Alta Rehab At Fairmont
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 5061 North Pulaski Road, Chicago, Illinois 60630
- CMS Provider Number
- 145867
- Inspections on file
- 42
- Latest survey
- April 6, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Alta Rehab At Fairmont during CMS and state inspections, most recent first.
A resident dependent on staff for toileting hygiene, with moderately impaired cognition, experienced a prolonged delay in incontinence care after a bowel movement, becoming tearful and expressing upset and frustration while waiting in a soiled brief for about an hour before a CNA arrived to provide care. In addition, two residents dependent on staff for ADLs and personal hygiene were observed with unkempt facial hair and debris: one male resident had a full beard and mustache with food-like debris covering his mouth and eyes filled with a wet, green substance, and another female resident had noticeable facial hair on her upper and lower lips and chin, stated she looked ugly, and agreed to shaving. Nursing staff acknowledged these conditions and indicated they had reported grooming needs or recognized that the residents needed to be shaved, but the care was not provided in a timely manner, contrary to facility policies on bathing, incontinence care, and shaving.
Two cognitively intact residents with flaccid extremities and contractures did not receive ordered restorative ROM and related services. One resident reported never receiving exercise assistance and not receiving needed adaptive feeding utensils despite therapy and IDT recommendations for AROM, PROM, bed mobility, and adaptive equipment. Another resident reported inconsistent application of an arm splint and no ROM exercises, despite documented recommendations and care plan directives for PROM and bed mobility. The Restorative RN acknowledged there was no set schedule for restorative services, was unaware of one resident’s need for adaptive utensils, and reported there was no QA process to monitor the restorative program, while a restorative aide assigned to both residents could not recall the last time PROM was provided.
Multiple residents with sleep apnea and complex respiratory conditions had physician orders for nightly CPAP/BiPAP that were not consistently followed or documented, and there was no documentation that masks, tubing, and exhalation ports were cleaned daily as required by facility policy. One resident with acute and chronic respiratory failure and morbid obesity reported not receiving BiPAP the first night after admission and was later found very sleepy with increased respirations and transferred to the hospital for acute respiratory failure and altered mental status, while the record lacked evidence that BiPAP was applied at bedtime as ordered. Other residents reported intermittent CPAP/BiPAP use and one stated the device had not been cleaned for months, and review of MARs, TARs, and notes for all affected residents showed no entries indicating daily cleaning of the CPAP/BiPAP equipment, despite the DON’s expectation that such care be performed and documented.
A resident with diabetes and cardiac conditions did not receive scheduled blood glucose checks or insulin administration as ordered, with the RN failing to provide morning medications or perform required monitoring. The omission was confirmed through observation, interviews, and documentation, and facility policy requires timely administration of such medications.
Surveyors found that kitchen staff did not consistently label or dispose of food items according to facility policy, with some salads and thickened water lacking proper dates or being kept beyond the recommended time. Staff confirmed that labeling and timely disposal are required for resident safety, and at least one resident required specialized thickened liquids.
Surveyors found that staff did not date opened multi-dose insulin for three residents and failed to store unopened Latanoprost eye drops at the required refrigerated temperature for two residents. Insulin pens and vials were observed without open dates, and eye drops requiring refrigeration were kept at room temperature, contrary to pharmacy labeling and facility policy. Nursing staff and the DON confirmed the need for proper dating and storage, and facility policies outlined these requirements.
Staff failed to perform hand hygiene and properly use PPE during direct care activities, including medication administration and ADL care, for several residents. The same blood pressure device was used on multiple residents without cleaning, and reusable equipment was not sanitized between uses. Staff did not follow Enhanced Barrier Precaution protocols, such as wearing gowns and gloves during high-contact care, and the facility lacked a policy for cleaning reusable medical equipment.
A resident with severe cognitive impairment returned from a hospital visit still wearing a wristband that displayed personal information, including name, age, date of birth, and gender. Staff acknowledged that the wristband should have been removed to protect the resident's privacy, as its continued presence exposed sensitive information in violation of privacy policies.
A resident with intact cognition was found with Tamsulosin capsules left at the bedside without a physician order, assessment, or care plan for self-administration. The DON and LPN confirmed that medications should not be left at the bedside and that self-administration requires formal assessment and authorization, which was not present in this case.
A resident's Quarterly MDS assessment was not completed within the required 14-day timeframe from the Assessment Reference Date, as confirmed by the MDS/Care Plan Coordinator and facility records. This resulted in a late submission to CMS, contrary to regulatory requirements.
A resident with GERD and dyspepsia consistently ate meals while lying down, despite posted instructions to sit upright and repeated staff education about choking risks. Staff were aware of the resident's preference but did not communicate it to management or update the care plan to reflect this behavior, resulting in the absence of a person-centered care plan addressing the resident's eating position.
A resident with dementia and dysphagia was observed eating lunch in bed with the head of the bed at about 30 degrees, rather than upright as required by their care plan. Staff acknowledged the resident should have been repositioned to prevent aspiration, but the CNA placed the meal tray without doing so. The facility lacked policies for aspiration precautions and feeding setup in bed, contributing to the deficiency.
A resident with dysphagia and other chronic conditions was not provided with the required one-to-one feeding assistance during a meal, despite clear orders, care plan documentation, and posted signage indicating strict aspiration precautions. The resident was observed eating independently without staff present, and facility leadership confirmed there were no policies in place for aspiration precautions or ADL care.
Two residents were affected when staff failed to follow protocols for midline catheter care and aspiration precautions. One resident did not receive required midline dressing changes, measurements, or maintenance flushes, and lacked a care plan for midline use. Another resident with a strict 'no straws' order due to aspiration risk was found with a straw accessible at bedside, and staff did not promptly remove it. The facility also lacked a policy for aspiration precautions.
Two residents with dementia and a history of falls were observed with their beds not in the lowest position, contrary to their care plans and facility policy. Staff interviews confirmed that the beds should have been kept low as a fall precaution, but this intervention was not in place at the time of observation.
A resident with a gastrostomy tube and complex medical needs, including dialysis and heart failure, received water flushes at a rate higher than the most recent physician order. Despite updated orders to reduce the volume and frequency of water flushes, staff continued to administer the previous regimen, as confirmed by observations and staff interviews.
Two residents did not receive oxygen therapy as ordered by their physicians: one had a nasal cannula not applied while the oxygen concentrator was running, and another received a higher oxygen flow rate than prescribed. Staff confirmed the discrepancies between the physician orders and the care provided, and both residents had significant respiratory and cognitive conditions requiring staff assistance.
Two residents were found using bed side rails without current risk assessments, care plans, or documented informed consent, despite facility policy requiring these steps. Staff confirmed that side rail use should be addressed in the care plan and regularly reviewed, but this was not done for either resident.
Surveyors observed a medication error rate of 34.29% during medication administration, with multiple errors involving wrong doses, incorrect timing, and omission of medications by LPNs. Errors included giving the wrong dose of cough and iron medications, administering blood pressure and diabetes medications at the wrong times, and failing to give a prescribed diuretic. The DON confirmed that staff are expected to follow a two-hour window and the '5 rights' of medication administration, but these protocols were not followed during the observed medication passes.
A resident with complex medical needs was discharged without receiving a completed Discharge Instruction, as required. Only the initial sections of the Discharge Assessment were filled out by social services, while nursing failed to complete and provide critical sections covering medications, diet, and follow-up care. The discharge paperwork was not printed, signed, or uploaded to the EHR, resulting in the resident and family not receiving necessary instructions for post-discharge care.
A resident with multiple pressure ulcers was readmitted with documented wounds, but necessary wound care orders were not entered on the Physician Order Sheet, and prescribed treatments were not consistently performed or documented. Nursing staff interviews confirmed that wound care was not initiated as required, and missing signatures on the Treatment Administration Record indicated treatments were not completed, resulting in a failure to provide necessary care for the resident's pressure ulcers.
A resident with significant physical frailty was physically pushed multiple times onto a bed by a larger, cognitively intact roommate during a verbal altercation. Staff present attempted to intervene but were unable to prevent the physical abuse. The aggressor had a documented history of agitation and prior incidents of threatening behavior. Facility policy prohibits abuse, but the measures in place did not prevent this incident.
The facility failed to follow its infection control program, particularly in managing isolation for two residents with infectious diseases. Observations showed improper PPE use and disposal, with clear plastic liners used instead of red biohazard bags. Additionally, isolation signage was inaccurate, and staff were not consistently aware of the correct protocols, potentially affecting all 153 residents.
The facility failed to maintain an effective pest control program, with residents reporting mice and roaches in their rooms. Despite evidence of pests, the facility's pest control measures were inadequate, focusing only on common areas and not resident rooms. The maintenance director admitted to incomplete documentation and follow-up on pest sightings, and an inspection revealed improperly set bait stations and large openings in ceiling tiles, indicating a lack of thoroughness in addressing pest issues.
The facility failed to maintain a clean and homelike environment, as a resident was observed urinating and defecating on the floor and bed, causing distress to roommates. Despite being moved to a room with a bathroom, the resident continued these behaviors, and staff were aware but ineffective in addressing the issue. The room had damaged walls, a loud bathroom fan, and multiple soiled urinals, violating residents' rights to a safe and comfortable environment.
A facility failed to protect residents from physical abuse during an altercation between two residents, resulting in injuries. One resident, with a history of bipolar disorder and osteoporosis, reported a thumb injury, while the other, with anxiety and depression, sustained scratches. Conflicting accounts from the residents led to an inconclusive investigation by the facility staff.
A resident with limited mobility and high fall risk fell from bed, sustaining a femur fracture and forehead hematoma, due to inadequate supervision and failure to follow care plan protocols. The CNA repositioned the resident alone, contrary to the requirement for two-person assistance, and was unaware of the resident's fall risk status.
A facility failed to update a resident's family on a grievance regarding insulin ordering issues, despite being aware of the problem. The resident was uncertain about insulin monitoring, and the family was charged for unused insulin. The DON and MDS Coordinator acknowledged the issue, but it was not addressed in a care plan meeting. The resident's Financial Power of Attorney was not informed about the meeting or the grievance resolution, violating the facility's grievance policy.
A resident developed facility-acquired deep tissue injuries (DTIs) on her ankles after staff left her legs crossed for an extended period. Despite having a care plan for skin breakdown prevention, the facility failed to implement necessary interventions, resulting in pressure ulcers. The resident, who was cognitively intact, reported the incident, and the wound care team confirmed the DTIs.
Two residents experienced significant weight loss due to the facility's failure to document monthly weights, consider dietary preferences, and provide adequate meal options. One resident lost 7.1% of their weight in one month, while another lost 11.6% over six months. Despite being on supplements, both residents frequently refused them, and their dietary preferences were not included in assessments.
The facility failed to provide necessary mobility devices, such as wheelchairs, for two residents who required them for transfer assistance. Despite care plans indicating the need for wheelchairs, the Kardexes did not include this information, and staff were unaware of the requirement. The facility also lacked a policy on accommodating resident needs, contributing to the deficiency.
The facility failed to include the potential for abuse or neglect in the care plans of several residents, despite policy requirements. The Care Plan Coordinator acknowledged that these plans were not developed unless residents verbalized concerns, even though all residents are at risk.
The facility failed to follow its menu and emergency planning procedures after the kitchen was closed due to health violations, affecting 155 residents. Meals from a sister facility did not match the posted menu, and no revised menu was provided. The facility lacked a specific emergency plan for kitchen closure, and the menu was not accessible to residents and families as required.
The facility failed to manage a suspected scabies outbreak effectively, as it did not follow its infection control policies, including posting signs, completing infection logs, and performing necessary skin tests. Residents with rashes were not isolated, and treatments were inconsistently administered, potentially affecting all 153 residents.
Two residents in a LTC facility were found to be involuntarily secluded due to inadequate transfer assistance and lack of wheelchairs. Despite their dependence on staff for transfers and expressed desire to get out of bed, the facility failed to provide necessary equipment and assistance, resulting in confinement to bed. Documentation inconsistencies further indicated prolonged periods of seclusion.
A facility failed to properly schedule and prepare a resident for a colonoscopy, ordered due to significant weight loss. The procedure was delayed due to transportation issues and inadequate preparation, with no policies in place for scheduling or transportation. The resident did not receive necessary bowel prep or dietary orders, and the facility lacked documentation of appointments and results.
