrition, did not have initial wound measurements documented by the LPN upon admission, leaving no baseline for the wound care team. Additionally, required weekly weights were missed, with only two weights recorded instead of the policy-mandated weekly monitoring, hindering proper nutritional assessment and intervention.
A resident with diabetes and multiple comorbidities did not receive appropriate blood glucose monitoring or consistent diabetes medication administration upon admission. Despite physician orders for blood sugar checks and insulin, only one blood sugar reading was documented in the first week, while diabetes medications were administered without monitoring. Nursing staff confirmed that blood glucose checks should have been performed according to orders, highlighting a lapse in following care protocols.
The facility failed to accurately assess fall risks and implement preventive interventions for two residents, resulting in multiple falls and injuries. One resident with Alzheimer's disease experienced several falls, including one causing a head injury requiring staples, without updates to their care plan. Another resident with dementia and hemiplegia had an inaccurately scored fall risk assessment and inadequate supervision, leading to a head laceration. The facility did not adhere to its fall management policy, resulting in deficiencies in fall prevention practices.
A facility failed to develop a comprehensive care plan for a resident involved in an alleged abusive relationship with a CNA. Despite the resident's admission 5.5 months prior, the care plan did not include a risk for abuse. The ADON confirmed the omission and was unsure if abuse should be included in care plans, contrary to the facility's policy requiring a person-centered care plan within 7 days of the MDS completion.
The facility failed to update care plans for two residents, leading to deficiencies in care. One resident's care plan for fall risk and behavioral health pass program had expired target dates, and the ADON confirmed they were not reviewed as required. Another resident experienced a fall with a head injury, but the care plan was not updated with preventive interventions. The facility's policies require care plan revisions based on changes in condition and quarterly reviews, which were not followed.
A resident with a history of aggression became physically and verbally aggressive in the dining room. Despite staff attempts to deescalate, the resident grabbed a broom and swung it at a social worker. A housekeeper, untrained in CPI, intervened physically, resulting in the resident falling. This violated the facility's abuse policy, as the housekeeper acted outside his scope of duty.
A resident with multiple health issues experienced significant weight loss due to the facility's failure to implement and revise care plan interventions for nutritional support. Observations showed the resident struggling to eat without staff assistance, and documentation of food intake was inconsistent. The care plan lacked necessary updates, and staff interviews highlighted the need for 1:1 assistance and proper positioning during meals.
A resident with hemiplegia and dementia was observed struggling to eat independently due to the lack of a plate guard, which was documented as necessary in her care plan. Despite the resident's need for adaptive equipment and supervision during meals, staff did not provide the required assistance or ensure cleanliness, and the dietary supervisor confirmed that the necessary equipment was on order but not yet available.
A facility failed to maintain accurate and complete medical records for a resident, as required by its policy and professional standards. The resident's community survival assessment was not documented in the electronic health record before the surveyor's request, and there was a discrepancy between a handwritten assessment and the electronic record. The Director of Behavioral Health admitted the electronic assessment was inaccurate, leading to a handwritten version. The electronic assessment conflicted with the physician's orders, and the assessment was overdue, violating the facility's policy for annual or significant change assessments.
The facility did not follow fall prevention interventions for residents with dementia at risk for falls. Observations revealed several residents wearing smooth-bottomed socks instead of non-skid footwear, contrary to their care plans. The Memory Care Director and a CNA confirmed the oversight. Records showed these residents were assessed as fall risks, requiring proper footwear, as per the facility's Fall Management Program.
The facility failed to maintain the community shower room on the fourth floor East-Wing in a sanitary condition due to a drain/sewer back-up. A wet towel was found covering black liquid oozing from the drain, and the issue was not documented in the maintenance logbook until prompted by a surveyor. The Maintenance Director later attempted to clear the drain, highlighting a lapse in maintenance request procedures.
A facility failed to effectively control a bed bug infestation on the third floor, affecting multiple residents. Despite reports of bed bugs in beds and on curtains, the facility only treated rooms with sightings, allowing the problem to persist. Staff confirmed the issue, noting corporate approval was needed for treatments, limiting the number of rooms addressed. The facility's protocol was not fully implemented, as room changes were undocumented.
A resident with a suspicious breast mass refused a STAT mammogram and ultrasound due to fear, and the LTC facility failed to document or reschedule the appointment promptly. Staff interviews revealed confusion and lack of communication regarding the rescheduling, and the facility lacked a documentation policy, leading to a deficiency in meeting the resident's medical needs.
The facility failed to administer medications as ordered and did not document reasons for missed doses, affecting five residents. Interviews revealed that a resident was not given medications due to various reasons like computer issues or unavailability. The MARs showed multiple missing entries without explanations, contrary to the facility's policy requiring documentation of medication administration.
A resident with a history of falls and multiple medical conditions fell and fractured her finger due to the facility's failure to ensure her call light was within reach and her bed was in a low position. Staff admitted to not checking on the resident or ensuring necessary safety interventions were in place.
The facility failed to store food in accordance with professional standards, with expired food items found in the fridge and freezer, and opened food items without proper labeling. Additionally, a cook was observed preparing fortified pudding without using measuring utensils, deviating from the recommended recipe. These deficiencies have the potential to affect all 180 residents.
