Addolorata Villa
Inspection history, citations, penalties and survey trends for this long-term care facility in Wheeling, Illinois.
- Location
- 555 Mchenry Road, Wheeling, Illinois 60090
- CMS Provider Number
- 145724
- Inspections on file
- 28
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Addolorata Villa during CMS and state inspections, most recent first.
A resident with dementia, OA, cardiomyopathy, HF, Afib, and a history of osteomyelitis with toe amputation, who required substantial/max assist for chair/bed-to-chair transfers, was observed ambulating while pushing a w/c. An activity aide, who was not trained to perform transfers, took the w/c, positioned it behind the resident, and verbally instructed him to sit without using a gait belt or standing in front to control the descent. As the resident attempted to sit, he fell forward, striking his head and face on the floor, resulting in a facial laceration, nasal fx, and a type 2 odontoid fx. PT later described that safe transfer from standing to w/c requires staff to stand in front of the resident with a gait belt, and the DON stated activity aides should call for assistance, consistent with the facility’s fall prevention policy and the resident’s care plan requirements for high-level transfer assistance.
A resident with severe cognitive impairment and mobility deficits was not provided with required care plan interventions, including the use of a gait belt and walker during ambulation. Staff allowed the resident to ambulate without these safety measures, resulting in a fall and hip fracture. Facility policy required the use of a gait belt for assisted ambulation, but this was not followed at the time of the incident.
A resident with dementia and multiple comorbidities made a statement alleging abuse after an incident with a CNA, but staff did not report or investigate the allegation as required by facility policy. The nurse documented the statement as a behavioral issue, and neither the administrator nor the DON were notified, resulting in a failure to follow abuse reporting protocols.
A resident with a history of heart failure and a recent ankle fracture developed a facility-acquired unstageable pressure ulcer due to the facility's failure to assess and prevent pressure ulcers. Despite being at moderate risk, the resident's ulcer was not reported or documented in a timely manner, and staff failed to encourage mobility or reposition the resident regularly. The lack of communication and documentation among staff contributed to the deficiency.
A cognitively impaired resident with a high fall risk fell from a wheelchair in the common area, resulting in a hip fracture, due to inadequate supervision. Despite being aware of the resident's tendency to stand up from the wheelchair, staff failed to provide continuous monitoring, leading to the incident. The facility's fall prevention policy was not effectively implemented, contributing to the deficiency.
The facility failed to provide bed hold notifications to residents and their families when residents were discharged to a hospital. This affected several residents with various medical conditions, as the facility did not adhere to its policy requiring notification about bed hold duration and payment. The Administrator and DON acknowledged the oversight, revealing a lack of staff training and awareness of the policy.
The facility exhibited deficiencies in food handling and hygiene practices, including improper food storage, inadequate dishwasher temperatures, and poor hand hygiene. Carrots were stored on the floor, and containers lacked labeling. The dishwasher failed to reach the required final rinse temperature, and a dietary server did not perform hand hygiene between tasks. These issues were acknowledged by the Director of Dining Services, the Director of Nursing, and the Infection Preventionist.
A resident with dementia and other medical conditions experienced an unwitnessed fall and complained of hip pain. The facility failed to implement a STAT X-ray order and did not document the fall in the medical record. The resident was transferred to the hospital ten hours later, where a hip fracture was diagnosed. The facility lacked proper documentation and communication protocols, contributing to the deficiency.
A resident with dementia and poor impulse control kicked another resident, causing a 7 cm skin tear, after becoming frustrated with the loud speaking of the first resident. The incident occurred in the common area, and staff did not anticipate the aggressive behavior despite the facility's policy against abuse.
A resident did not receive prescribed medications upon admission due to a delay in pharmacy delivery. The facility's staff communicated with the resident's family about the delay, but the medications were not administered as per the prescriber's orders. The resident's sarcastic demeanor added to the communication challenges faced by the staff.