The facility failed to post and maintain daily nursing staffing information, affecting all 160 residents. The Lead Receptionist and Staffing Coordinator were unaware of the requirements, leading to a lack of posted staffing sheets and improper record-keeping. The last recorded staffing sheet was from February, and the Director of Nursing confirmed the need for daily postings and retention of records.
The facility failed to properly label and date food items in the kitchen, potentially affecting 157 residents on an oral diet. Observations revealed opened bags of corn and chocolate chips without dates, peas with freezer burn, and expired peach cobbler. The Dietary Cook and Supervisor acknowledged the importance of labeling to prevent illness. Facility policies require proper dating and storage of food items.
The facility failed to ensure dumpster lids were closed, potentially affecting all 160 residents. Observations revealed open dumpster lids, and staff interviews confirmed the importance of keeping them closed to prevent rodent infestation and maintain infection control. Facility policies and job descriptions emphasize maintaining a clean and sanitary environment.
The facility failed to properly store oxygen tanks and discard a lancet, affecting two residents. An unsecured oxygen cylinder was found in a resident's room, posing a potential hazard, while a lancet was left on another resident's bedside drawer, risking injury. Both incidents were confirmed by staff, highlighting non-compliance with facility policies on oxygen safety and medical waste disposal.
The facility failed to follow its policy for changing nebulizer tubing and storing nasal cannulas, affecting several residents. Observations showed outdated nebulizer tubing and nasal cannulas left uncovered or on the floor, risking contamination. Staff were unaware of the replacement schedule, and the facility's infection control practices were not consistently applied.
The facility failed to manage medications properly, with expired medications found in storage and loose pills in medication carts. A resident's expired Rosuvastatin was not discarded, and nurses were unable to identify loose pills, risking medication errors. The deficiencies affected one resident directly and potentially impacted all residents assigned to the medication carts and storage room.
The facility failed to properly log refrigerator temperatures and maintain freezers for residents' personal refrigerators, affecting multiple residents. Observations revealed missing temperature log entries and ice buildup in freezers, indicating a lack of daily monitoring and maintenance. Interviews with residents and staff confirmed inconsistent temperature checks and unclear defrosting procedures, posing a potential health risk due to spoiled food.
The facility failed to update a resident's isolation status, leading to potential infection control issues. A resident with MRSA and C. diff had outdated isolation orders, despite completing antibiotics. Additionally, a clean linen cart was improperly brought into a resident's room, risking contamination. Staff also failed to follow hand hygiene and PPE protocols, as observed during care activities.
The facility failed to secure a handrail in Unit 2B, potentially affecting all residents in the unit. A CNA confirmed the handrail had been unsecured for a long time, and the Maintenance Director was unaware of the issue. The DON emphasized the importance of fixed handrails for resident safety, as residents rely on them for support. An email from the Administrator highlighted the need to ensure all handrails are properly secured.
The facility failed to maintain the dignity of two residents by not covering their indwelling catheter drainage bags. One resident with neurogenic bladder had an exposed urinary drainage bag, despite the presence of a privacy bag. An LPN confirmed the expectation to use privacy bags. Another resident's catheter bag was also left uncovered, facing the door, until an LPN placed it in a privacy bag. The facility's policy emphasizes covering catheter bags to uphold resident dignity.
A facility failed to maintain the privacy of electronic health records when an LPN left a resident's medication administration record open and unattended on a laptop. The DON confirmed that staff are expected to close or minimize the screen when leaving the computer to prevent unauthorized access, in compliance with HIPAA.
Two residents experienced deficiencies in their living environment, with one unable to close their bathroom door for privacy and another having a stained ceiling and damaged floor tiles. An LPN and the Maintenance Director confirmed these issues, acknowledging the need for repairs to ensure safety and privacy.
A facility failed to conduct a new PASARR assessment for a resident diagnosed with schizoaffective disorder and major depression after admission. The Social Services Director confirmed the oversight, noting that the admissions and social services departments are responsible for ensuring PASARR assessments are completed when new psychiatric diagnoses occur. Despite the facility's policy requiring such assessments, none were conducted following the resident's new diagnoses.
The facility failed to provide adequate ADL care for two residents, compromising their personal hygiene. One resident with cognitive impairment did not receive timely incontinence care, resulting in a wet bed and worn pad. Another resident with diabetes had unclean fingernails with food debris, despite expressing a desire for nail care. Facility policies requiring regular care were not followed, leading to these deficiencies.
Failure to Provide Timely Incontinence and Personal Hygiene Care
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and personal hygiene/ADL care to three dependent residents. One resident, who was dependent on staff for toileting hygiene and had moderately impaired cognition (BIMS score of 8), was observed in bed upset and tearful, stating she needed to be changed after a bowel movement and could not remember the last time she had been changed. She reported having to wait so long for incontinence care that she sometimes ripped off her brief and expressed fear of getting bed sores and a desire to leave the facility. At 10:45 a.m., an RN said she would inform a CNA to clean the resident once the CNA finished helping another resident, but the CNA did not enter the room to provide incontinence care until 11:40 a.m. The CNA later stated she had informed the DON that she needed help with residents on her team and was told there was nothing the DON could do. The ADON stated it was not acceptable for a resident to wait one hour to be changed and that residents should not wait more than 10–15 minutes. The facility also failed to provide timely ADL care related to shaving and facial hygiene for two other dependent residents. One resident, dependent on staff for all personal hygiene including shaving, was observed lying in bed with eyes closed and filled with a wet, green substance, and with a full beard and mustache covering his mouth and containing debris that appeared to be food; an RN stated she had told the ADON that this resident needed a shave. Another resident, cognitively intact with an ADL self-care/mobility performance deficit, was observed in bed with unkempt facial hair above and below her lips and on her chin; when asked if she wanted to be shaved, she replied that she did and stated she looked ugly. An RN described this resident’s facial hair as unkempt and said she definitely needed to be shaved. Facility policies on bathing, incontinence care, and shaving state purposes of ensuring cleanliness, proper hygiene, comfort, dignity, and improved morale, which were not followed in these instances.
Failure to Provide Ordered Restorative ROM Services and Adaptive Equipment
Penalty
Summary
The facility failed to provide restorative services to maintain or improve range of motion and mobility for two cognitively intact residents with significant physical impairments. One resident had flaccid legs and contracted hands and reported never receiving exercise assistance and not receiving promised adaptive feeding utensils needed to feed herself due to stiff fingers. Another resident with flaccid legs and right arm reported that staff applied an arm splint only sometimes and that no one exercised his legs or arms. During observation, neither resident had splints or adaptive equipment in place. Both residents had documented therapy-to-nursing recommendations and restorative observations indicating they would benefit from PROM, AROM, and bed mobility exercises, and their care plans called for regular ROM and bed mobility interventions several times per week. The Restorative RN stated she was the only restorative nurse with seven restorative aides, that there was no set schedule of residents to see daily, and that she did not know one resident needed assistance with feeding or adaptive utensils despite having assessed the resident. She also stated there was no QA program to monitor the restorative program, and that residents on restorative programs should exercise three to six times per week. A restorative aide assigned to both residents could not recall the last time she performed PROM with either resident. The facility’s written Restorative Nursing Program policy stated its purpose was to promote each resident’s ability to maintain or regain the highest degree of independence as safely as possible, but the documented recommendations and care plan interventions for ROM, bed mobility, and adaptive equipment were not being consistently implemented for the two residents.
Failure to Follow CPAP/BiPAP Orders and Perform Required Daily Equipment Cleaning
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for BiPAP/CPAP use and to ensure daily cleaning of BiPAP/CPAP equipment for multiple residents with sleep apnea and complex respiratory conditions. One resident with acute and chronic respiratory failure, morbid obesity (BMI ≥70), obstructive sleep apnea, and chronic heart failure was admitted with an order for BiPAP via full mask at bedtime. The admission summary and physician documentation confirmed that this resident was to receive BiPAP nightly. The resident reported that on the first night after admission he did not receive BiPAP, only oxygen via nasal cannula, and that he subsequently "passed out" and was transferred to the hospital the following morning. The clinical record for that night did not show documentation that BiPAP was applied at bedtime as ordered. Nursing staff interviews were inconsistent: the admitting RN stated BiPAP should have been documented on the MAR/TAR if given, and the night RN later stated she did not place the BiPAP mask until after 1:00 a.m., removed it around 4:00 a.m., then briefly reapplied it around 5:00 a.m., with no corresponding documentation in the record. On the morning after admission, staff observed this same resident to be very sleepy and difficult to keep awake, with increased respiratory rate. The CNA reported that the resident was on oxygen, looking at him but not speaking, and not eating breakfast, prompting notification of the nurse. The day RN confirmed that at shift change the resident was sleeping in bed with oxygen via nasal cannula and that the BiPAP machine was not on. The nurse practitioner evaluated the resident twice that morning, noting that he was not waking up, had tachypnea with respiratory rates in the high 20s to low 30s, and required increased oxygen, leading to transfer to the hospital for altered mental status and acute respiratory failure. The NP and physician both stated that failure to provide BiPAP at bedtime as ordered could potentially contribute to a change in mental status, although they also cited the resident’s chronic respiratory failure, morbid obesity, obstructive sleep apnea, and other comorbidities as contributing factors. The facility’s own policy required that CPAP/BiPAP be ordered by a physician, set up by respiratory therapy, and that mask, tubing, and exhalation port be cleaned daily. For four additional residents with intact cognition and diagnoses including obstructive sleep apnea, chronic respiratory failure, COPD, morbid obesity, and other serious conditions, surveyors observed CPAP or BiPAP machines at bedside and confirmed active physician orders for nightly use. These residents reported using their devices at bedtime, sometimes inconsistently due to discomfort or personal preference, and one resident stated that staff had not cleaned the CPAP device for months, only wiping off excess water from the mask. For all five residents reviewed (including the first resident), the February and March MARs, TARs, and progress notes did not reflect that CPAP/BiPAP masks, tubing, and exhalation ports were cleaned daily as required by facility policy. The DON confirmed that nurses were expected to follow physician orders for CPAP/BiPAP, document administration on the MAR/TAR or in progress notes, and clean the devices daily for infection control, stating that if it was not documented, it was considered not done. This combination of missing documentation of ordered BiPAP use and lack of documented daily cleaning of CPAP/BiPAP equipment constituted the identified deficiency.
Failure to Administer Scheduled Medications and Blood Glucose Monitoring
Penalty
Summary
A deficiency occurred when a resident with multiple medical diagnoses, including type 2 diabetes mellitus with diabetic autonomic neuropathy, heart failure, and atrial fibrillation, did not receive scheduled medications as ordered. The resident's care plan required regular blood glucose monitoring and administration of insulin with meals, as well as other medications for cardiac conditions. On the day in question, the resident reported not having received any medications or blood glucose checks by lunchtime, despite orders for blood glucose monitoring before meals and insulin administration. Observation and interviews confirmed that the assigned RN had not administered the resident's morning medications, nor had she performed the required blood glucose checks at the scheduled times. The RN acknowledged that the resident should have had blood sugar checks and insulin administered at specific times, but these actions were not completed. Documentation in the resident's progress notes and medication administration records further indicated that the insulin and blood glucose checks were missed until later in the afternoon, and the nurse practitioner was notified after the omission was discovered. Facility policy and the RN's job description both require medications to be administered as prescribed and within specified time frames, particularly for time-sensitive medications such as insulin and blood pressure medications. The Director of Nursing confirmed that staff are expected to follow physician orders and administer medications within the appropriate window, and that failure to do so is not acceptable. The nurse practitioner also stated that all medications are expected to be given when due and that missed doses can have adverse effects.
Failure to Properly Label and Store Food Items in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to follow proper food labeling and storage practices in the kitchen, which could affect all 141 residents receiving food from this area. During an initial kitchen tour, it was found that cartons of thickened lemon-flavored water in the milk cooler were not sealed and either lacked an opened date or had an outdated opened date. In the reach-in refrigerator, several salad bowls and plates were labeled inconsistently, with some missing use-by dates and others exceeding the facility's stated three-day use period for salads. Staff interviews confirmed that salads should be used within three days and that proper labeling is required for resident safety. The Dietary Manager and Cook both acknowledged the importance of labeling and discarding food items according to policy to prevent serving expired food to residents. The facility's policy requires opened food items to be labeled with an opened-on date and disposed of once expired. At the time of the survey, there was at least one resident who required honey-thick water, highlighting the need for strict adherence to food safety protocols. The failure to consistently label and dispose of food items as per policy was directly observed and confirmed by staff.