The facility failed to provide adequate staffing on the second floor, affecting all residents residing there. On multiple occasions between October 2023 and December 2023, the second floor had fewer aides than required, despite efforts by the Staffing Coordinator to cover call-offs and holidays. This led to the facility triggering with CMS for excessively low weekend staffing.
The facility failed to administer prescribed medications in a timely manner due to a nurse arriving late for her shift, affecting twelve residents. The facility's eMAR indicated the delay, and the protocol for such situations was not properly followed.
The facility failed to properly clean and disinfect multi-use blood pressure cuffs and pulse oximeters between resident use, did not follow proper hand hygiene protocols during peri-care, and did not post a required contact isolation precaution sign for a resident with specific diagnoses.
The facility failed to ensure that call light devices were within reach for two residents, placing them at risk of not being able to call for help. One resident with limited arm movement due to strokes and another with a right arm contracture were unable to reach their call lights. The facility's LPN acknowledged the importance of accessible call lights, and the facility's policy mandates that call lights be within reach at all times.
The facility failed to refer two residents with newly evident or possible serious mental disorders to the appropriate state-designated authority for review. One resident was diagnosed with bipolar disorder, and another had major depressive disorder, psychosis, and schizophrenia. Due to staff turnover and vacancies, the necessary screenings were not conducted as required.
The facility failed to provide regular showers to a resident with multiple medical conditions, including stage four and stage three pressure ulcers, dementia, and Alzheimer's disease. Documentation showed the resident did not receive a shower for two weeks, despite requiring substantial assistance with personal hygiene.
A facility failed to document catheter changes for a resident with multiple diagnoses, including stage four pressure ulcer and dementia. Despite protocols requiring weekly catheter changes, there was no documentation of any changes from admission in March 2024 until the end of May 2024. The resident's care plan also lacked information about the catheter and necessary care to prevent infections.
A resident did not receive prescribed medications due to the facility's failure to respond to pharmacy notifications about insurance issues, resulting in the unavailability of the medications. The nursing staff documented the administration of these medications despite their absence.
The facility failed to discard expired medications for two residents, as observed on medication carts managed by LPNs on the 3rd and 4th floors. Despite weekly audits and policies requiring immediate removal of expired medications, the expired medications were not discarded, posing a potential risk to resident safety.
A resident returning from the hospital was not provided a meal, resulting in hunger. The resident, with multiple medical conditions, was found struggling to get dressed and locate her call light. Staff failed to check on her or offer food after her return, despite knowing snacks were available.
A facility failed to implement effective fall prevention measures and supervision for three residents, resulting in falls and injuries. One resident, with dementia and hemiplegia, sustained a fall causing a laceration requiring sutures. Another resident, with vascular dementia, had inadequate floor mat placement, and a third resident experienced an unwitnessed fall due to insufficient supervision. Staff were not fully aware of or able to locate fall prevention interventions, highlighting a lack of proper documentation and communication.
The facility failed to revise care plans with appropriate interventions for three residents at risk for falls. One resident was sent to the hospital post-fall without preventive measures added. Another resident, with cognitive impairments, had floor mats added but lacked supervision. A third resident had a floor mat placed on one side of the bed, despite the risk of falling from either side. These actions did not adequately address fall prevention.
Failure to Prevent, Identify, and Report New Pressure Ulcer
Penalty
Summary
A resident with multiple medical conditions, including hemiplegia, heart failure, and incontinence, was assessed as being at moderate risk for developing pressure ulcers. The resident required substantial assistance for bed mobility and was unable to reposition independently. Despite being identified as at risk, the facility failed to prevent, identify, report, and treat a new pressure ulcer that developed on the resident's sacrum. During a surveyor's observation, an open skin area approximately 2 by 2 inches with a red wound base was found on the resident's sacrum, covered only with barrier cream and without a proper dressing. Certified Nursing Assistant (CNA) staff observed the open wound during routine care but did not report it to the nursing staff as required by facility policy. The CNA initially claimed to have reported the wound but later admitted to assuming someone else had done so and ultimately did not notify the nurse. Licensed Practical Nurses (LPNs) and the Assistant Director of Nursing (ADON) were unaware of the wound prior to the surveyor's observation, and there was no documentation of the wound in the resident's electronic health record, progress notes, or skin assessments prior to the surveyor's findings. The wound care team and physician were not notified until after the surveyor brought the wound to the facility's attention. Facility records, including the resident's care plan and turning/repositioning program, indicated that staff were to check the resident's skin daily and report abnormalities. However, documentation from CNAs on shower/bath reports repeatedly indicated no new skin issues, and there was no record of the pressure ulcer in the days leading up to the survey. The facility's policy required prompt identification and reporting of skin alterations, but this process was not followed, resulting in a delay in assessment and treatment of the resident's pressure ulcer.
