Alden Estates Cts Of Huntley
Inspection history, citations, penalties and survey trends for this long-term care facility in Huntley, Illinois.
- Location
- 12140 Regency Parkway, Huntley, Illinois 60142
- CMS Provider Number
- 146186
- Inspections on file
- 34
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Alden Estates Cts Of Huntley during CMS and state inspections, most recent first.
A resident with multiple cardiac and renal comorbidities, generally alert but sometimes confused, was mistakenly given another resident’s morning medications, including several BP-lowering agents, in addition to her own diuretic. An LPN, relying on a photo and asking the wrong name, misidentified the resident and administered the other resident’s medications, despite facility policy requiring accurate resident identification and prohibiting administration of one resident’s medications to another. The error was discovered when the intended recipient questioned not receiving her medications, and an RN then found the affected resident hypotensive, lethargic, and slumped in a wheelchair, with very low BP readings. The resident’s daughter later reported that the hospital diagnosed iatrogenic hypotension and that the resident required ICU care and IV medications to raise her BP.
Oxygen tubing for several residents receiving oxygen therapy was not labeled or dated as required by physician orders and facility policy. Staff interviews revealed confusion about responsibility for changing and labeling the tubing, and missed duties were noted following staff turnover. The deficiency involved both nursing and CNA staff and affected residents with orders for continuous or as-needed oxygen.
Surveyors found that insulin pens were not properly labeled with open and expiration dates, and expired pens were not disposed of as required. Additionally, the medication refrigerator used for storing insulins was not consistently checked for temperature twice daily, with documentation missing for several days. These deficiencies were confirmed by staff interviews and review of facility policy.
A CNA provided high-contact care to a resident with a suprapubic catheter, wearing only gloves instead of both gown and gloves as required by the facility's Enhanced Barrier Precautions (EBP) policy. The resident had orders for EBP due to an indwelling device, and signage outside the room instructed staff to use full PPE during care. An LPN confirmed that the correct PPE was not used during the observed care activity.
A resident with a history of pulmonary embolism did not receive several doses of Warfarin, and neither the resident nor the PCP was notified of the missed doses. The MAR lacked documentation of the medication order during the missed period, and the PCP confirmed no notification was received, which would have prompted further clinical action. The resident's emergency contact was also not informed about the missed doses.
A resident with a history of pulmonary embolism and peripheral vascular disease missed four doses of physician-ordered Warfarin after the order was not promptly entered into the MAR. The lapse was not identified by nursing staff, and the primary care physician confirmed the order had been given but not implemented until several days later.
A resident with a history of pulmonary embolism and peripheral vascular disease missed four consecutive doses of Warfarin after a physician's order was not entered into the MAR. Staff confirmed the lapse, and the DON acknowledged the medication was not administered as required, in violation of facility policy.
The facility failed to protect resident rights by allowing a video with identifiable resident images to be posted on a staff member's social media account, violating the facility's Social Media Policy. Additionally, residents at the same dining table were not served meals simultaneously, leading to dissatisfaction and delays, partly due to a lack of clean dishes. The Dietary Supervisor was unaware of these issues, and the facility's policy did not ensure simultaneous meal service.
The facility failed to prevent cross-contamination during food preparation for 15 residents on a pureed diet. The Executive Chef did not follow hand hygiene protocols, using bare hands to handle thermometers and touching various surfaces without sanitizing them. The Dietary Supervisor confirmed the need for handwashing and sanitizing thermometers, as outlined in the facility's policies, but these practices were not adhered to, resulting in a deficiency.
A resident with respiratory issues received oxygen therapy administered by CNAs, contrary to the facility's policy that only nurses should apply oxygen to ensure compliance with physician's orders. The CNAs believed it was within their scope, but the DON clarified it was not.
The facility failed to obtain daily weights for a resident with CHF, perform timely dressing changes and wound assessments for a resident with a surgical wound, and provide adequate skin care for a resident with reddened skin. These deficiencies highlight lapses in following care plans and physician orders, as well as communication issues among staff.