Failure to Properly Date and Store Insulin and Eye Drops
Penalty
Summary
Surveyors observed that the facility failed to properly date opened multi-dose insulin for three residents and did not ensure that multi-dose eye drops were stored at the appropriate temperature for two residents. During inspections of medication carts and a medication room, opened Lantus insulin pens and vials were found without open dates, despite pharmacy labels indicating that insulin should be dated upon opening and discarded after 28 days. Additionally, unopened Latanoprost eye drops, which require refrigeration until opened, were found stored at room temperature in medication carts, contrary to pharmacy labeling and facility policy. Interviews with nursing staff, including an RN, an LPN, and the DON, confirmed that medications such as insulin and Latanoprost should be dated when opened and stored according to manufacturer and pharmacy recommendations. The facility's own policies and reference guides also specify proper storage temperatures and expiration dating for these medications. Physician order sheets for the affected residents documented active orders for Lantus insulin and Latanoprost eye drops, further confirming the need for proper medication management as outlined in the facility's procedures.
Failure to Follow Infection Control and PPE Protocols
Penalty
Summary
Surveyors observed multiple failures in infection prevention and control practices among staff during direct resident care. Staff members, including an agency LPN and CNAs, did not perform hand hygiene before and after entering or exiting resident rooms, nor after direct contact with residents. The same blood pressure device was used on several residents consecutively without cleaning or disinfecting it between uses. Staff also failed to perform hand hygiene when donning and doffing gloves and PPE, and reusable medical equipment such as blood pressure cuffs and pulse oximeters were not sanitized between residents. In rooms with Enhanced Barrier Precautions (EBP) signage, staff did not follow required protocols. Staff were observed entering rooms and providing care, such as medication administration and vital sign checks, without performing hand hygiene or properly donning and doffing PPE, including gowns and gloves. In one instance, a CNA provided activities of daily living (ADL) care, including changing linens and briefs for a resident with chronic wounds and a gastrostomy tube, without wearing a gown as required by EBP protocols. Another CNA, identified as an orientee, also failed to wear a gown while handling soiled linens and entering and exiting the resident's room. Interviews with the Director of Nursing confirmed that staff are expected to perform hand hygiene and sanitize reusable equipment between residents to prevent infection. However, the facility was unable to provide a policy for cleaning reusable medical equipment when requested by surveyors. The facility's existing hand hygiene and infection control policies require routine handwashing and maintenance of necessary equipment, but these were not followed as observed during the survey.
Failure to Remove Hospital Wristband Exposing Resident's Personal Information
Penalty
Summary
A resident with severe cognitive impairment and multiple medical diagnoses, including dementia, alcoholic cirrhosis, and dysphagia, was observed wearing a hospital wristband that displayed personal information such as name, age, date of birth, and gender. The wristband was still on the resident's wrist after returning from a recent hospital visit, making the resident's identifying information visible to anyone. Staff, including a registered nurse and the director of nursing, acknowledged that the wristband should have been removed upon the resident's return to protect privacy, as the exposed information constituted a violation of privacy policies and was considered a HIPAA concern. Facility policy requires that resident labels be placed in a manner that is both conspicuous and respectful of dignity, which was not followed in this instance.
Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
A deficiency was identified when a resident was observed with two capsules of Tamsulosin/Flomax in a medication cup at their bedside. The resident, who had an intact cognition per the most recent MDS, stated that the medication was brought by a nurse but was unsure when. Upon inquiry, an LPN confirmed the medication was scheduled for nighttime administration and suggested it may have been left by the night nurse. Review of the resident's electronic health record revealed no assessment or care plan for self-administration of medication, and there was no physician order permitting the resident to keep medication at the bedside. The facility's policy requires an interdisciplinary team assessment and a prescriber's order before allowing residents to self-administer medications. The DON confirmed that nurses are not supposed to leave medications at the bedside and that self-administration should be formally assessed, care planned, and ordered by a physician. The resident's records showed an active order for Tamsulosin to be given at bedtime, but no documentation supported self-administration or leaving medication at the bedside, resulting in noncompliance with facility policy and regulatory requirements.
Late Completion of Quarterly MDS Assessment
Penalty
Summary
The facility failed to complete the Quarterly Minimum Data Set (MDS) assessment for one resident within the required regulatory timeframe. According to interview and record review, the MDS/Care Plan Coordinator confirmed that the MDS, which is used to describe the resident and guide their care, must be submitted to CMS every quarter or more frequently if there is a significant change in the resident's condition. For the resident in question, the Assessment Reference Date (ARD) was completed late, and the assessment was not finalized within 14 days as required by the RAI manual. Documentation showed that the assessment completion date exceeded the 14-day window, resulting in a late submission.
Failure to Care Plan Resident's Preference for Eating Position
Penalty
Summary
The facility failed to develop and implement a person-centered care plan that addressed a resident's preference to eat while lying down, despite clear evidence of the resident's ongoing behavior and associated risks. Observations showed the resident eating meals in bed with the head of the bed only slightly elevated, resulting in the resident bending their neck to eat and experiencing coughing during meals. Signage above the bed instructed staff to ensure the resident was upright while eating and drinking, but the resident reported consistently eating in a reclined position and sliding down even when staff attempted to elevate the bed. The resident also stated that staff would pull them up, but they would slide back down, and this occurred at every meal. Interviews with staff revealed that both a CNA and an LPN were aware of the resident's preference to eat lying down and had educated the resident about the risks of choking and aspiration. However, neither staff member reported this preference or behavior to the Director of Nursing or management. The Director of Nursing confirmed they were not aware of the resident's eating position and that the care plan did not address the resident's preference or the associated risks. The facility was unable to provide a care plan that incorporated the resident's choice to eat while lying down, despite the resident's medical diagnoses of gastro-esophageal reflux disease and dyspepsia, and the facility's policy requiring care plans to reflect resident preferences and needs.
Failure to Properly Position Resident During Meals
Penalty
Summary
A deficiency was identified when a resident with diagnoses including dementia, dysphagia (oropharyngeal phase), and a history of falls was observed eating lunch while lying in bed with the head of the bed at approximately 30 degrees, rather than in an upright position. The resident's lunch tray was placed on the bedside table across the bed, and the resident was seen feeding themselves in this position. Staff interviews confirmed that the resident was not properly positioned for eating, with both a Licensed Practical Nurse and a Certified Nursing Assistant acknowledging that the resident should have been repositioned to at least a 45-degree angle to prevent aspiration. The CNA admitted to placing the meal tray without first repositioning the resident and stated an intention to reposition the resident in the future. The resident's care plan specifically indicated the need for upright positioning during meals due to a swallowing problem, and the resident required setup or clean-up assistance for eating as well as partial/moderate assistance to move from lying to sitting. Despite these documented needs, the facility did not have policies in place for choking or aspiration precautions, nor for feeding setup in bed, as confirmed by the Administrator and Director of Nursing. The lack of proper positioning and absence of relevant policies contributed to the deficiency in ensuring the resident did not lose the ability to perform activities of daily living safely.
Failure to Provide Required 1:1 Feeding Assistance for Resident on Aspiration Precautions
Penalty
Summary
A deficiency occurred when a resident with a history of dysphagia, Alzheimer's disease, type 2 diabetes mellitus, and chronic obstructive pulmonary disease was not provided with the required one-to-one feeding assistance during lunch. The resident was observed eating independently in bed with the head of the bed elevated, despite clear signage and dietary orders indicating the need for strict aspiration precautions and one-to-one feeding. The meal ticket, posted signage, and clinical records all specified that the resident required staff to feed her, using small spoonfuls and ensuring the mouth was cleared before offering additional bites, and that the resident should not be left alone with the meal tray. Further interviews confirmed that the speech pathologist had discharged the resident from therapy with recommendations for mechanical soft solids, thin liquids, and full staff assistance with feeding, emphasizing the risk of choking or aspiration if not assisted. The care plan also documented the need for partial to moderate assistance and one-to-one feeding. When the surveyor requested the facility's policies and procedures for aspiration precautions and ADL care, the administrator stated that no such policies existed.
Failure to Follow Midline Catheter and Aspiration Precaution Protocols
Penalty
Summary
The facility failed to follow its own policies and procedures regarding the care and management of a resident with a midline catheter and another resident with aspiration precautions. For one resident with a midline catheter, staff did not measure the upper arm circumference or the external catheter length, did not change the midline dressing in a timely manner, did not provide the required maintenance flush, and did not develop a comprehensive care plan for midline use. The resident reported that the midline dressing had not been changed since admission, and there was no documentation of required measurements or flushing. The Director of Nursing confirmed that these actions were necessary to monitor for complications and should have been documented and care planned according to facility policy. For another resident with a history of hemiplegia, dysphagia, and impaired cognition, the facility failed to ensure that physician orders for aspiration precautions were followed. Despite an active order and posted signage indicating a strict 'no straws' restriction due to aspiration risk, a cup of water with a straw was observed within the resident's reach. Staff confirmed the order and signage but did not remove the straw until prompted. The facility also lacked a policy and procedure for aspiration precautions, as confirmed by the administrator.
Failure to Implement Fall Prevention Interventions for At-Risk Residents
Penalty
Summary
Surveyors observed that the facility failed to implement fall prevention interventions for two residents identified as being at risk for falls. Both residents were found in their beds, which were not in the lowest position, despite care plans and staff interviews indicating that the beds should be kept low to reduce the risk of injury from falls. One resident was observed with a fall mat next to the bed, and both residents required assistance to get out of bed. Staff, including an LPN and a CNA, confirmed that the beds should have been in the lowest position as a fall precaution, but this intervention was not in place at the time of observation. Both residents had medical histories that included dementia and previous falls, and their care plans specifically identified them as fall risks, requiring interventions such as keeping the bed in the lowest position. Facility policy also required individualized fall prevention measures based on resident assessments. Despite these documented needs and policies, the required interventions were not consistently implemented, as evidenced by direct observation and staff interviews.
Failure to Administer Enteral Water Flushes per Physician Orders
Penalty
Summary
A deficiency occurred when the facility failed to ensure that water flushes for a resident with a gastrostomy tube were administered according to the most current physician orders. Observations and interviews revealed that the resident's feeding pump was set to deliver water flushes at 160 ml every 6 hours, despite a documented recommendation and approved order to decrease water flushes to 100 ml every 8 hours. The discrepancy was noted during multiple observations, and staff confirmed the settings on the pump did not match the updated orders. The Director of Nursing and Registered Nurse both referenced the need to follow physician orders for enteral feedings and flushes, but the actual practice did not align with the documented changes. The resident involved had significant medical complexities, including end stage renal disease requiring dialysis, chronic heart failure, and severe cognitive impairment. The dietician had recommended the reduction in water flushes due to concerns about fluid overload and the resident's ability to tolerate excess fluids, given their dialysis and cardiac status. Despite these recommendations and the nurse practitioner's approval, the water flushes continued at the previous, higher rate, contrary to the updated physician order.
Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents by not following physician orders regarding oxygen therapy. One resident was observed lying in bed with the oxygen concentrator set to 2 liters per minute (lpm), but the nasal cannula tubing was not applied and was instead wrapped around the bed rail with the nasal prong on the floor. The resident was not in distress at the time, but the oxygen was not being delivered as ordered. A Certified Nursing Assistant later applied the nasal cannula and acknowledged it should have been in place. Another resident was found receiving oxygen via nasal cannula at a flow rate of 3 lpm, despite a physician's order for continuous oxygen at 2 lpm. This discrepancy was confirmed by both an agency LPN and a Registered Nurse, who verified the order and the incorrect setting. The Director of Nursing stated that oxygen administration must follow the physician's order, as it is considered a medication. Both residents had significant medical histories, including chronic respiratory conditions and cognitive impairments, and required staff assistance for mobility and care.