Failure to Inform and Distribute Resident Personal Funds
Penalty
Summary
The facility failed to properly inform residents of their monthly personal funds amounts and did not distribute personal fund monies as required. Three residents were affected by this deficiency. One resident, who had moderately impaired cognition, was unaware of why she was not receiving her monthly trust fund disbursement and had not authorized her nephew to manage her finances. The facility did not notify her that her monthly trust fund money was being given to her nephew, and there was confusion regarding who was the authorized representative payee for her Social Security and pension funds. Another resident, with severely impaired cognition, reported not receiving her trust fund money and was unaware of the amount she should receive. The facility staff stated that this resident's family was the representative payee, but the resident was not informed about this arrangement. A third resident, also with moderately impaired cognition, stated he had not received any trust fund money and expressed a desire to receive it. There was further confusion regarding the power of attorney and who was authorized to receive and manage his personal funds. Facility staff interviews and record reviews revealed inconsistent practices in the management and distribution of residents' personal funds. Staff were unclear about the proper procedures for handling Social Security and pension disbursements, and residents were not consistently informed about their personal fund accounts or monthly disbursements. The facility's own policy required uniform guidelines for the protection of personal funds, but these were not followed, resulting in residents not receiving or being informed about their entitled funds.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential or actual accidents. Specific details regarding the nature of the hazards, the supervision provided, or the individuals affected are not included in the report.
Failure to Document Wound Measurements and Monitor Weekly Weights
Penalty
Summary
The facility failed to follow its own policies regarding the documentation of wound measurements and the monitoring of weights for a resident admitted with multiple complex medical conditions, including a stage 4 sacral pressure ulcer and severe protein-calorie malnutrition. Upon admission, the wound nurse measured the resident's wound but did not document the measurements, resulting in the absence of baseline data for the wound care team and physician to assess wound progression. The wound nurse practitioner confirmed that no initial wound measurements were available prior to his assessment several days after admission, which hindered the ability to monitor wound improvement or deterioration. Additionally, the facility did not adhere to its policy of obtaining a baseline weight upon admission and conducting weekly weights for the first four weeks. The resident's weights were only recorded on two occasions, missing several required weekly weigh-ins. Both the dietitian and assistant director of nursing acknowledged that these missed weights prevented accurate monitoring of the resident's nutritional status and timely intervention. The physician order sheet and facility policy both specified the need for weekly weights, which was not followed in this case.
Failure to Monitor Blood Glucose and Ensure Continuity of Diabetes Care
Penalty
Summary
A deficiency occurred when a resident with multiple complex diagnoses, including type 2 diabetes mellitus, was not provided with appropriate blood glucose monitoring and continuity of diabetes medication administration upon admission. The resident was admitted with orders for blood glucose monitoring and several diabetes medications, including insulin and oral agents. Despite these orders, there was only one documented blood sugar reading on the day of admission, with no further monitoring recorded until a week later. During this period, the resident received diabetes medications, including insulin and oral agents, without concurrent blood glucose monitoring as ordered. Interviews with nursing staff and facility leadership confirmed that blood glucose monitoring should have been performed according to physician orders, especially for residents receiving insulin. Staff acknowledged that monitoring is necessary to safely administer insulin and oral diabetes medications and to detect abnormal blood sugar levels that require intervention. The Director of Nursing and Assistant Director of Nursing both stated that the expectation is to follow physician orders for blood glucose checks and that such monitoring is critical for diabetic residents, particularly those on insulin therapy. Record review showed that the resident was administered diabetes medications, including Lantus Insulin Glargine and Empagliflozin, before blood glucose monitoring was initiated. Additionally, an ordered insulin (Semglee) was not administered due to a delay in pharmacy supply. The lack of blood glucose monitoring and incomplete medication administration represented a failure to provide appropriate care and management for the resident's diabetes as ordered and as required by facility policy.
Inadequate Fall Prevention and Supervision
Penalty
Summary
The facility failed to ensure accurate fall risk assessments and implement preventive interventions for two residents, leading to multiple falls and injuries. Resident 5, diagnosed with Alzheimer's disease and severe cognitive impairment, experienced several falls, including one resulting in an intracranial hemorrhage and traumatic head injury requiring staples. Despite being identified as at risk for falls, the resident's care plan was not updated following a significant fall incident, and interventions were not revised to prevent further falls. Resident 2, with a history of dementia and hemiplegia, also experienced multiple falls, including one that resulted in a head laceration requiring sutures. The resident's fall risk assessment was inaccurately scored, failing to account for hypotension and impaired memory, which would have indicated a higher risk. The care plan included interventions such as call light placement and regular rounding, but these were not effectively implemented, as evidenced by the call light being out of reach during an observation. The facility's management of falls policy requires comprehensive assessments and timely updates to care plans to address fall risks. However, the facility did not adhere to these protocols, resulting in inadequate supervision and failure to prevent accidents. The lack of appropriate interventions and supervision contributed to the residents' injuries and highlighted deficiencies in the facility's fall prevention practices.
Failure to Develop Comprehensive Care Plan for Abuse Risk
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident (R4) who was involved in an alleged abusive relationship with a Certified Nursing Assistant (V7). The State Agency received allegations of this intimate relationship, which was considered abuse. Despite R4 being admitted to the facility approximately 5.5 months prior, the comprehensive care plan received on 2/26/25 did not include a risk for abuse. During a surveyor's inquiry, the Assistant Director of Nursing (V3) confirmed that R4's care plan did not address the risk of abuse, and V3 was unsure if abuse should be included in care plans. The facility's policy from 11/2017 requires the interdisciplinary team to develop a person-centered comprehensive care plan within 7 days of the completion of the required comprehensive MDS, which should describe services to maintain the resident's well-being and identify responsible professional services.