A facility failed to maintain a resident's indwelling urinary drainage bag properly, leading to potential contamination and infection risk. The resident's catheter bag was observed resting on the wheelchair footrest and not below the bladder level, with no documented education provided to the resident on proper catheter care. The facility's policy requires the drainage bag to be below the bladder to prevent urine stasis, which was not followed.
The facility failed to prevent cross-contamination during a dressing change for a resident with a surgical incision by using the same gauze for multiple wounds without changing it or performing hand hygiene. Additionally, the facility did not consistently post enhanced barrier precaution (EBP) signage for a resident with an IV midline, as required by policy. These deficiencies highlight lapses in infection prevention and control practices.
A resident with a history of dysphagia and cognitive impairment experienced a fatal choking incident due to the facility's failure to provide 1:1 supervision during meals. Despite orders from a nurse practitioner for close supervision following a previous choking episode, the necessary precautions were not communicated or implemented, resulting in the resident's death from aspiration pneumonia.
A resident with dysphagia and other health issues experienced a fatal choking episode after facility staff failed to implement a physician's order for a mechanical soft diet. Despite specific instructions from a nurse practitioner, the order was not entered into the medical record, nor communicated during shift reports, resulting in the resident receiving regular food and choking on sausage.
A resident sustained burns from spilled coffee due to the facility's failure to ensure safe service of hot liquids. The resident, with a history of right-sided weakness, was unable to avoid the spill. Staff were not adequately trained, and there was no clear process for managing hot liquid temperatures, leading to unsafe serving practices.
A resident with a history of stroke and other medical conditions suffered burns from spilled coffee, and the facility failed to track and manage the wounds properly. The wound care nurse did not measure the burns, and the resident's care plan indicated a risk for delayed healing. The wound care provider had not seen the resident until several days after the incident, and the facility lacked a clear policy for burn care.
A resident did not receive the physician-ordered Nystatin cream due to the facility running out of the medication and failing to reorder it in a timely manner. Despite the facility's policy to reorder medications when a 2-day supply remains, the resident missed several doses, leading to feelings of neglect and a request to speak with the DON.
The facility failed to ensure consistent PPE usage for staff entering COVID-positive resident rooms, with some staff wearing only surgical masks instead of the required N95 masks and face shields. This inconsistency was noted despite the facility's policy mandating N95 respirators, eye protection, gowns, and gloves. Residents expressed concerns about the lack of mask-wearing, particularly those who were immunocompromised.
A resident with dementia and a history of impulsive behavior fell and fractured her hip during ADL care when a CNA failed to ensure she was seated while adjusting her shoe. The resident, previously able to walk with a walker, became unable to ambulate independently after the fall, requiring surgical intervention. The facility's DON acknowledged the expectation for CNAs to be aware of fall risks.
A resident with a history of falls and agitation was placed in a high back wheeled recliner without adequate supervision, leading to a fall and subdural hematoma. The CNA involved left the resident unattended, and the recliner tipped over, causing the injury. The facility's Fall Management Program was not effectively implemented.
A resident, who was alert and normally continent of stool, had to wait 35 minutes for assistance after activating the call light, resulting in incontinence of stool. This incident, which was embarrassing for the resident, was not isolated, as a similar situation occurred a few days earlier. The facility's policy was to respond to call lights within 3-8 minutes, but there was no system to track response times.
A resident with osteoarthritis and chronic gout, who had range of motion impairments and a contracture in her left hand, was not provided with an alternative call light despite informing staff of her difficulties. The resident had to rely on her roommate to push the call light button, as confirmed by both the resident, her roommate, and a CNA. The DON acknowledged that an alternative call light should have been provided.
The facility failed to obtain daily weights for two residents with CHF as ordered by their physicians. One resident was not weighed for over a week despite a recent hospitalization and daily weight order, while another resident had multiple days without recorded weights. The Director of Nursing confirmed the importance of daily weights for monitoring CHF, but the facility did not adhere to this protocol.
A resident's medication was found left at the bedside, and the resident did not know what it was or how long it had been there. A nurse identified the medication as Carbidopa-Levodopa, but there was no documentation allowing the resident to self-administer medications. Another nurse confirmed that medications should never be left at the bedside.