Unsafe Transfer by Activity Aide Leads to Resident Fall and Serious Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement safe transfer and supervision practices during a wheelchair-to-standing and return-to-sitting transfer, resulting in a resident fall with serious injuries. An activity aide (V6) reported witnessing the resident ambulating while pushing his wheelchair, then taking the wheelchair from the resident, turning it around, placing it behind him, and verbally instructing him to sit. V6 stated she positioned herself behind the wheelchair, did not use a gait belt, and did not stand in front of the resident to control the descent. As the resident attempted to sit, he fell forward, striking his head and face on the floor. The resident sustained a facial laceration, nasal fracture, and a type 2 odontoid (neck) fracture and was hospitalized, later returning to the facility where the family chose hospice care. The resident had multiple medical diagnoses including Alzheimer’s disease, unspecified dementia with agitation, osteoarthritis, cardiomyopathy, heart failure, atrial fibrillation, and a history of left foot osteomyelitis with toe amputation. The care plan and MDS indicated the resident had ADL self-care and mobility performance deficits related to dementia and other conditions, and required substantial/max assistance for chair/bed-to-chair transfers, with interventions specifying transfer assistance at a moderate to maximum level with two staff. Physical therapy documentation showed the resident ambulated with minimal assist and wheelchair follow using a front-wheeled walker, and PT later stated that for safe transfer from standing to sitting in a wheelchair, staff should stand in front of the resident, apply a gait belt, and assist back to the wheelchair to prevent frontal falls. The DON confirmed that activity aides were not trained to perform transfers and should call for assistance, and the facility’s fall prevention policy required assessment of fall risk and implementation of appropriate interventions, including determining and addressing factors contributing to falls.
Failure to Implement Care Plan Interventions During Ambulation
Penalty
Summary
A deficiency occurred when staff failed to implement care plan interventions for a resident with severe cognitive impairment, Parkinson's Disease, and dementia. The resident's care plan required ambulation with contact guard, use of a gait belt, and a wheeled walker for safety. On the day of the incident, the resident was observed ambulating without the walker and without a gait belt. Although staff intervened and provided supervision, the resident continued to ambulate without the required gait belt and at times refused to use the walker. Despite being positioned next to the resident, staff were unable to prevent a fall when the resident lost balance and fell after standing up and walking away from the nurse station. The resident sustained a left hip fracture as a result of the fall and required hospital admission. Interviews with staff confirmed that the gait belt, a required intervention per the care plan and facility policy, was not used at the time of the fall. The facility's policy mandates the use of gait belts for all transfers and assisted ambulation according to assessed needs and care plans. The failure to follow these interventions directly contributed to the resident's fall and subsequent injury.
Failure to Report and Investigate Resident Abuse Allegation
Penalty
Summary
The facility failed to follow its abuse prevention policy by not reporting and investigating an allegation of abuse made by a resident with a history of making such claims. The resident, an elderly female with diagnoses including dementia with behavioral disturbance, chronic venous hypertension with ulcers, stage 3 chronic kidney disease, hypothyroidism, and recurrent severe major depressive disorder, was admitted to the facility and had documented behavioral issues. On one occasion, after an incident in the bathroom, the resident stated that she had been abused and expressed a desire to contact a family member. This statement was documented in the behavior progress note, but no abuse investigation report was completed for the allegation. Interviews with facility staff revealed that the administrator and DON were not made aware of the resident's statement, and the nurse involved considered the comment to be a manifestation of the resident's psychiatric behavior rather than a reportable abuse allegation. The facility's policy requires all allegations of abuse, including resident reports, to be immediately reported to the administrator and state authorities. However, in this case, the staff did not follow the required protocol, and the incident was not reported or investigated as an abuse allegation.