Failure to Assess and Care Plan for Side Rail Use
Penalty
Summary
The facility failed to properly assess and document the use of side rails for two residents, resulting in deficiencies related to resident safety and care planning. For one resident with diagnoses including dementia, hypertension, and chronic kidney disease, observations showed the resident using two upper half side rails while in bed. Despite the resident's cognitive impairment and need for substantial to maximal assistance with bed mobility and transfers, there was no current side rail assessment, no physician order for side rail use, and no care plan addressing side rails since the resident's admission. The last side rail assessment on record was from a previous admission, and staff confirmed that no updated assessment or care plan had been completed for the current stay. Another resident, admitted with multiple complex medical conditions such as end stage renal disease and vertebral fractures, was also observed with two upper side rails in use. This resident required total or partial assistance with most activities of daily living and was dependent for transfers. Although a side rail assessment was present in the electronic health record, there was no care plan addressing the use of side rails. Staff interviews confirmed that side rail use should be included in the care plan and that assessments should be completed and reviewed regularly, but this was not done for the resident in question. The facility's own policy requires that alternatives to bed rails be attempted and documented, that a risk versus benefit assessment be completed, and that informed consent be obtained prior to installation. The policy also mandates that the use of side rails be addressed in the resident's care plan, including details on medical need, monitoring, and interventions to minimize risks. These steps were not followed for the two residents, as evidenced by the lack of assessments, care plans, and documentation of alternatives or informed consent.
High Medication Error Rate Due to Incorrect Dosing, Timing, and Omission
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 34.29% as observed during medication administration for three residents. Surveyors directly observed licensed nursing staff preparing and administering medications that did not match the physician orders and Medication Administration Records (MAR). Errors included administering the wrong dose of Mucinex and ferrous sulfate to one resident, and giving medications such as Senna, Nifedipine, and insulin at incorrect times to another resident. Additionally, a third resident received multiple medications at the wrong times, and a dose of furosemide was omitted entirely during the observed medication pass. Interviews with the Director of Nursing confirmed that nurses are expected to follow the facility's medication administration policy, which includes a two-hour window for timely administration and adherence to the '5 rights' of medication administration. The facility's own procedures require medications to be administered safely and effectively, with verification against the MAR at each step. Despite these policies, the observed actions of the nursing staff led to multiple medication errors involving wrong dose, wrong time, and omission of ordered medications.
Failure to Complete and Provide Discharge Instructions at Resident Discharge
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a Discharge Instruction was completed and provided to a resident upon discharge, which is necessary for a safe and effective transition of care. The process for completing the Discharge Assessment involved multiple departments, with the Social Services Director completing initial sections and nursing staff responsible for the remaining sections, including medications, diet/nutrition, ADL/bowel & bladder/restorative nursing, education/appointments, and skin condition on discharge. However, upon review, it was found that only the initial sections were completed, and the critical nursing sections remained incomplete. The Discharge Instruction was not printed, signed by the resident or responsible party, or provided at the time of discharge. Interviews with facility staff revealed that the nurse responsible for discharging the resident did not remember completing or providing the Discharge Instruction, and there was no reminder system in place to ensure completion. The Medical Records/Transportation staff confirmed that the discharge paper was not uploaded to the electronic health record, as it was never placed in the scan box by nursing. The facility's process required the nurse to print and provide the completed Discharge Assessment for the resident or family to sign, but this step was missed, resulting in the absence of documentation and notification regarding the resident's needs post-discharge. The affected resident had significant medical conditions, including hemiplegia, hemiparesis, sequelae of cerebral infarction, and morbid obesity. The resident's care plan indicated a desire to be discharged home with family and required written instructions to ensure continuity of care. The incomplete Discharge Instruction meant that essential information regarding medications, follow-up appointments, diet, and other care needs was not communicated to the resident or family, as required by facility policy and procedure.
Failure to Provide Prescribed Wound Care for Pressure Ulcers
Penalty
Summary
A resident with multiple complex medical diagnoses, including bacteremia, morbid obesity, chronic kidney disease, and chronic respiratory failure, was readmitted to the facility with several unhealed pressure ulcers. Upon readmission, the resident had documented wounds to the left buttocks, bilateral buttocks, left hip, and sacral area, as well as other sites. Despite these documented wounds, there were no corresponding treatment orders for these areas on the resident's Physician Order Sheet (POS) at the time of readmission. Interviews with nursing staff, including the wound care nurse, LPN, and wound care coordinator, revealed that it was the responsibility of the admitting nurse or wound care nurse to ensure that hospital treatment orders were entered and that wound care began upon admission. However, the review of the Treatment Administration Record (TAR) and POS showed missing treatment orders and missing signatures for wound care treatments, indicating that prescribed wound care was not performed for certain wounds. Staff members acknowledged that if treatment orders are not present or not signed out, it is assumed that the treatment was not performed, which could result in wounds worsening or becoming infected. Documentation from the resident's care plan and hospital records confirmed the presence of pressure ulcers and the need for ongoing wound care. Despite this, the facility failed to ensure that necessary wound care orders were entered and that treatments were administered as prescribed. The absence of a wound care coordinator at the time further contributed to the lack of oversight and follow-through on wound care orders, as confirmed by staff interviews and review of facility policies and job descriptions.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident (R1) from physical abuse by another resident (R2). On the morning of the incident, staff members, including a CNA and an RN, heard yelling and cursing coming from the shared room of R1 and R2. Upon entering, staff observed both residents engaged in a verbal altercation. Despite attempts by the CNA to de-escalate the situation and physically intervene by pulling on R2's shirt, R2 managed to push R1 down onto the bed multiple times. The CNA and other staff present were unable to prevent R2 from making physical contact with R1 during the altercation. R1 was described as physically fragile, with a history of liver cell carcinoma, bone neoplasm, spinal fusion, pathological fracture, severe malnutrition, and other significant medical conditions. R1 was wheelchair-bound and cognitively intact. R2, who was significantly larger in stature, also had multiple medical diagnoses but was ambulatory and cognitively intact. Prior to this incident, R2 had demonstrated verbally and physically agitated behavior, including an earlier episode where R2 swung a cane at staff. Both residents had a history of verbal arguments, and R2's care plan noted a risk for abuse/neglect due to agitated behavior, with interventions to observe R2 when in the company of peers. The incident was witnessed by multiple staff members and corroborated by documentation in progress notes and interviews. R2 admitted to pushing R1 and expressed ongoing aggression towards R1 after being removed from the room. The facility's policy affirms the right of residents to be free from abuse and requires the establishment of a secure environment, but in this case, the measures in place were insufficient to prevent the physical abuse of R1 by R2.
Inadequate Infection Control Practices for Isolation Precautions
Penalty
Summary
The facility failed to adhere to its infection prevention and control program, specifically in managing isolation protocols for residents diagnosed with infectious diseases. Two residents, one diagnosed with Influenza A and RSV, and the other with Influenza, were placed on droplet/contact isolation. However, the facility did not ensure that appropriate Personal Protective Equipment (PPE) was used and disposed of correctly. Observations revealed that the required PPE, such as N95 masks, was not included in the isolation protocol, and PPE disposal was not conducted in accordance with the facility's guidelines, as evidenced by the use of clear plastic liners instead of red biohazard bags. Additionally, the facility failed to maintain proper signage for isolation precautions. The signs on the residents' doors did not accurately reflect the required contact and droplet precautions, and staff were not consistently aware of the correct isolation protocols. The infection prevention nurse confirmed that the facility's protocol required contact and droplet precautions for residents with Influenza A and RSV, yet the signage and staff responses did not align with these requirements. This lack of adherence to established protocols has the potential to affect all 153 residents in the facility.
Inadequate Pest Control Measures in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of mice and roaches in resident rooms. Three residents reported sightings of pests, including mice and roaches, in their rooms. One resident provided video evidence of a roach crawling on the wall and a picture of a dead roach on a heater. Despite these reports, the facility's pest control measures were inadequate, with pest control services only inspecting common areas and not resident rooms. The facility's pest control program was not effectively implemented, as the maintenance director admitted to not following up on all reported pest sightings. The pest control log was incomplete, with missing entries for treatment dates and technician initials. Additionally, the maintenance director acknowledged that some reported pest sightings were not documented or followed up on, indicating a lack of thoroughness in addressing pest issues. During an inspection of a resident's room, a surveyor found a bait station that was not set and a glue station with live and dead insects adhered to it. The maintenance director was unaware of how to use the bait station and admitted that it had not been set. Furthermore, there were large openings in the ceiling tiles, which could serve as entry points for pests. These findings highlight the facility's failure to address pest control issues effectively, potentially affecting the health and safety of all residents.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for residents, as evidenced by the conditions observed in the rooms of three residents. One resident, identified as R2, was reported to have been urinating and defecating on the floor and bed, using sheets to clean himself, and disposing of waste improperly. Despite being moved to a room with a bathroom, R2 continued these behaviors, causing distress to his roommates, R1 and R3, who reported the incidents to staff and the facility administrator. The facility staff, including LPNs and CNAs, were aware of the situation but failed to effectively address the issue, as R2 continued to refuse to use the bathroom or call for assistance. The physical environment of the facility was also found to be lacking. Observations included a dried brown substance on R2's mattress and floor mat, multiple soiled urinals beneath R2's bed, and a loud screeching noise from the bathroom exhaust fan, which R2 indicated was a reason for not using the bathroom. The room shared by R2 and R3 had damaged walls, spray foam protruding from the baseboard, a dangling baseboard beneath the heater, and a discolored ceiling tile with large openings. These conditions contributed to an environment that was neither clean nor comfortable, violating the residents' rights to a homelike setting. The facility's policies on resident rights and housekeeping services were not adhered to, as the environment did not meet the sanitation needs of the residents. Despite repeated education and encouragement from staff, R2's behavior persisted, and the facility's failure to maintain a clean and orderly environment was evident. The surveyor's findings highlighted the facility's inability to provide adequate care and support for daily living, as required by regulatory standards.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by an altercation between two residents, R1 and R2. The incident occurred when R2 allegedly grabbed R1's thumb, causing pain, and R1 retaliated by grabbing R2's chest, resulting in multiple scratches and pain. Both residents had conflicting accounts of the event, with R1 claiming that R2 initiated the altercation by physically and verbally assaulting her, while R2 stated that she acted in self-defense after R1 grabbed her shirt. The facility's staff were unable to substantiate the incident due to the differing stories provided by the residents. R1's medical history includes bipolar disorder, major depressive disorder, osteoporosis with a history of pathological fractures, and HIV. At the time of the incident, R1 reported pain in her left thumb, which was later examined and found to have an inconclusive diagnosis of an acute fracture. Despite being advised to seek medical attention, R1 refused to go to the hospital and later canceled an orthopedic appointment, expressing distrust in the facility's associated doctors. R1's care plan indicated a low risk for abuse, but the assessment did not account for her mental health diagnoses, which could have increased her risk level. R2's medical history includes anxiety disorder, depression, and bipolar disorder. Her care plan identified her as being at moderate risk for abuse, with interventions to monitor her interactions with peers. Following the altercation, R2 was found to have scratch marks on her chest, which were documented by the nursing staff. The facility's policy on abuse prevention and reporting emphasizes the importance of creating a secure environment for residents and identifying those with increased vulnerability to abuse. However, the facility's response to the incident was limited to separating the residents and changing their rooms, without a clear resolution to the conflicting accounts of the altercation.
Inadequate Supervision and Fall Risk Management
Penalty
Summary
The facility failed to provide adequate supervision and a safe environment for a resident, resulting in a fall and injury. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction, was dependent on staff for mobility and required a two-person assist for repositioning. Despite these needs, a Certified Nursing Assistant (CNA) attempted to reposition the resident alone, leaving her at the edge of the bed. This action led to the resident falling from the bed, resulting in a right femur fracture and a hematoma on the forehead. The Director of Nursing (DON) confirmed that the resident was at risk for falls due to limited mobility and required two staff members for transfers and repositioning. The CNA involved was unaware of the resident's fall risk status and did not follow the care plan, which specified the need for two-person assistance. The facility's fall prevention program was not adequately implemented, as the resident's bed was not maintained in a low position, and the CNA was not informed of the resident's high fall risk status. The resident's care plan and fall risk assessments indicated a high risk for falls, with interventions such as keeping the bed in a locked position and ensuring frequently used items were within reach. However, these measures were not effectively communicated or adhered to by the staff. The failure to follow established protocols and provide the necessary level of assistance directly contributed to the resident's fall and subsequent injuries.