Failure to Update Care Plans for Fall Risk and Behavioral Health
Penalty
Summary
The facility failed to follow its policy procedures and did not review or revise comprehensive care plans for two residents, leading to deficiencies in care. For one resident, the care plan for fall risk and behavioral health pass program had expired target dates, and the Assistant Director of Nursing (ADON) acknowledged that the care plans were not reviewed or revised as required. The ADON confirmed that the fall care plan should have been reviewed every three months, but it was not updated within the specified timeframe. Another resident experienced a fall resulting in a head injury, but the care plan was not updated to include preventive interventions or revisions following the incident. The ADON confirmed that the care plan was not updated to reflect the fall incident. The facility's policies require that care plans be revised based on changes in the resident's condition and at least quarterly, but these procedures were not followed, resulting in the deficiencies noted by the surveyor.
Untrained Staff Involvement in Resident Altercation
Penalty
Summary
The facility failed to adhere to its abuse policy for a resident who exhibited aggressive behavior. The resident, who has a history of difficulty managing anger and frustration, was involved in an incident where she became verbally and physically aggressive, throwing food and other items. During this episode, a housekeeper, who was not trained in Crisis Prevention Interventions (CPI), attempted to intervene physically, resulting in the resident falling to the floor. The incident began when the resident entered the dining room, cursing and throwing her food on the floor. Despite attempts by staff to deescalate the situation, the resident continued to act out, eventually grabbing a broom and swinging it at a social worker, breaking his glasses. The housekeeper, who was called to clean the floor, attempted to take the broom from the resident, leading to both the resident and the housekeeper ending up on the floor. The housekeeper's actions were outside his scope of duty, as he was not trained to handle aggressive residents and should not have physically engaged with the resident. The facility's abuse policy clearly states that residents should be protected from physical abuse, which includes controlling behavior through corporal punishment. The housekeeper's involvement in the physical altercation with the resident was a violation of this policy, even though the resident did not sustain any injuries.
Failure to Provide Adequate Nutritional Support
Penalty
Summary
The facility failed to implement and revise the care plan interventions necessary for a resident's nutritional support, leading to significant unplanned weight loss. The resident, a [AGE] year-old individual with multiple diagnoses including chronic obstructive pulmonary disease, dementia, and muscle weakness, was observed struggling to eat without adequate assistance from staff. Despite the resident's evident difficulty in maintaining a comfortable eating position and using utensils, no staff intervened to assist during meal times. The resident's weight log indicated a significant weight loss from 138 pounds in August to 119 pounds in October, with no hospitalizations to account for this change. The Clinical Nutrition Manager noted that the resident required setup assistance and encouragement during meals, yet documentation of the resident's food intake and assistance needs was inconsistent and incomplete. The resident's care plan did not include an assessment for the use of finger foods, which could have facilitated easier eating. Interviews with staff, including a Nurse Practitioner and a CNA, highlighted the need for 1:1 assistance and proper positioning during meals, which were not consistently provided. The facility's policy on comprehensive care plans emphasized the need for person-centered care, yet the resident's care plan lacked necessary updates and interventions to address the resident's nutritional needs effectively.
Failure to Provide Adaptive Eating Equipment and Assistance
Penalty
Summary
The facility failed to provide special eating equipment and appropriate assistance for a resident, identified as R3, who has a history of hemiplegia and hemiparesis following a cerebral infarction, dementia, and generalized muscle weakness. Observations on November 6, 2024, revealed that R3 was having difficulty using a spoon to eat independently in the dining room, often dropping food and resorting to using her left hand to grab food directly. Despite the resident's documented need for a plate guard to assist with eating, no such adaptive equipment was provided during the observed meal times. Additionally, staff did not offer assistance or ensure the resident's hands were clean before eating. Further investigation on November 7, 2024, showed that R3 was being fed by an LPN while lying in bed, again without the use of a plate guard as indicated on her dietary slip. The dietary supervisor confirmed that plate guards were on order but had not yet been received. R3's care plan and assessments documented the need for adaptive equipment and supervision during meals, yet these were not consistently provided. The facility's policy emphasizes the importance of providing appropriate treatment and services to maintain or improve residents' abilities, which was not adhered to in this case.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, as required by its policy and accepted professional standards. During a review of the resident's electronic health record, it was found that the most recent community survival assessment was not documented in the electronic health record prior to the surveyor's request. The assessment, which was completed on a previous date, was not signed until the day of the surveyor's inquiry. Additionally, there was a discrepancy between a handwritten assessment provided by the facility and the electronic assessment in the resident's record, with conflicting information regarding the resident's pass privileges. The Director of Behavioral Health acknowledged that the electronic assessment was completed inaccurately and instructed the Behavioral Health Counselor to complete a new form, resulting in a handwritten assessment. The electronic assessment indicated that the resident could not have unsupervised pass privileges, which conflicted with the physician's orders allowing unrestricted independent passes. Furthermore, the community survival skills assessment was past due, as it was completed more than a year after the previous assessment. The facility's policy requires comprehensive assessments to be conducted annually or upon significant change, but this was not adhered to in this case.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plans for residents with dementia who are at risk for falls. During an observation on the fourth floor, several residents were seen wearing smooth-bottomed socks instead of the required non-skid socks or shoes. Specifically, one resident was observed walking in the hallway and near the nursing station with red smooth-bottomed socks, while three other residents were seen in the day room with similar footwear. The Memory Care Director confirmed that these residents were supposed to wear non-skid socks, and a CNA acknowledged the need to change their socks. The records for the affected residents indicated that they were all assessed to be at risk for falls due to various factors such as poor safety awareness, impaired cognition, unsteady gait, and use of assistive devices. Their care plans specifically stated the need for proper, well-maintained, and non-skid footwear as a preventive measure against falls. The facility's Fall Management Program also emphasized the importance of using standard fall safety precautions for all residents. Despite these documented interventions, the facility did not ensure that the residents were wearing the appropriate footwear, thereby failing to adhere to the established fall prevention strategies.