Failure to Prevent and Manage Pressure Ulcer
Penalty
Summary
The facility failed to assess and prevent the development of a pressure ulcer for a resident, resulting in the resident developing a facility-acquired unstageable pressure ulcer. The resident, a female with a history of heart failure and a recent ankle fracture, was admitted with intact skin and a Braden score indicating moderate risk for pressure sores. Despite this, the resident developed a pressure ulcer on the sacrum, which was first noted on December 4th, 2024, and later became unstageable due to necrosis. The deficiency was exacerbated by a lack of communication and documentation among the staff. The resident's pressure ulcer was not reported or documented in a timely manner, as evidenced by the absence of skin alterations noted in the shower sheets and the surprise expressed by staff members upon discovering the ulcer. The facility's policy required immediate initiation of treatment for newly identified pressure ulcers, but this was not effectively implemented, leading to a delay in appropriate care. Interviews with staff revealed that the resident was often in bed due to her ankle injury, which increased her risk for pressure ulcers. The staff failed to consistently encourage mobility or reposition the resident every two hours, as recommended. Additionally, there was a lack of consistent monitoring and documentation of the resident's skin condition, contributing to the development and progression of the pressure ulcer.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to adequately monitor and supervise a cognitively impaired resident, identified as R120, which resulted in a fall from a wheelchair in the common area and an acute subcapital femoral neck fracture. R120, a female resident with severe cognitive impairment and a high fall risk, was initially admitted with diagnoses including dementia and repeated falls. Despite being identified as a high fall risk, the facility did not implement sufficient interventions to prevent her from standing up and falling from her wheelchair. On the day of the incident, R120 was left unsupervised in the common area while staff were occupied with other duties. The nurse on duty, V24, was attending to a phone call and medication cart when R120 attempted to stand and subsequently fell. The incident report and interviews with staff revealed that R120 frequently attempted to stand from her wheelchair, and staff were aware of her behavior but failed to provide continuous supervision. The care plan for R120 included interventions for fall risk and poor safety awareness, but these were not effectively implemented or updated to address her behavior of standing up in the wheelchair. The facility's policy on fall prevention and management emphasizes the need for adequate supervision based on individual resident needs. However, the supervision provided to R120 was insufficient, as evidenced by the lack of staff presence in the common area at the time of her fall. Interviews with staff, including the Director of Nursing, confirmed that the facility's protocol for monitoring residents in the common area was not followed, leading to the deficiency in preventing R120's fall.
Failure to Provide Bed Hold Notifications
Penalty
Summary
The facility failed to provide bed hold notifications to residents and/or their family members when residents were discharged to a local hospital. This deficiency was identified during interviews and record reviews, affecting five residents out of a sample of 38. The residents involved had various medical conditions, including pneumonia, sepsis, dysphagia, acute kidney failure, Pick's disease, hemiplegia, hemiparesis, Alzheimer's disease, and fractures. Despite being transferred to a hospital, there was no documentation of bed hold notifications for these residents, indicating a lapse in the facility's adherence to its own policy. The facility's Administrator and Director of Nursing acknowledged the oversight, stating that the bed hold policy had not been followed throughout the facility. The Director of Nursing admitted unfamiliarity with the policy and mentioned that communication with families was limited to informing them about the discharge and follow-up with the hospital. The facility's policy, effective since 2019, requires informing residents and their representatives about the duration of the bed hold and the payment policy. However, this procedure was not implemented, and the staff was not adequately trained or informed about the policy, leading to the deficiency.
Deficiencies in Food Handling and Hygiene Practices
Penalty
Summary
The facility failed to adhere to proper food storage and handling practices, as well as maintaining appropriate dishwasher temperatures, which could lead to food-borne illnesses. During a kitchen tour, it was observed that three 50-pound bags of carrots were placed directly on the floor, and containers of flour, salt, sugar, and navy beans were not labeled with open and used by dates. The Director of Dining Services acknowledged these issues, stating that staff are expected to follow facility policy regarding food labeling and storage. Additionally, the facility's dishwasher was not maintaining the required final rinse temperature. The surveyor noted that the final rinse temperature was below the expected range of 180F to 190F, with readings of 174F and 175F. The Director of Dining Services indicated that a local company was contacted to address the issue, as one of the dishwasher's elements was not functioning, and parts were ordered for repair. Furthermore, improper hand hygiene practices were observed in the dining room. A dietary server was seen handling food with the same gloves used to open a refrigerator, without performing hand hygiene in between tasks. The Director of Nursing and the Infection Preventionist confirmed that staff are expected to wash their hands or use hand sanitizer before and after care, after removing gloves, and when changing tasks. The facility's policies emphasize the importance of hand hygiene and proper glove use to prevent contamination and infection.