The facility failed to change gloves and perform hand hygiene during incontinence care for two residents, leading to potential cross-contamination. CNAs did not follow the facility's hand hygiene policy after touching contaminated items.
Significant Medication Error Leading to Iatrogenic Hypotension
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, resulting in iatrogenic hypotension and hospitalization. The resident was an elderly female admitted with multiple complex diagnoses, including cellulitis of both lower limbs, sepsis, anemia in chronic kidney disease, hypertensive heart and chronic kidney disease, acute pulmonary edema, paroxysmal atrial fibrillation, chronic congestive heart failure, and venous insufficiency. Her admission and initial nursing assessments documented that she was generally alert to person and time, oriented to person and place, but confused at times. On the morning of the incident, nursing documentation indicated that she was in bed at the start of the shift without distress, and later seated in a chair during the morning medication pass with no complaints or observable concerns. A nursing assessment around 10:00 a.m. reportedly showed findings within normal limits and consistent with her baseline, and her scheduled morning medications were administered per physician orders with no immediate adverse reactions observed. The events leading to the medication error centered on the actions of an LPN who was passing morning medications. The LPN stated that the resident was new to the facility and that she checked the photograph in the electronic system, which she believed matched the resident. She then approached the resident, who was sitting near the nurse’s station in a wheelchair, and asked if her name was that of another resident with a different medication profile. According to the LPN, the resident nodded and verbally affirmed that name. The LPN reported that she checked vital signs and believed the blood pressure was within acceptable parameters, then prepared and administered the other resident’s medications to this resident. The facility’s documentation showed that the other resident’s 9:00 a.m. medication regimen included venlafaxine, furosemide, carvedilol, Entresto, Procardia, aspirin, and clopidogrel, and the DON later specified that the affected resident actually received venlafaxine, furosemide, aspirin, Entresto, iron, omeprazole, oxybutynin, and Procardia, in addition to her own prescribed Bumetanide. The resident did not normally receive blood pressure medications. After the incorrect administration, the other resident whose medications had been intended approached the nurse’s station questioning her morning medications and stating she did not want them and wanted to discharge. This prompted staff to realize that the medications had likely been given to the wrong resident. The RN who assessed the affected resident found her at the nurse’s station with her head slumped to the side, very lethargic, and no longer at her reported baseline of being alert and oriented to person and time. The RN obtained a blood pressure reading around 64/40 and described the pulse as so faint that a manual blood pressure could not be obtained reliably; paramedics later reported a blood pressure in the range of 55/30. The medical director, who was present in the facility, also attempted to check the blood pressure and found it very feeble. The resident’s daughter reported that the hospital informed her that the resident had been given her own medications plus another resident’s medications, including four different blood pressure-lowering medications, and that the resident was in “shock,” requiring IV medications to raise her blood pressure, ICU care, and involvement of poison control. Hospital discharge paperwork listed a diagnosis of iatrogenic hypotension. The facility’s own policies required that residents be correctly identified prior to medication administration by checking the photograph and/or asking the resident to identify themselves by name, and explicitly stated that medications prescribed for one resident shall not be administered to another resident, as well as emphasizing correct resident identification in medication pass guidelines.
Failure to Change and Label Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to ensure that oxygen equipment, specifically oxygen tubing, was properly changed and labeled for four residents who were receiving oxygen therapy. During observations, it was noted that multiple residents were using oxygen via nasal cannula or portable tank, but their oxygen tubing was not dated as required. Interviews with staff, including an LPN and a CNA, revealed uncertainty about who was responsible for changing and labeling the tubing. Physician orders for each resident specified that oxygen tubing should be changed monthly during the night shift and as needed, but this was not consistently followed. Further interviews with nursing staff and the Assistant Director of Nursing confirmed that nurses are responsible for dating and changing oxygen tubing, with some tubing scheduled for weekly or monthly changes depending on the order. The facility's policy also required monthly and as-needed changes for nasal cannulas. The deficiency was attributed to missed responsibilities, particularly on the third floor after the departure of the former Director of Nursing, and a lack of clear communication regarding staff duties for changing and labeling oxygen tubing.