Failure to Update Family on Insulin Grievance
Penalty
Summary
The facility failed to adhere to its grievance policy by not updating the family of a resident regarding an ongoing issue with insulin ordering. The resident, identified as R4, expressed uncertainty about the monitoring of his insulin. The Director of Nursing (V2) acknowledged that there was an issue with the pharmacy charging the family for insulin that was not used and had to be discarded after 28 days. Despite being aware of the issue, V2 admitted that it was not addressed during a care plan meeting. The Minimum Data Set Care Plan Coordinator (V8) also confirmed receiving an email from R4's son about the insulin charges and noted that nurses were incorrectly ordering new insulin instead of adjusting the dosage from existing supplies. The resident's Financial Power of Attorney (V7) was not informed about the care plan meeting and had not received any updates on the grievance since July. The facility's Administrator (V1) was unaware of the insulin issue and stated that it was not discussed in the care plan meeting because the family did not bring it up. The facility's grievance policy requires grievances to be resolved within five business days, but the family was not notified of any extension or resolution, indicating a failure to follow the policy.
Failure to Prevent Pressure Ulcers in Resident
Penalty
Summary
The facility failed to implement interventions to prevent the development of deep tissue injuries (DTIs) for a resident who was admitted with multiple diagnoses, including a hip fracture and chronic conditions. The resident, who was cognitively intact, reported that staff crossed her legs at the ankles during care and did not reposition them afterward, leaving them in that position for approximately eight hours. This resulted in the development of pressure ulcers on her ankles, which were later identified as facility-acquired DTIs by the wound care team. The resident's care plan included interventions for the prevention and treatment of skin breakdown, but these were not effectively implemented. Observations and interviews with the wound care staff confirmed the presence of DTIs on the resident's ankles, which were initially thought to be venous or arterial ulcers. The facility's pressure ulcer prevention policy emphasized the use of positioning devices to reduce pressure and friction, but this was not adhered to in the resident's care, leading to the deficiency.
Failure to Provide Adequate Nutritional Care Leads to Significant Weight Loss
Penalty
Summary
The facility failed to ensure adequate nutritional care for two residents, resulting in significant weight loss. Resident R2, diagnosed with end-stage renal disease and protein-calorie malnutrition, experienced a 7.1% weight loss in one month. The facility did not document R2's monthly weights as required by policy, missing several months of records. R2 reported that meal portions had decreased since a change in ownership, and the facility no longer offered menu choices or double portions. Despite being on supplements for weight management and wound healing, R2 frequently refused these supplements, and their dietary preferences were not included in nutritional assessments. Resident R1, with a history of hypertension secondary to renal disorders, lost 11.6% of their body weight over six months. R1 expressed dissatisfaction with the kidney diet provided, which they no longer required, and reported nausea from the meals. R1 requested specific foods like cottage cheese but rarely received them, relying on Ensure when meals were inadequate. Despite significant weight loss, R1's dietary preferences were not considered in their nutritional assessments, and there was no follow-through on their requests to see a dietician. The facility's registered dietician and medical director acknowledged the significant weight loss in both residents but attributed it to existing medical conditions and medication effects. However, the facility's failure to document weights consistently, consider dietary preferences, and provide adequate meal options contributed to the residents' unplanned weight loss. The facility's policy required monthly weight documentation and reporting of significant weight changes, which was not adhered to, leading to these deficiencies.
Failure to Provide Required Mobility Devices for Residents
Penalty
Summary
The facility failed to ensure that staff were aware of and provided necessary mobility devices for residents, specifically wheelchairs, as required for their transfer assistance. This deficiency was observed in two residents, R2 and R5, who were both dependent on staff for chair/bed to chair transfers and required wheelchairs as per their care plans. However, their Kardexes did not include information about the required mobility devices, and the staff, including a CNA and the Restorative Nurse, were unaware of the need to provide these devices. R2, who had been in the facility for over two years, reported not having been provided a wheelchair, and R5 also confirmed the absence of a wheelchair in her room. The Restorative Nurse acknowledged the oversight and stated that wheelchairs could be provided if needed, but none were available in storage at the time of inspection. The facility's lack of a policy on wheelchair provision and accommodation of resident needs further contributed to the deficiency. The Assistant Director of Nursing confirmed the absence of such a policy when requested by the surveyor. The failure to include mobility devices in the Kardex and the lack of a clear policy on accommodating resident needs resulted in the residents not receiving the necessary equipment for their mobility and transfer assistance, potentially affecting all 153 residents in the facility.
Failure to Include Abuse/Neglect Risk in Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans that included the potential for abuse or neglect for four out of five residents sampled, which could potentially affect all 153 residents in the facility. The residents in question had been admitted to the facility between seven to twenty-three months prior to the survey. Despite the facility's policy requiring the development of a baseline care plan within 48 hours of admission, and the potential for a comprehensive care plan to replace the baseline plan if completed within the same timeframe, the care plans for these residents did not address the risk of abuse or neglect. During the survey, the Care Plan Coordinator (V9) acknowledged that comprehensive care plans are developed for admissions, quarterly, annually, and upon significant changes. However, V9 admitted that the care plans for the residents did not include potential for abuse or neglect unless the residents verbalized such concerns. The surveyor pointed out that all residents are at risk for abuse, to which V9 agreed, yet confirmed that the care plans for the sampled residents did not include this aspect. This oversight indicates a failure to adhere to the facility's policy and best practices for care planning.
Failure to Follow Menu and Emergency Planning Procedures
Penalty
Summary
The facility failed to adhere to its policy procedures and ensure that the menu was followed, affecting 155 residents. This deficiency was identified during a survey following a Facility Reported Incident (FRI) where the Health Department issued a non-serve citation due to mouse droppings found in the employee dining room, leading to the closure of the facility's kitchen. As a result, the facility enacted its Emergency Management Plan and began transporting food from a sister facility. However, the meals provided did not align with the posted menu, and no revised menu was posted to reflect the changes. The Assistant Dietary Manager confirmed that the meals served were based on what was received from the sister facility, rather than the planned menu. Further investigation revealed that the facility did not have a specific emergency plan policy for kitchen closure, and the menu was not posted in areas accessible to residents and families, as required by the 2020 menu posting policy. The Director of Nursing provided documentation indicating the number of residents affected and presented the Emergency Preparedness and Training Policy, which lacked specific plans for emergency menu and food preparation. Additionally, a Certified Nursing Assistant stated that the menu was never posted, and staff only had access to diet cards, not the daily menu. This lack of adherence to menu policies and emergency planning contributed to the deficiency.
Inadequate Infection Control During Scabies Outbreak
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, particularly in managing a suspected scabies outbreak. Observations and interviews revealed that the facility did not follow its own policies and procedures, such as posting required infection control signs and ensuring that the infection log was complete with necessary details like symptom onset dates and treatment dates. The facility also failed to follow physician orders and did not document skin integrity impairments or report ongoing rash and itching to the physician or nurse practitioner in a timely manner. These lapses were noted in the cases of two residents who were reviewed for scabies, among others. The report highlights specific instances where the facility's actions were inadequate. For example, one resident was not isolated despite having a rash and refusing treatment, and another resident in the same room was also affected. The facility's infection log was incomplete, with missing onset dates and treatment details for several residents. Additionally, the facility did not perform skin scrapings for scabies testing on all affected residents, relying instead on prophylactic treatment without confirmed diagnoses. This approach was inconsistent with the facility's own scabies control policy, which requires skin scrapings for diagnosis. Interviews with staff, including the Assistant Director of Nursing and the Nurse Practitioner, revealed a lack of clarity and consistency in handling the outbreak. Staff admitted to not performing skin tests on all residents with rashes and not adhering to the prescribed treatment schedule. The Medical Director acknowledged that isolation precautions should have been implemented for residents with rashes of unknown origin, but this was not consistently done. The facility's failure to adhere to its infection control policies and procedures potentially affected all 153 residents, as the outbreak was not effectively contained or managed.
Failure to Provide Transfer Assistance Leads to Involuntary Seclusion
Penalty
Summary
The facility failed to ensure that two residents, R2 and R5, were free from involuntary seclusion due to inadequate transfer assistance. R2, who is dependent on staff for chair/bed to chair transfers and uses a mechanical lift, was observed lying in bed without a wheelchair. Despite R2's intact cognition and expressed desire to get out of bed, staff did not provide the necessary assistance or equipment. Documentation inconsistencies were noted, with entries marked as 'N/A' or blank for bed to chair transfers, indicating that R2 was confined to bed for several days. Similarly, R5, who also requires a mechanical lift for transfers, was found without a wheelchair in her room. R5 expressed willingness to get out of bed, but staff did not facilitate this. The documentation for R5 showed similar inconsistencies, with numerous entries marked as 'N/A' or blank, suggesting that R5 was also confined to bed for extended periods. The facility's failure to provide the necessary mobility devices and transfer assistance resulted in the involuntary seclusion of both residents. The facility's abuse prevention policy outlines the need to prevent unreasonable confinement or involuntary seclusion, yet the staff failed to adhere to these guidelines. The policy requires staff to identify residents with increased vulnerability and ensure their needs are met, but the lack of proper documentation and equipment provision indicates a significant oversight. The surveyor's findings highlight the facility's inability to meet the residents' care needs, as evidenced by the absence of wheelchairs and the failure to perform necessary transfers.
Deficiency in Colonoscopy Scheduling and Preparation
Penalty
Summary
The facility failed to ensure proper scheduling and preparation for a resident's colonoscopy, which was ordered due to significant weight loss. The colonoscopy was initially ordered in February, but due to various issues, it was not completed until late August. The facility did not have policies or procedures in place for scheduling colonoscopies or arranging transportation, leading to missed appointments and inadequate preparation. The resident's appointments were rescheduled multiple times due to transportation issues and poor bowel preparation, and the facility did not retain records of scheduled appointments or transportation arrangements. Additionally, the facility failed to follow physician orders for bowel preparation and dietary restrictions prior to the colonoscopy. The resident did not receive the required bowel prep medication or NPO/clear liquid diet orders before the scheduled procedures. Despite the colonoscopy being ordered months in advance, the facility did not ensure timely services or receive the diagnostic results in a timely manner. The lack of documentation and communication among staff contributed to the delays and deficiencies in care for the resident experiencing significant weight loss.
Failure to Post and Maintain Daily Nursing Staffing Information
Penalty
Summary
The facility failed to ensure that the Daily Nursing Staffing information was posted daily and that previous records were maintained, potentially affecting all 160 residents. On the morning of August 5, 2024, it was observed that there was no daily nursing staffing sheet posted by the reception area. The Lead Receptionist stated that they were unaware of the current location of the staffing sheet due to issues with the wall where it was previously posted. The Staffing Coordinator, responsible for the schedule, admitted to not having filled out the daily nursing staffing sheet for that day and revealed that they typically discard the sheets after use, unaware of the requirement to keep them. Further investigation revealed that the last recorded Daily Nursing Staffing sheet was from February 6, 2024, indicating a significant lapse in record-keeping. The Director of Nursing confirmed that staffing should be posted daily and retained in a binder. An email from the Administrator outlined the expectations for staffing postings, including the need to display current nurse staffing numbers, total FTE count, and daily facility census in a prominent location accessible to residents and visitors. It also specified that copies should be kept for three years after removal from the visible area.
Improper Food Labeling and Expired Items in Kitchen
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items in the kitchen, which could potentially affect all 157 residents receiving an oral diet. During an observation of the facility's walk-in freezer, several food items were found to be improperly labeled or expired. These included a bag of corn and a bag of chocolate chips, both opened with no open date, and a bag of peas that was exposed to air and had freezer burn. Additionally, a peach cobbler was found with an expiration date that had passed. The Dietary Cook confirmed that the facility's policy requires opened food to be labeled with an open date and expiration date to prevent residents from consuming expired food, which could make them sick. Further inspection of the facility's walk-in refrigerator revealed a plastic container of cucumbers that was opened without an open date or expiration date. The Dietary Supervisor reiterated the importance of labeling to ensure food safety and prevent illness. The facility's policy on labeling and dating foods, dated 2020, outlines the procedures for dating food items upon receipt and after opening, using the first in-first out method for storage. The job descriptions for the Dietary Manager and Cook emphasize the responsibility for maintaining quality nutritional services and following food service procedures in accordance with established policies.