Failure to Implement STAT X-ray Order and Document Fall
Penalty
Summary
The facility failed to implement a physician's order for a STAT X-ray after a resident sustained an unwitnessed fall and complained of pain in the right hip area. The resident, who had a history of dementia, chronic obstructive pulmonary disease, and hypertension, was found on the floor by a Certified Nurse Assistant after his roommate pulled the call light. Despite the resident's complaint of hip pain, the nurse assessed the resident and moved him to a wheelchair without conducting a full assessment or calling 911. The physician was contacted and ordered a STAT X-ray, but the X-ray was not performed as the portable X-ray company did not arrive, and the nurse failed to notify the physician of this delay. The resident was transferred to a local emergency room ten hours after the fall, where he was diagnosed with a right hip fracture. The Director of Nursing confirmed that there was no documentation in the resident's medical record regarding the fall, which was against the facility's expectations. The resident's care plan indicated a high risk for falls, and the resident was unable to use the call light due to cognitive impairment. The facility's staff did not follow the standard protocol for neurological checks after an unwitnessed fall, and there was a lack of communication with the physician regarding the unfulfilled X-ray order. The report highlights several failures in the facility's response to the resident's fall, including inadequate documentation, failure to perform necessary medical assessments, and lack of communication with the physician. The facility did not have policies in place for neurological checks or carrying out doctors' orders, contributing to the deficiency. The resident's condition worsened, leading to a diagnosis of acute and chronic respiratory failure with hypoxia, and a fracture was confirmed through an X-ray at the hospital.
Failure to Prevent Resident-to-Resident Aggression
Penalty
Summary
The facility failed to prevent an incident of resident-to-resident physical aggression, which resulted in one resident kicking another, causing a 7 cm skin tear. The incident occurred in the common area when a resident with dementia and severe impairment, who is known for speaking loudly due to being hard of hearing, was addressing another resident who was shaking a table. A second resident, also with dementia and poor impulse control, became frustrated with the loud speaking and kicked the first resident in the leg. The incident was witnessed by staff members who were present in the common area and nearby nurse's station. The nurse on duty was alerted by a shout and found the injured resident bleeding from the leg. The resident was immediately treated for the skin tear, and the two involved residents were separated to prevent further aggression. The staff did not anticipate the aggressive behavior from the second resident, who had a history of verbal aggression but not physical aggression. The facility's investigation revealed that both residents involved have dementia and exhibit behaviors such as poor impulse control and difficulty interpreting their environment. The facility's policy affirms the right of residents to be free from abuse, including physical abuse by other residents. Despite this policy, the staff did not foresee the physical aggression, which led to the deficiency in protecting residents from abuse.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that a resident received her medications as ordered upon admission. The resident, identified as R5, was admitted to the facility, and her Medication Administration Record indicated that she was prescribed several medications, including Allegra, Amlodipine, Cefpodoxime Proxetil, Januvia, Telmisartin, Bisoprolol Fumarate, and Preservision. However, none of these medications were signed out as administered. The Pharmacy Manifest Document revealed that the medications were not delivered until the following day, indicating a delay in medication administration. Interviews with facility staff highlighted communication issues and procedural lapses. An RN, V23, explained the process of obtaining and verifying medication orders, while another RN, V22, mentioned that the family had their own stock of medications and was informed about the delay in pharmacy delivery. V22 expressed difficulty in communicating with the resident due to her sarcastic demeanor, which complicated the situation further. The facility's policy on medication administration mandates that medications be administered according to the prescriber's written orders, which was not adhered to in this instance.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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