Sanitation Deficiency in Community Shower Room
Penalty
Summary
The facility failed to maintain the large community shower room on the fourth floor East-Wing in a sanitary condition, as evidenced by a drain/sewer back-up. This issue was observed when a wet towel was found covering black liquid oozing from the drain. The Assistant Director of Nursing acknowledged the problem and mentioned that maintenance would be notified. However, the Maintenance logbook did not initially document the clogged drain issue. The Maintenance Director later confirmed being informed about the problem and attempted to clear the drain using a wire. The maintenance logbook was updated only after the surveyor's inquiry, indicating a lapse in the facility's maintenance request procedures.
Inadequate Pest Control Measures Lead to Persistent Bed Bug Infestation
Penalty
Summary
The facility failed to provide effective pest control for residents on the third floor, as evidenced by multiple reports of bed bug infestations affecting seven residents in a sample of ten. Residents reported bed bugs crawling on them, their beds, and privacy curtains, leading to multiple room changes. The facility's pest control measures were inadequate, as they only treated rooms where bed bugs were sighted, rather than conducting a comprehensive treatment of the affected area. This approach allowed the bed bug problem to persist since at least January 2024, with residents experiencing repeated infestations and embarrassment due to the need for room changes. Interviews with staff, including the administrator and a licensed practical nurse, confirmed the ongoing bed bug issue on the third floor. The administrator noted that corporate approval was required for extermination treatments, which limited the number of rooms treated at any given time. The pest control invoices reviewed indicated sporadic treatments of individual rooms, rather than a coordinated effort to address the infestation comprehensively. Additionally, the facility's bed bug protocol was not effectively implemented, as room changes were not documented in residents' clinical records, and the pest control contractor's inspections were limited to rooms with reported sightings.
Failure to Address Resident's Refusal for Critical Medical Appointment
Penalty
Summary
The facility failed to address a resident's refusal to attend a scheduled mammogram and ultrasound appointment, which was ordered on a STAT basis due to a highly suspicious mass found in a previous ultrasound. The resident, who has intact cognitive function, refused to attend the appointment out of fear that her breast would be removed. Despite this refusal, there was no documentation of any further attempts to reschedule the appointment until a later date, and the facility's records lacked evidence of timely communication with the physician regarding the resident's refusal. Interviews with facility staff revealed a lack of clarity and communication regarding the rescheduling of the appointment. The Clinical Director of Behavioral Health Services and the Licensed Practical Nurse were unsure if the appointment had been rescheduled, and the nurse practitioner was informed of the refusal but did not document it. The Director of Nursing was unaware of the STAT order and acknowledged that the documentation was late, indicating a failure in the facility's process for handling such critical appointments. The facility's documentation practices were found to be lacking, as there was no policy for documentation, and the nurse responsible for rescheduling the appointment did not document her actions. The resident's rights document indicated that the facility must make reasonable arrangements to meet the resident's needs and choices, which was not adhered to in this case. The deficiency highlights a failure in ensuring timely and appropriate care for the resident, as well as a breakdown in communication and documentation processes within the facility.
Failure to Administer and Document Medications
Penalty
Summary
The facility failed to administer medications as ordered by the physician and did not document the reasons for not administering these medications. This deficiency affected five residents who were reviewed for medication administration. During interviews, one resident reported that the nurse did not provide medications on several occasions, citing reasons such as computer issues, unavailability of medication, or inability to find keys. The Medication Administration Records (MAR) for these residents showed multiple missing entries without any chart codes or explanations for the missed doses. The Director of Nursing and Licensed Practical Nurses confirmed that MAR should not be left blank and that chart codes should be used to indicate reasons for missed medications, such as resident refusal or absence from the facility. However, the MARs for the residents in question had several blank entries, indicating that the medications were not given. The facility's policy requires medications to be administered according to the physician's written orders, but this was not adhered to, leading to the deficiency.