Failure to Properly Close Dumpster Lids
Penalty
Summary
The facility failed to ensure that the dumpster lids were closed, which has the potential to affect all 160 residents residing at the facility. During an observation with the Dietary Supervisory, it was noted that two dumpster lids were open. The Dietary Supervisory acknowledged that housekeeping staff also use the dumpsters and admitted uncertainty about who left the lids open, but confirmed that they should be closed to prevent mice from entering. Further interviews with the Housekeeping Director confirmed that the dumpsters should be closed at all times when not in use to prevent rodent infestation and maintain infection control. The facility's policy on garbage and rubbish disposal, dated 2020, mandates that all outside dumpsters be maintained in a clean and sanitary condition, with garbage and rubbish containing food waste covered when not in immediate use to prevent access by vermin. Job descriptions for the Dietary Manager and Housekeeping Supervisor emphasize maintaining a clean, safe, and sanitary environment.
Improper Storage of Oxygen Tanks and Lancet Disposal
Penalty
Summary
The facility failed to ensure the proper storage of oxygen tanks for a resident diagnosed with primary generalized osteoarthritis, unspecified dementia, mood disturbance, and anxiety, who uses oxygen therapy for respiratory illness and conversational dyspnea. During an observation, an unsecured oxygen cylinder was found on the floor behind the resident's bed. A Licensed Practical Nurse (LPN) confirmed the improper storage and removed the tank, acknowledging the potential hazard of the tank tipping over and causing an explosion. The Director of Nursing later affirmed that all oxygen cylinders must be stored safely in a holder to prevent such hazards, as outlined in the facility's Oxygen Safety policy. Additionally, the facility failed to discard a lancet used for blood sugar monitoring for a resident with type 2 diabetes mellitus and cognitive impairments. A surveyor observed the lancet left on the resident's bedside drawer, which was confirmed by an LPN who stated that lancets should not be left in residents' rooms due to the risk of injury. The facility's job description for LPNs and the Medical Waste Disposal policy both emphasize the importance of following safety regulations and proper disposal of medical waste, including sharps like lancets.
Failure to Maintain Respiratory Equipment
Penalty
Summary
The facility failed to adhere to its policy regarding the maintenance and replacement of respiratory equipment, specifically nebulizer tubing and nasal cannulas. Observations revealed that the nebulizer tubing for a resident was not changed weekly as required, with the tubing label indicating it had not been replaced since 07/22/2024. The resident confirmed daily use of the nebulizer, and a Licensed Practical Nurse (LPN) admitted to being unaware of the tubing replacement schedule. Additionally, the facility did not ensure that nasal cannulas were properly stored when not in use, leading to potential contamination. Observations showed nasal cannulas on the floor or not contained in a plastic bag for several residents. Both the Director of Nursing (DON) and an Infection Preventionist confirmed that nasal cannulas should be stored in a plastic bag to prevent contamination, although the DON could not find this requirement in the facility's written policy. The facility's policy, dated 11/28/12, mandates that oxygen and nebulizer equipment be changed every seven days and as needed. However, the survey found that this policy was not consistently followed, as evidenced by undated and uncovered nasal cannulas and humidifier bottles. These deficiencies affected multiple residents, including those with chronic respiratory conditions, highlighting a lapse in infection control practices.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly manage and store medications, leading to several deficiencies. During an observation, a registered nurse found an expired Sodium chloride irrigation water bottle in the medication room, which should have been discarded as it was past its expiration date. Additionally, a resident's medication bottle containing Rosuvastatin tablets was found in a medication cart with a discard date that had already passed, indicating that the medication should have been removed and reordered from the pharmacy. Furthermore, loose pills were discovered in the medication carts, with nurses unable to identify them, highlighting a lack of proper labeling and storage. These deficiencies affected one resident directly and had the potential to impact all residents assigned to the medication carts and storage room. The resident involved had multiple diagnoses, including Type 2 Diabetes Mellitus, Chronic Kidney Disease, and Major Depressive Disorder, and had an active order for Rosuvastatin. The facility's policy on medication storage was not adhered to, as expired and improperly stored medications were not immediately removed and disposed of, posing a risk of medication errors.
Deficiencies in Refrigerator Temperature Logging and Maintenance
Penalty
Summary
The facility failed to properly log refrigerator temperatures for residents' personal refrigerators, affecting 10 residents. Observations revealed missing temperature log entries for specific dates, indicating a lack of daily monitoring as required by the facility's policy. Interviews with residents and staff confirmed that the temperature checks were not consistently performed, and some residents were unaware of the monitoring process. The facility's policy mandates daily temperature logging by housekeeping staff, but this was not adhered to, leading to incomplete records. Additionally, the facility failed to adequately maintain the freezers in residents' personal refrigerators for two residents. Observations showed ice buildup in the freezers, with one freezer door frozen shut, preventing access. Housekeeping staff stated that defrosting was done every 1.5 to 2 months or as needed, but the presence of ice buildup suggests this was not effectively managed. The housekeeping supervisor confirmed that maintaining cleanliness and defrosting were their responsibilities, but the process was not consistently executed. The deficiencies in temperature logging and freezer maintenance have the potential to affect the safety of personal food items for all residents reviewed. The facility's failure to ensure proper monitoring and maintenance of personal refrigerators could lead to spoiled food, posing a health risk to residents. Interviews with staff highlighted a lack of clarity regarding the frequency of defrosting and the importance of daily temperature checks, contributing to the observed deficiencies.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to update a resident's isolation status, leading to potential infection control issues. A resident with a history of methicillin-resistant Staphylococcus aureus (MRSA) and Clostridioides difficile (C. diff) was observed with outdated contact isolation orders, despite having completed antibiotics and not having an active infection. The infection preventionist acknowledged that the isolation orders should have been discontinued, emphasizing the importance of accurate records to prevent the spread of infections. Additionally, the facility did not adhere to proper infection control practices regarding the handling of clean linen. A clean linen cart was improperly brought into a resident's room, which was against the facility's policy to prevent contamination. The staff member responsible admitted the mistake, and the Director of Nursing and Infection Preventionist confirmed that such actions could lead to cross-contamination, as the cart should remain in the hallway and be covered. The facility also failed to ensure staff followed hand hygiene and personal protective equipment (PPE) protocols. Staff members were observed not sanitizing hands before donning gloves, handling items that had fallen on the floor, and performing resident care without appropriate PPE. These lapses in infection control practices were acknowledged by the staff involved, highlighting a lack of adherence to the facility's infection prevention and control policies.
Unsecured Handrail in Unit 2B
Penalty
Summary
The facility failed to ensure a handrail was firmly secured to the wall in Unit 2B, which has the potential to affect all residents in that unit. On August 5, 2024, at 10:45 am, it was observed that the handrail in Unit 2B was not fixed to the wall. This observation was confirmed by a Certified Nursing Assistant, who stated that the handrail had been in that condition for a long time. At 10:55 am, the Housekeeping Supervisor/Maintenance Director/Laundry Director also checked the handrail and confirmed it was not secured. Later, at 11:23 am, the same individual stated they were unaware of the issue and acknowledged the danger posed by an unsecured handrail. On August 6, 2024, at 3:30 pm, the Director of Nursing emphasized the importance of fixed handrails for resident safety, noting that residents rely on them for support while ambulating. An email correspondence with the Administrator on August 7, 2024, highlighted the need to ensure all handrails are properly secured to protect residents and visitors. The Residents' Rights for People in Long-Term Care Facilities document also underscores the facility's obligation to maintain a safe environment for residents.
Failure to Maintain Resident Dignity by Covering Catheter Bags
Penalty
Summary
The facility failed to ensure that indwelling catheter drainage bags were covered to maintain the dignity of residents. This deficiency affected two residents, R27 and R109, who were observed with their urinary drainage bags exposed. R109, who has a diagnosis of neurogenic bladder, was observed with an uncovered urinary drainage bag hanging on the bed frame, despite the presence of a black privacy bag intended for this purpose. A Licensed Practical Nurse (LPN) confirmed that the drainage bag should have been kept in the privacy bag to maintain the resident's dignity. The Director of Nursing (DON) also affirmed that the facility's expectation is for all urinary drainage bags to be kept in privacy bags. Similarly, R27's indwelling catheter bag was observed facing the door and not in a privacy bag. An LPN noted that a Certified Nurses Aide (CNA) might have emptied the bag and failed to return it to the privacy bag. The LPN then placed the catheter bag inside the privacy bag, acknowledging the importance of covering the bag for the resident's dignity. R27 has a diagnosis of female genital tract fistula and chronic kidney disease, with a severely impaired mental status. The facility's Dignity Policy emphasizes the importance of maintaining residents' dignity by covering urinary catheter bags, which was not adhered to in these instances.
Failure to Maintain Privacy of Electronic Health Records
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of electronic health records, which is a violation of HIPAA. During an observation, a surveyor noted that a medication administration record for a resident was left open and unattended on a laptop attached to a nursing cart. No staff were present near the cart at the time. A Licensed Practical Nurse (LPN) admitted to forgetting to close the laptop screen before leaving the area. The Director of Nursing (DON) confirmed that the facility's expectation is for staff to close or minimize the screen when stepping away from the computer to prevent unauthorized access to medical records.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for two residents, both of whom have intact cognition as indicated by their BIMS scores. One resident, who has multiple diagnoses including the absence of the right foot and severe protein-calorie malnutrition, reported that their bathroom door does not close, which compromises their privacy. This was confirmed by an LPN who acknowledged the issue and stated that the door should close for privacy. Another resident, with diagnoses including chronic obstructive pulmonary disease and end-stage renal disease, was observed to have a large brown stain on the ceiling above their bed and a hole in the floor tile at the foot of their bed. The LPN noted that the stain, caused by the air conditioning, poses a safety issue, and the hole in the floor could lead to accidents. The Maintenance Director confirmed that water sometimes stains the ceiling tiles when it rains and acknowledged the need to replace the floor tiles and fix the bathroom door hinge to ensure privacy and safety.
Failure to Complete PASARR Assessment for New Psychiatric Diagnosis
Penalty
Summary
The facility failed to complete a new Pre-Admission Screen and Resident Review (PASARR) assessment for a resident after a new diagnosis of schizoaffective disorder was identified. The resident, who was initially admitted with no known mental health issues, was later diagnosed with schizoaffective disorder and major depression. Despite this significant change in the resident's mental health status, the facility did not conduct a new PASARR assessment as required. The Social Services Director confirmed that the admissions department is responsible for ensuring PASARR assessments are completed prior to admission, and the social services department is responsible for completing them if a new psychiatric diagnosis is made while the resident is in the facility. The director acknowledged that a new PASARR assessment should have been completed following the new diagnoses but was not. A review of the facility's policy and the Maximus system confirmed that no additional PASARR assessments had been conducted for the resident since their admission.
Failure to Provide Adequate ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for two residents, R45 and R74, which compromised their personal hygiene. R45, who has a diagnosis of hemiplegia, hemiparesis following cerebral infarction, dementia, atrial fibrillation, and hypertension, was observed with a wet bed and worn incontinence pad. Despite the care plan indicating the need for assistance after attempting tasks, R45 did not receive timely incontinence care. A Certified Nursing Assistant (CNA) admitted to not having provided the necessary care since starting her shift at 7:00 am, which was confirmed as unacceptable by the Director of Nursing (DON). The facility's policy requires incontinence care every two hours to prevent skin breakdown and maintain dignity, which was not adhered to in this case. R74, diagnosed with type 2 diabetes mellitus, peripheral vascular disease, and other conditions, was observed with unclean fingernails containing food debris. Despite being cognitively intact and expressing a desire for nail care, R74's nails were not cleaned or trimmed as required. A Licensed Practical Nurse (LPN) and a CNA confirmed that CNAs are responsible for maintaining residents' nail hygiene, including diabetic residents. The facility's policy mandates regular observation and maintenance of nail cleanliness, which was not followed, leading to the deficiency in R74's personal hygiene care.
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A resident with severe mental illness, cognitive impairment, and a well-documented history of elopement and exit-seeking was placed on 1:1 monitoring but was allowed by a CNA to be behind a closed bedroom door and out of direct visual supervision, contrary to facility expectations for 1:1 status. During this lapse, the resident exited through a window, climbed a fence, and was later found outside with a displaced foot fracture. In a separate incident, a cognitively intact resident with a history of substance abuse, whose family visits were supposed to be supervised, had an unsupervised visit with grandparents known to bring contraband, was later found unresponsive with signs of overdose, received naloxone, and tested positive for oxycodone despite having no order for it, while his roommate had an active oxycodone prescription and staff found a white powdery substance and related items in the room, indicating a failure to prevent resident access to an unprescribed opioid.