Failure to Ensure Safe Environment for Resident
Penalty
Summary
The facility failed to ensure a safe environment free from accidents and hazards for a resident, resulting in the resident falling and sustaining a fracture of the second left finger. The resident, who has a history of falls and multiple medical conditions including end-stage renal disease, hemiplegia, and type 2 diabetes, was observed sitting at the edge of her bed in incontinence underwear, struggling to get dressed and find her call light. The resident reported that she had not been checked on by staff since returning from the hospital that morning and was very hungry. The call light was found to be out of reach, and the resident's bed was not in a low position, which is a necessary intervention for fall risk residents. The Certified Nursing Assistant (CNA) who assisted the resident back to bed after her return from the hospital admitted to not checking on the resident again or ensuring the call light was within reach. The CNA also confirmed that the resident's bed could not be lowered, which is contrary to the facility's policy for fall risk residents. The Assistant Director of Nursing (ADON) acknowledged that the resident had multiple falls in the past year and should have had interventions such as a low bed, floor mats, and a call light within reach. The Licensed Practical Nurse (LPN) also admitted to not checking on the resident after her initial assessment and not ensuring the bed was in a low position or the call light was accessible. The Maintenance Director confirmed that the bed model used for the resident could not be adjusted for height and did not have half rails to assist the resident in getting in and out of bed. The Assistant Administrator swapped the resident's bed with her roommate's bed, which could be lowered, after the surveyor's observation. The Nurse Practitioner emphasized the importance of having floor mats, a call light within reach, and a bed in a low position for the resident due to her high risk of falls and fractures. The facility's policy on fall management was not followed, leading to the resident's fall and subsequent injury.
Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety and sanitation. During a kitchen observation, a cook was seen without a hair net while preparing food, and expired food items were found in the main fridge and freezer. Specifically, the surveyor observed expired potato salad, chicken base, magic cup, Worcestershire sauce, mayonnaise cole-slaw dressing, and grits. Additionally, there were opened food items without proper labeling, such as vanilla ice-cream in a damaged container and an opened red-hot bottle without an open or expiration date. The facility's policy requires that all food products with pre-printed manufacturer date labels be discarded by the noted date, and any opened food should be labeled with the date and time it was placed in the refrigerator. The failure to adhere to these policies was evident during the surveyor's inspection. Furthermore, the facility did not follow the recommended portion size for the menu and failed to utilize measuring utensils when mixing ingredients. A cook was observed preparing fortified pudding by mixing ingredients without using any measuring utensils, relying instead on visual estimation. This practice deviated from the US Foods Management System production recipe for fortified pudding, which specifies precise measurements for ingredients. The dietary manager confirmed that all staff should follow protocol when preparing meals and mixing ingredients, and that expired foods should be discarded immediately. The failure to follow these protocols has the potential to affect all 180 residents in the facility.
Inadequate Staffing on Second Floor
Penalty
Summary
The facility failed to provide adequate staffing for one out of four floors, specifically the second floor, which affects all residents residing there. On multiple occasions, the second floor was understaffed, with fewer aides than required. For instance, on several Sundays and Saturdays between October 2023 and December 2023, the second floor had only three or four aides instead of the required six for various shifts. This pattern of understaffing was confirmed through interviews and record reviews, including statements from the Staffing Coordinator, who acknowledged the staffing issues and the efforts made to cover call-offs and holidays. The deficiency was highlighted by the facility triggering with CMS for excessively low weekend staffing. The Staffing Coordinator detailed the usual staffing levels, which include five nurses per shift and a varying number of aides based on floor acuity and census. Despite these efforts, the second floor, which has the highest acuity, consistently fell short of the required staffing levels, leading to the identified deficiency. The report does not mention any specific residents' medical history or conditions at the time of the deficiency but emphasizes the overall impact on the second floor residents due to inadequate staffing.
Failure to Administer Medications Timely
Penalty
Summary
The facility failed to administer residents' prescribed medications in a timely manner according to physician orders. On 05/28/2024, a registered nurse (V3) arrived late for her shift, starting at approximately 8:20 AM instead of the scheduled 7:00 AM. Consequently, V3 began administering medications at around 9:00 AM, which was beyond the acceptable time frame for timely medication administration. The facility's electronic medication administration record (eMAR) indicated that medications for twelve residents were administered late, as the eMAR turned red to signify the delay. The facility's policy mandates that medications should be administered within one hour of the prescribed time, which was not adhered to in this instance. The Assistant Director of Nursing (V23) confirmed that the protocol for such situations involves the unit supervisor or another nurse from the previous shift administering medications until the scheduled nurse arrives. However, it was unclear who was responsible for administering medications on the first floor until V3 arrived. The medication administration audit report and time clock punches corroborated that V3 and another nurse (V22) were late in administering medications to the affected residents. This lapse in protocol and timely medication administration affected twelve residents in the facility.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure that multi-use blood pressure cuff devices and pulse oximeters were properly cleaned and disinfected between resident use. Observations revealed that staff members did not clean or disinfect these devices after using them on multiple residents, including R12, R20, R27, R29, R83, R98, R124, R126, R159, and R161. This failure was noted during medication administration observations on different floors of the facility. Staff members placed the used devices back on the medication cart without cleaning them, which was confirmed by the Assistant Director of Nursing (ADON) and Infection Preventionist, who acknowledged the potential for the spread of germs and infections due to this oversight. The facility also failed to ensure that staff followed proper hand hygiene protocols while performing peri-care. During an observation, a Certified Nursing Assistant (CNA) did not change gloves or perform hand hygiene after cleaning a resident's peri-area and before applying a new brief. The CNA admitted that she was not informed about the necessity of changing gloves after such procedures. The facility's policy on perineal care and hand hygiene clearly states the importance of removing gloves and washing hands to prevent infection and odor. Additionally, the facility did not post a contact isolation precaution sign for a resident identified as having a physician order for contact isolation precautions. The resident, who had diagnoses including chronic osteomyelitis, pressure ulcers, urinary tract infection, sepsis, and pericarditis, was observed without the required contact isolation sign outside his room. Staff members provided conflicting information about the resident's isolation status, and it was noted that sometimes staff did not wear gowns when entering the resident's room. The facility's infection prevention and control manual mandates the use of appropriate personal protective equipment (PPE) and the posting of a CDC contact precaution sign for residents on contact isolation.