A resident with multiple chronic conditions and severe cognitive impairment was found unresponsive and not breathing, with no documented code status, POLST, or DNR in the medical record. Nursing staff verified the absence of respirations and pulse but did not initiate CPR or call 911. An LPN reported she proposed starting CPR due to the unknown code status, but an RN declined. Leadership and clinical staff stated in interviews that facility practice and expectations are that, when a code status is unknown or no POLST is on file, the resident is to be treated as full code and CPR should be initiated.
A resident with multiple comorbidities was admitted with an unstageable sacral pressure ulcer and placed on Medi-Honey dressings three times weekly. Over several weeks, the wound enlarged and remained covered with slough, but a wound specialist NP was not consulted until the ulcer had significantly worsened. When the NP did evaluate the wound, she performed debridements and ordered daily Dakin’s solution and later Dakin’s with Silvadene and calcium alginate, but the facility’s TAR showed staff largely continued Medi-Honey three times weekly, applied Dakin’s on only a few days, and never administered Silvadene. The wound progressed to a stage 4 ulcer with odor and signs of infection, later cultured positive for MRSA and diagnosed in the hospital as an infected stage 4 decubitus ulcer with osteomyelitis requiring surgical debridement, contrary to the facility’s own policy requiring timely reassessment and implementation of MD/NP-directed wound care.
A resident with extensive traumatic fractures, internal injuries, and a long history of chronic pain management was admitted on existing orders for ibuprofen PRN and Percocet for pain, with hospital discharge instructions indicating scheduled Percocet three times daily. During the first night after admission, staff administered only ibuprofen, documented as ineffective, and did not provide any Percocet because the hospital had not sent written narcotic prescriptions and the DON did not obtain a timely verbal order to access Percocet from the emergency kit. The resident repeatedly complained of severe, escalating pain, used the call light frequently, yelled out, and ultimately called 911, signed out AMA, and was transported to the ED, where she reported uncontrolled pain and opioid withdrawal symptoms and received Percocet.
The facility did not maintain ceiling structures and plumbing in a safe and clean condition, resulting in long‑standing stained and bulging ceiling tiles above the nurses’ station and an actively leaking pipe in the ice machine/vending area. Surveyors observed missing ceiling tiles exposing insulation, wiring, and water pipes, standing water collected in a trash can, and soaked blankets and towels on the floor. An RN and an LPN reported that the ceiling tiles above the nurses’ station had been stained for months or longer, and that the ceiling had been leaking in the ice machine area for several days, where the ice machine is used for all residents. The Regional Maintenance Director confirmed the stained tiles and the leaking pipe and acknowledged that the tiles had not yet been replaced.
The facility did not ensure that all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention. Review of records for two agency CNAs showed no documented annual CNA training, despite a facility assessment stating that nurse aide in‑services must total at least 12 hours per year and address competency needs. One agency CNA reported not receiving any annual competency training or knowing it was required, and another reported receiving no training in the past year while providing care to all residents. The AIT and DON confirmed that these CNAs had not received the required annual training from either the facility or their agency.
The facility did not ensure that all CNAs, including agency CNAs, received required behavioral health training as outlined in its facility assessment, which called for dementia management, resident abuse prevention, and care of cognitively impaired residents with behaviors. Review of training records for two agency CNAs showed no behavioral health training over the prior year, and both CNAs reported they had not received such training from either the facility or their agency, despite one CNA confirming they provide care to all residents. The AIT and DON acknowledged that these CNAs had not received the required behavioral health training.
Surveyors identified multiple unsanitary conditions and ineffective sanitization practices in the kitchen, including a non-functioning, leaking garbage disposal with rotting food, leaking pipes near the ice machine, and a dirty HVAC unit shedding debris onto surfaces. The kitchen door to the dining room was damaged and improperly hinged, and staff reported it had recently been cut and sanded as part of a replacement. The wall-mounted chemical dispenser lacked compatible sanitizer bottles, and when staff prepared sanitizer solution, test strips showed no chlorine present; staff instead used dish soap and multipurpose cleaner from housekeeping to clean food contact surfaces. These failures affected the sanitation of food preparation and service areas for all residents in the facility.
A resident with dementia and behavioral disturbances consistently kept her TV volume excessively loud, to the point it could be heard from the nurse’s station and the end of the hallway, disturbing nearby residents who reported difficulty sleeping and ongoing disruption. Multiple residents stated that the loud TV had been a problem for some time, especially at night, and one reported needing headphones to block the noise. Staff, including an LPN and a CNA, confirmed frequent complaints, noted that the resident became verbally aggressive when asked to lower the volume, and reported that she insisted on keeping her door open and held the remote to prevent staff from adjusting the sound, despite a care plan indicating an agreed-upon lower volume level.
A resident with a known history of aggressive behavior deliberately kicked another resident while residents were lined up for a smoke break, causing the victim to fall onto his hip and later report ongoing left hip pain requiring an X-ray. Multiple witnesses, including another resident and CNAs, described the act as intentional physical abuse. Although an LPN, the DON, and the ADON all recognized the event as reportable abuse under facility policy, facility staff did not call the police or an ambulance for the victim despite his repeated requests, and the Administrator confirmed the incident was not reported to the state surveying agency.
Failure to Supervise High-Risk Resident on 1:1 and Prevent Access to Unprescribed Opioid
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and ensure adequate supervision for residents at high risk for elopement and substance misuse. One resident with schizophrenia, psychosis, major depressive disorder, severe cognitive impairment, and a documented history of wandering, elopement, and exit-seeking behaviors was identified as an elopement risk and placed on an elopement care plan and 1:1 supervision. Nursing and psychiatry notes documented repeated attempts by this resident to use keypads, push and kick exit doors, set off alarms, hover at exits, attempt to climb through windows, and a prior incident of exiting the building and being returned by social services. Despite this, while on 1:1 monitoring, the assigned CNA allowed the resident’s bedroom door to be fully closed and the resident to be out of direct line of sight, contrary to the facility’s expectations that residents on 1:1 remain in continuous visual contact with the aide and that doors not be shut. On the morning of the elopement event, the night-shift CNA reported that the resident had been up visiting, eating, and sleeping, and that at 5:45 AM the resident was in her room on the floor. Shortly thereafter, the resident stated she wanted to use the bathroom; the CNA reported seeing her enter the bathroom with the bedroom door left open so the bathroom door could be observed. When the day-shift CNA arrived to assume the 1:1, she found the bedroom door completely shut, opened it, and was told by the night-shift CNA that the resident was in the bathroom. After briefly leaving to put away her belongings and returning, the day-shift CNA found the resident no longer in the room and the window open. The nurse initiated a headcount and search, and the resident was found outside near a tree, holding herself up due to foot pain. Investigation and hospital records showed the resident had exited through her window, climbed over a fence approximately six feet high, and sustained a displaced fracture of the left metatarsal bone after landing on the ground while attempting to escape. A second deficiency concerns the facility’s failure to ensure a resident with a history of substance abuse was protected from access to an opioid medication not prescribed to him. This resident, cognitively intact with diagnoses including schizophrenia, anxiety disorder, bipolar disorder, and major depression, had a care plan noting behavior problems and a history of returning from family outings intoxicated or under the influence of unknown substances, with instructions that family visits be supervised in common areas. On the day of the incident, the resident, who lived on a locked behavior unit, had an unsupervised visit outside with grandparents known by staff to have previously brought contraband into the building. Later that day, staff observed the resident stumbling in the hallway wearing sunglasses and then becoming unresponsive in his room, with slow, abnormal breathing and no response to sternal rubs. Nurses recognized signs consistent with drug overdose, administered naloxone, and the resident was transferred to the emergency room, where a urine drug screen was positive for oxycodone, despite no oxycodone order for this resident. Further review showed that the resident’s roommate at the time had an active PRN order for oxycodone 5 mg for pain related to a right tibia fracture, and both residents had histories of substance abuse. Staff reported finding a white powdery substance and empty bags with white residue in the overdosed resident’s dresser drawer, and another resident on the unit was found snorting a crushed substance with paraphernalia on his dresser. The DON acknowledged that the overdosed resident had an oxycodone overdose diagnosis from the emergency room and that it was plausible he had taken the roommate’s medication, although the exact source of the oxycodone could not be confirmed. Facility policies required that medications, including controlled substances such as oxycodone, be administered only to the resident for whom they were prescribed and be securely stored in locked compartments inaccessible to residents and visitors, but the events showed that the resident was able to obtain and self-administer oxycodone that was not prescribed to him.
Failure to Initiate CPR for Resident With Unknown Code Status
Penalty
Summary
The deficiency involves the facility’s failure to initiate cardiopulmonary resuscitation (CPR) and call emergency medical services for an unresponsive resident whose code status was unknown. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, hypertension, and dysphagia, and was documented as severely cognitively impaired and dependent on staff for several activities of daily living. The resident’s medical record did not contain any documentation of a code status, POLST, DNR order, or other advance directive limiting resuscitative efforts. In the early morning hours, a nurse entered the resident’s room to assist the roommate and observed that the resident was not breathing but was still warm to the touch. The nurse then obtained a second nurse to verify the absence of breathing. The facility’s final investigation report states that the nurse assessed the resident and noted absence of respirations, absence of a palpable pulse, and physical findings consistent with post-mortem changes, and determined the resident had expired. Despite the lack of any documented DNR or advance directive in the record available for review at that time, CPR was not initiated and 911 was not called. Interviews with staff confirmed that the resident’s code status was unknown at the time of the event and that no resuscitative efforts were made. The ADON stated that if a resident’s code status or POLST form cannot be found, the resident is considered a full code, and that when in doubt a resident is a full code. The DON reported that the LPN who found the resident did not know the code status and did not initiate CPR or call 911, even though the resident was a recent admission and no POLST form was on file. The LPN stated she suggested initiating CPR because there was no POLST, but the RN present told her not to start CPR. Other staff interviewed stated that if a resident’s code status is not known or cannot be found, CPR is supposed to be initiated.
Failure to Obtain Timely Wound Consultation and Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely wound specialist involvement and adherence to ordered wound treatments for a resident admitted with an existing unstageable sacral-coccygeal pressure ulcer. The resident, a 75-year-old with multiple comorbidities including type 2 diabetes mellitus, prior necrotizing fasciitis, hemiplegia, DVT, and hypothyroidism, was admitted with an unstageable sacral pressure ulcer measuring 1.5 cm x 1.5 cm, fully covered with slough but documented as clean, without odor or signs of infection. The admission physician orders indicated the resident may be seen by a wound care physician, and the initial treatment ordered on admission was cleansing the coccyx area, applying skin prep, Medi-Honey, fluff gauze, and a dry dressing three times weekly and as needed. Despite this, the wound care nurse did not obtain a wound specialist consultation until approximately five weeks after admission, during which time the wound measurements increased and remained unstageable with slough covering the wound bed. Over the ensuing weeks, the wound care nurse documented weekly assessments showing progressive enlargement of the wound, which by early November measured 4.3 cm x 3.8 cm with excoriation around the wound and a bed fully covered with slough. The treatment administration record for November showed the resident continued to receive the same Medi-Honey treatment three times a week. The wound specialist NP first evaluated the resident on a date in early November, documenting an unstageable/unclassified pressure ulcer measuring 5.0 cm x 6.0 cm x 0.2 cm with 100% slough, moderate serosanguinous drainage without odor, and no signs of infection in the peri-wound area. The NP recommended cleansing, Medi-Honey, calcium alginate, and foam dressing three times weekly and as needed, and performed a bedside debridement to remove slough and necrotic tissue. A second debridement was performed one week later, after which the NP ordered Dakin’s 1/4 strength solution with wet-to-moist gauze and foam dressing daily and as needed. The NP later documented that Dakin’s was ordered as a debriding agent and antiseptic to help prevent infection and that daily treatment was important. Despite the NP’s subsequent orders and recommendations, the facility did not consistently implement the updated wound care regimen. The NP’s note on a mid-November visit documented the wound as now a stage 4 pressure injury measuring 6.5 cm x 4.5 cm x 2.0 cm, with moderate serosanguinous drainage and odor, 100% slough, and peri-wound signs and symptoms of infection. The NP ordered a wound culture and topical antibiotics, including Dakin’s solution and Silvadene cream with calcium alginate and foam or dry dressing daily and as needed. However, the treatment administration record showed the resident continued to receive Medi-Honey three times weekly, with Dakin’s solution applied only on three specific days and no documentation that Silvadene was ever provided. The wound nurse acknowledged that she typically received verbal orders from the NP and did not read the NP’s written notes for one to two days, and that the only change she recalled was increasing Medi-Honey frequency and later changing to Santyl. The primary physician stated he relied on consultants’ recommendations, but the record showed the resident was not seen by the wound specialist until the wound had significantly deteriorated. Ultimately, the wound culture was positive for MRSA, and hospital records documented an infected stage 4 sacral decubitus ulcer with osteomyelitis requiring operative excisional debridement of skin, subcutaneous fat, muscle, and fascia. The facility’s own wound prevention and healing policy required nurses to provide wound care per physician orders, notify the physician of lack of progress, and have the wound MD/NP evaluate and change treatment when the patient was not responding, which was not followed in this case.