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call light devices were within reach for two residents, R14 and R17, which placed them at risk of not being able to call for help if needed. On 05/28/24, the surveyor observed R17 in bed with limited movement in her right arm due to a history of strokes. The call light was placed under her right arm, making it difficult for her to reach it with her left hand. R17 confirmed that she often could not reach her call light due to a lack of strength. Similarly, on the same day, the surveyor observed R14's call light hanging from the right side of his bed's side rail, which he could not reach due to a right arm contracture. R14 confirmed his inability to reach the call light when questioned by the surveyor. The facility's Licensed Practical Nurse (LPN) acknowledged the importance of having call lights within residents' reach to ensure they can call for assistance in emergencies. R17's medical records indicate she is a cognitively intact female with a history of hemiplegia, hemiparesis following cerebral infarction, generalized anxiety disorder, and muscle weakness. R14's records show he is a male with moderately impaired cognition, muscle contracture, and generalized muscle weakness. The facility's policy, dated 9/20, mandates that call lights be placed within residents' reach at all times, which was not adhered to in these cases.
Failure to Refer Residents with Serious Mental Disorders for Review
Penalty
Summary
The facility failed to refer two residents with newly evident or possible serious mental disorders to the appropriate state-designated authority for review. This deficiency affected two residents, one of whom was diagnosed with bipolar disorder and the other with major depressive disorder, psychosis, and schizophrenia. The first resident, a man diagnosed with bipolar disorder, was admitted to the facility with an initial OBRA screen indicating no reasonable basis for suspecting mental illness. However, he was later diagnosed with bipolar disorder, and the facility did not initiate a new screening as required. The psychosocial coordinator acknowledged that due to staff turnover and vacancies, the necessary screenings might not have been conducted, despite quarterly assessments prompting for changes in resident diagnoses. The second resident had diagnoses including major depressive disorder, psychosis, and schizophrenia, which are considered serious mental illnesses. Despite these diagnoses, the initial PASRR Level I screen indicated no need for a Level II screening. The resident was readmitted to the facility after a hospital stay, and it appears that the necessary diagnoses were not updated in the Maximus system. The psychosocial coordinator confirmed that the facility did not notice the discrepancy between the screening and the resident's records until much later, prompting a new Level I screening. The facility's policy mandates that residents be screened for severe mental illness or developmental disabilities prior to admission and upon any changes in status, which was not adhered to in these cases.
Failure to Provide Regular Showers to Resident
Penalty
Summary
The facility failed to provide showers to a resident who is unable to maintain good personal hygiene. This deficiency affected a [AGE] year-old female resident with multiple medical diagnoses, including stage four pressure ulcer of the sacral region, stage three pressure ulcers of the right heel and other sites, dementia, Alzheimer's disease, high blood pressure, visual disturbance, and wasting syndrome. The resident's Minimum Data Set (MDS) indicated that she was not alert and required substantial/maximal assistance with showers and bathing. The resident's care plan noted a functional performance deficit in activities of daily living (ADL) and required staff assistance with personal hygiene. However, documentation revealed that the resident did not receive a shower for two weeks in May 2024, with the last recorded shower on May 1, 2024, and the next on May 15, 2024. The Assistant Director of Nursing confirmed that residents are supposed to be showered once a week and as needed, and if a shower is not documented, it was not done.
Failure to Document Catheter Changes
Penalty
Summary
The facility failed to document catheter changes for a resident requiring an indwelling catheter. The resident, a [AGE] year-old female with multiple diagnoses including stage four pressure ulcer, dementia, and Alzheimer's disease, was observed with a very dark urine and old, discolored catheter tubing containing dark sediment. Despite the facility's protocol to change catheters weekly and as needed, there was no documentation of any catheter change from the resident's admission in March 2024 until the end of May 2024. Interviews with nursing staff revealed that catheter changes should be documented in progress notes, but a review of the resident's progress notes showed no such documentation. The Assistant Director of Nursing confirmed that nurses are expected to follow physician orders, change visibly dirty catheters, notify the physician, and document the change and the resident's condition. However, the resident's care plan did not include any information about the catheter, its necessity, or the required care to prevent urinary tract infections.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the resident's physician for one resident. On the morning of 05/28/2024, a surveyor observed a registered nurse (V3) unable to locate the resident's medications in the medication carts. The nurse then contacted the facility's contracted pharmacy, which revealed that the resident's medications had not been shipped due to a loss of insurance. The pharmacy had previously notified the facility about the insurance issue via fax on multiple occasions, but the facility had not responded until the surveyor's visit on 05/28/2024. The resident, identified as R83, was admitted with diagnoses including acute chronic systolic heart failure, atrial fibrillation, pulmonary hypertension, and type 2 diabetes mellitus. The resident's physician had prescribed several medications, including Amiodarone, Apixaban, Empagliflozin, and Spironolactone, which were not available in the facility's emergency medication convenience box. The resident's medication administration record indicated that the nursing staff had been documenting the administration of these medications, despite their unavailability. The facility's policy on medication administration requires that medications be administered safely as prescribed and that the physician be notified if an order cannot be followed. However, the facility failed to adhere to this policy, resulting in the resident not receiving the prescribed medications for an extended period. The progress notes documented by the nurse on 05/28/2024 indicated that the issue was being addressed, but the deficiency had already occurred due to the facility's inaction in responding to the pharmacy's notifications and ensuring the resident's medications were available and administered as ordered.
Failure to Discard Expired Medications
Penalty
Summary
The facility failed to follow its policy to ensure that medications that are outdated are immediately removed or disposed of. This deficiency was observed for two residents out of three reviewed for medication storage and labeling. On the 3rd floor, a surveyor observed an expired budesonide formoterol fumarate dihydrate inhaler for a resident on cart #1, which had an expiration date of 5/13/2024. The LPN managing the cart confirmed that the medication was expired and should have been discarded. Similarly, on the 4th floor, the surveyor found an expired insulin Lispro pen injector and an expired Fluticasone Advair inhaler for another resident on cart #2. The LPN managing this cart also confirmed that these medications were expired and should have been discarded. The Associate Director of Nursing stated that weekly cart audits are conducted to ensure that medications are within their proper expiration dates and to reorder any necessary medications. The facility's policy requires that medications be labeled with the date they are first given and their expiration date, and that expired medications be immediately removed for the safety of the residents. Despite these procedures, the expired medications were not discarded as required, posing a potential risk to the residents' safety.
Failure to Provide Meal to Resident Returning from Hospital
Penalty
Summary
The facility failed to provide a meal to one resident (R85) who had returned from the hospital, resulting in the resident experiencing hunger. R85, a [AGE] year-old individual with multiple medical conditions including end-stage renal disease, hemiplegia, and type 2 diabetes mellitus, was observed in her room at 11:35 am, stating she was very hungry and had not been offered food since her return from the hospital earlier that morning. R85 was found struggling to get dressed and locate her call light, which was out of her reach. The Certified Nursing Assistant (CNA) who assisted the paramedics in transferring R85 to bed did not check on her or offer her food after the initial transfer. The Licensed Practical Nurse (LPN) also failed to check on R85 after the initial assessment and did not ensure the call light was within reach or offer food, despite knowing that breakfast time had ended and snacks were available in the kitchen. The Assistant Director of Nursing (ADON) confirmed that the nursing staff should have asked R85 if she was hungry and provided a meal, even if breakfast was over. The facility's policy on food substitutes and the always available menu, which includes items like grilled cheese and hamburgers, was not followed. This oversight led to R85 experiencing hunger and being unable to communicate her needs due to the call light being out of reach and the lack of staff follow-up after her return from the hospital.
Inadequate Fall Prevention and Supervision in LTC Facility
Penalty
Summary
The facility failed to ensure adequate fall prevention measures and supervision for three residents, leading to a significant incident involving one resident. This resident, diagnosed with dementia and hemiplegia, was at high risk for falls as indicated by their fall risk assessment. Despite this, the facility did not implement effective interventions after previous falls, resulting in the resident sustaining a fall that caused a laceration requiring sutures. The care plan was not adequately updated to prevent further incidents, and staff were not fully aware of the necessary interventions. Another resident, with vascular dementia and a history of falls, was also inadequately protected. The resident's care plan included interventions such as keeping the bed in the lowest position and using floor mats. However, during the survey, it was observed that only one floor mat was in place, despite the bed not being against a wall, which could have prevented falls from either side. The staff's understanding of the resident's fall prevention measures was incomplete, as they failed to mention the use of floor mats. A third resident, with cognitive impairments and a history of falls, was found on the floor after an unwitnessed fall. The care plan included the use of floor mats, but supervision was not mentioned as an intervention. Staff were unable to locate the resident's fall prevention interventions in the communication book, indicating a lack of proper documentation and communication regarding fall prevention strategies. This lack of awareness and implementation of fall prevention measures contributed to the residents' falls and injuries.
Failure to Revise Care Plans for Fall Prevention
Penalty
Summary
The facility failed to revise care plans with appropriate interventions for three residents who were reviewed for falls. For the first resident, the care plan noted a risk for falls and included an intervention to send the resident to the hospital for evaluation and treatment after a fall. However, this intervention did not address the prevention of future falls. The resident had fallen while receiving ADL care and sustained a head injury. The restorative nurse confirmed that sending the resident to the hospital would not prevent additional falls. The second resident's care plan identified risks related to muscle weakness, poor balance, poor safety awareness, and visual impairment. After an unwitnessed fall, the intervention added was the use of floor mats while in bed, but supervision was not included despite the resident's cognitive impairments. The third resident, diagnosed with vascular dementia and unsteadiness, had a care plan intervention to keep the bed in the lowest position and use a floor mat on one side of the bed. However, the resident could fall from either side as neither side of the bed was against the wall, and the intervention did not adequately address the risk of falls.
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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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