Failure to Provide Ordered Opioid Analgesia for Resident With Severe Traumatic Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered opioid pain medication to a newly admitted resident with extensive traumatic injuries and a history of chronic pain management. The resident was admitted following a serious motor vehicle accident that resulted in multiple fractures (thoracic vertebrae, ribs, pelvis, sacrum, humerus, ilium), lung contusions, traumatic pneumothorax, liver and spleen lacerations, and hemoperitoneum. Hospital documentation showed that prior to admission the resident had been on Percocet 5-325 mg three times daily as an outpatient and was discharged from the hospital with instructions to continue Percocet 5-325 mg one tablet three times daily (scheduled) and ibuprofen 800 mg every 8 hours as needed for pain. The facility’s physician orders on admission included ibuprofen 800 mg every 8 hours as needed and Percocet 5-325 mg every 8 hours as needed for pain. On the evening and night following admission, the facility administered only ibuprofen and did not provide any Percocet, despite the resident’s repeated complaints of severe pain. The MAR documented that ibuprofen 800 mg was given late in the evening for a pain level of 4 and was noted as ineffective in controlling the pain, with no documentation that Percocet was ever administered. The DON documented that the hospital had not sent written prescriptions (“hard scripts”) for the narcotic pain medication, that the pharmacy reported not receiving such scripts, and that the facility was unable to access narcotics from the emergency kit without a prescription. The DON contacted the pharmacy and the hospital but did not obtain an order that would allow access to Percocet from the emergency kit, and she did not contact a provider at the time she first realized the resident had arrived without the necessary narcotic prescriptions. The DON later stated she was not aware that a verbal order could have been used to access the emergency kit and acknowledged there was a discrepancy between the facility’s PRN Percocet order and the hospital’s scheduled Percocet order, of which she had not been aware. Throughout the night, the resident continued to report uncontrolled pain, which she later described as escalating to 10/10, and she reported yelling out in pain and repeatedly requesting Percocet. CNAs reported that the resident was constantly on the call light, complaining about needing pain pills, threatening to sign out AMA, and yelling out. The DON documented that the resident complained of pain and inability to sleep, had received PRN ibuprofen, and that vital signs were within normal limits; she also noted that the resident had two loose stools but did not associate them with opioid withdrawal. The pharmacy director confirmed that the correct dose of Percocet was available in the emergency kit and that it could have been accessed with a provider’s emergency verbal order. The medical director stated that, had he been contacted sooner, he could have given a verbal order to access Percocet from the emergency kit or ordered transfer to the ER. Instead, after the resident called 911 requesting transport for pain management, the medical director eventually ordered transfer to the ER at the resident’s request, and the resident signed AMA paperwork stating she would not return. In the ER, the resident presented with complaints of pain all over, nausea, vomiting, diarrhea, and reported opioid withdrawal symptoms, with documentation that no pain medication had been administered between the time of admission to the facility and arrival at the ER, approximately 12 hours later. The ER administered Percocet and discharged her with a prescription for Percocet. The facility’s own pain management policy stated that it was the policy of the facility to respect and support the resident’s right to optimal pain assessment and management, and referenced an opioid use policy and procedure. Despite this, the record shows that the facility did not provide the ordered opioid medication, did not resolve the lack of a written prescription in a timely manner through available mechanisms (such as obtaining a verbal order to access the emergency kit), and did not adjust its actions when ibuprofen was documented as ineffective. The combination of the resident’s extensive injuries, documented chronic pain management history, hospital discharge instructions for scheduled Percocet, and the facility’s failure to administer any Percocet or secure timely prescriber authorization led to the resident experiencing uncontrolled pain, reporting opioid withdrawal symptoms, and ultimately signing out AMA and calling 911 for transport to the ER for pain management.
Failure to Maintain Safe and Well-Repaired Ceilings and Plumbing
Penalty
Summary
The facility failed to maintain the physical environment in a safe, clean, and well‑repaired condition, specifically related to ceiling tiles and a cold water pipe. The Facility Maintenance Director job description required planning, organizing, and directing maintenance operations to ensure the building was safe and comfortable, including repairing facility property, coordinating outside vendors when needed, maintaining supplies and equipment, promptly reporting damage to the Administrator, and making weekly inspections. A former Maintenance Director was terminated for incompetence and unsatisfactory job performance, including failure to complete assigned tasks such as fixing or replacing stained ceiling tiles by an established deadline. At the time of the survey, the facility census was 72 residents, all potentially affected by the environmental deficiencies. On observation, surveyors noted an actively leaking water pipe in the ceiling of the ice machine/vending area, with a trash can placed beneath it containing about one inch of standing water, two soaked blankets and multiple wet towels on the floor, and a missing 2x2 ceiling tile exposing insulation, wiring, and water pipes. Twelve ceiling tiles above the nurses’ desk were brown‑stained and visibly bulging, suggesting ongoing water damage, and on a subsequent day the ice machine/vending area still had two missing 2x2 ceiling tiles with exposed insulation, wiring, and pipes. An RN reported that the ceiling tiles above the nurses’ station had been stained since she began working there months earlier, and an LPN stated the tiles had been stained for as long as she could remember and that the ceiling had been leaking in the ice machine area for several days, noting that the ice machine there was used for all residents. The Regional Maintenance Director confirmed the stained tiles above the nurses’ station and the leaking pipe in the ice machine/vending area, stating that the tiles had not yet been changed because they took time to cut and no one had done it.
Failure to Provide Required Annual Competency Training for CNAs
Penalty
Summary
The facility failed to ensure all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention, as required by its Facility Assessment Tool and federal regulations. The Facility Daily Census Report documented 72 residents residing in the facility at the time of the survey. The Facility Assessment Tool specified that required in‑service training for nurse aides must be at least 12 hours per year, sufficient to ensure continuing competence, address areas of weakness identified in performance reviews and the facility assessment, and may address special resident needs. Review of employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of the required 12 hours of annual CNA competency training. During interviews, one agency CNA (V9) stated that they had not received 12 hours of annual competency training from either the facility or the hiring agency and were unaware of the requirement for 12 hours of annual training. Another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) both confirmed that V9 and V10 had not received the required 12 hours of annual CNA training from either the facility or the agency that employed them.
Lack of Behavioral Health Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including agency CNAs, received behavioral health training as required by the facility’s own Facility Assessment Tool. The Facility Assessment Tool dated 3/26/26 specifies that required in‑service training for nurse aides must include dementia management, resident abuse prevention, and, for nurse aides providing services to individuals with cognitive impairments, training on the care of cognitively impaired residents with behaviors. Review of the Facility Daily Census Report dated 4/29/26 shows that 72 residents were residing in the facility at the time of the survey. Review of the employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of behavioral health training. In interviews, one agency CNA (V9) stated that they had not received behavioral health training from either the facility or the hiring agency, and another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) confirmed that these agency CNAs had not received behavioral health training from the facility or their agency.
Unsanitary Kitchen Conditions and Ineffective Surface Sanitization
Penalty
Summary
The facility failed to maintain effective sanitizer levels for cleaning food contact surfaces and to keep kitchen equipment in a safe and sanitary condition, potentially affecting all 64 residents documented on the census. During a kitchen walkthrough, surveyors observed a non-functioning garbage disposal containing chunks of food and clotted milk with water leaking from the seals, pooling on the floor, and draining into a floor drain, accompanied by a strong odor of rotting food. The sprayer above the disposal had hard water buildup that caused water to spray outward onto the wall, floor, and surrounding area. Pipes to the ice machine were leaking water down the wall and pooling on the floor. The HVAC unit in the kitchen had a large amount of brownish dirt and debris, including brown fuzzy lint-like material, with some pieces falling onto the surface below. The kitchen door to the large dining room had a broken top hinge, loose bolts, and a jagged, splintered knob-side edge. Staff interviews and observations further showed improper sanitation practices and lack of appropriate chemical supplies. The cook reported the garbage disposal had been leaking and non-functional for about a week and that maintenance staff were aware but unable to fix it. The cook also stated that maintenance staff had been sawing and sanding a replacement door in the kitchen while food was being cooked and served, although the maintenance director later stated the cutting and sanding were done outside. The wall-mounted chemical dispenser above the kitchen sink had no sanitizer bottles attached. When the dishwasher and assistant dietary manager prepared sanitizer solution using the dispenser, test strips showed no chlorine color change, and the dishwasher was unsure what color the strip should turn. The assistant dietary manager stated the facility did not have compatible chemical bottles for the dispenser and that staff were instead using dish soap in sanitizer buckets and multipurpose cleaner from housekeeping. The administrator stated the facility did not have an environmental policy for maintaining equipment.
Failure to Control Excessive TV Noise Affecting Nearby Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain environmental noise at a comfortable level for multiple residents due to one resident’s excessively loud television. Surveyors observed that one resident’s TV volume was so loud it could be heard from the nurse’s station and from the end of the hallway, even with other residents’ doors closed. A sign on this resident’s door stated “Do Not Shut Door,” and staff reported that the resident liked the TV volume loud and was non-compliant with requests to lower it. Nursing notes documented that when asked to reduce the TV volume, the resident became verbally aggressive toward staff. The resident’s diagnoses included unspecified dementia with behavioral disturbance, adjustment disorder with mixed anxiety and depressed mood, hemiplegia and hemiparesis following cerebral infarction, and restlessness and agitation. Other residents on the same hall reported ongoing disruption from the loud TV, particularly at night when they were trying to sleep. One resident across the hall stated that the loud TV had been an issue for a while and affected other residents on the hall. Another resident one room away reported that the neighbor’s TV was really loud all day and especially at night, that staff were asked to intervene, and that the resident with the loud TV would briefly turn it down and then increase the volume again; this resident reported needing to use headphones to cancel out the noise. Staff, including an LPN and a CNA, confirmed that residents complained they could not sleep due to the loud TV, that the resident with the TV became upset and verbally aggressive when asked to turn it down, and that the TV volume could be heard from the end of the hallway. The care plan for the resident with the loud TV identified a problem of turning the volume up excessively, with an agreed target volume level of 40 and instructions for staff to remind the resident of this agreed volume.
Failure to Protect Resident From Physical Abuse and to Report Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident with a known history of antagonistic, verbally and physically aggressive behavior kicked another resident, causing a fall and subsequent pain. Multiple witnesses, including another resident and two CNAs, reported that while residents were lined up for a smoke break, the aggressor resident grabbed the victim resident’s leg in an attempt to make him fall and, when that failed, deliberately kicked the victim’s left leg or knee, causing him to fall onto his left hip. The victim resident consistently reported that the kick knocked him off his feet, that he landed on his left hip, and that he continued to experience left hip and buttock pain rated 5/10 with walking and lying on his back. A behavior note documented that the aggressor resident stood up from his wheelchair and kicked the victim resident in the leg for no reason, witnessed by residents and staff, and a subsequent nurse’s note documented the victim’s complaint of left hip pain and an order for a left hip and pelvis X-ray. Despite staff recognizing the event as physical abuse and a reportable incident under the facility’s Abuse and Retaliation Prevention and Reporting policy, the facility did not take required reporting and response actions. An LPN stated that the incident was reportable and notified the Administrator, and both the DON and ADON acknowledged that one resident kicking another constitutes physical abuse that should be reported to the state surveying agency and to the police. However, the Administrator confirmed that the facility did not report the incident to the state surveying agency and that facility staff did not call the police or an ambulance for the victim resident, even though the victim repeatedly requested that the police and an ambulance be called. Instead, the aggressor resident independently called 911 for himself. The facility’s own policy defines physical abuse as willful infliction of injury, including kicking, and affirms residents’ right to be free from abuse, but these standards were not followed in this incident.
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