Failure to Label Insulin Pens and Monitor Medication Refrigerator Temperatures
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling and disposal of insulin pens and did not consistently monitor medication refrigerator temperatures as required. During inspection of a medication cart, an open Novolog insulin pen was found without the required open and expiration dates labeled, despite a sticker being present for this purpose. Another insulin pen was found with an expired date, yet it remained in use. Staff interviews confirmed that insulin pens should be dated when opened, have an expiration date of 28 days, and be disposed of when expired, but these procedures were not followed for the insulin pens belonging to the residents reviewed. Additionally, the medication refrigerator used to store insulins and other liquid medications was found to have incomplete temperature monitoring logs. The log indicated that temperatures were only checked once daily instead of the required twice daily, and there were missing entries for several days. Multiple insulin pens for different residents were stored in this refrigerator. The facility's policy requires that insulin pens be dated when opened, include an expiration date and staff initials, and be discarded when expired, as well as that refrigerator temperatures be checked and documented twice daily, but these protocols were not adhered to.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Staff failed to follow the facility's Enhanced Barrier Precautions (EBP) policy for a resident with a suprapubic catheter and diagnoses including benign prostatic hyperplasia and urinary retention. The resident's physician order sheet indicated EBP for device care or use of a urinary catheter, and signage outside the resident's room instructed staff to wear a gown and gloves for high-contact care activities. During morning care, a certified nursing assistant (CNA) was observed providing incontinence care and changing the resident's brief while only wearing gloves and not a gown, contrary to the posted instructions and facility policy. A licensed practical nurse (LPN) confirmed that the resident was on EBP due to the presence of the suprapubic catheter and that staff should have been wearing both gown and gloves during care. The facility's policy specifies that residents with indwelling medical devices are to be on EBP, and that high-contact care activities require both gown and gloves to reduce transmission of multidrug resistant organisms (MDROs).
Failure to Notify Resident and Physician of Missed Medication Doses
Penalty
Summary
The facility failed to notify a resident and the resident's primary care physician (PCP) of missed medication doses for one resident. The resident, an 82-year-old male with a history of peripheral vascular disease and pulmonary embolism, did not receive prescribed doses of Warfarin, a blood thinner, from March 24 through March 27, 2025. The Medication Administration Record (MAR) showed no Warfarin order during this period, and a new order was placed on March 28, 2025. The resident reported not being informed about the missed doses, and the PCP confirmed not being notified of the missed medication. The PCP stated that, had he been informed, he would have ordered lab tests and adjusted the medication accordingly. Additionally, the resident's emergency contact (family member) stated they were not notified about the missed medication doses, although they had been contacted for other significant events in the past. Progress notes indicated that a new Warfarin order was placed, but there was no documentation of physician notification regarding the missed doses. The Director of Nursing acknowledged that the physician should have been notified when it was realized the resident had not received the prescribed medication.
Failure to Timely Continue Physician-Ordered Anticoagulant Therapy
Penalty
Summary
A deficiency occurred when the facility failed to ensure the continuation of a physician-ordered medication for a resident with a history of pulmonary embolism and peripheral vascular disease. The resident was supposed to receive Warfarin, a blood thinner, at a dose of 3mg as ordered by the primary care physician following a lab result. However, the order for Warfarin was not entered into the Medication Administration Record (MAR) until four days after the physician's order, resulting in the resident missing four consecutive doses of the medication. Interviews and record reviews confirmed that the lapse was not identified or addressed by nursing staff during this period. The LPN responsible for entering the order did not do so promptly, and the Director of Nursing was unable to explain why the medication was not continued as ordered. The primary care physician confirmed that the order was given but not implemented until several days later, and there was no documentation of communication or clarification regarding the missed doses during the gap.
Missed Warfarin Doses Result in Significant Medication Error
Penalty
Summary
A significant medication error occurred when an eighty-two-year-old male resident with a history of peripheral vascular disease and pulmonary embolism did not receive prescribed doses of Warfarin, a blood thinner, over a four-day period. The resident's medical records showed that on 3/24/25, the primary care physician ordered continuation of Warfarin 3mg after reviewing Protime/INR results. However, this order was not entered into the Medication Administration Record (MAR), resulting in the resident missing four consecutive doses from 3/24/25 through 3/27/25. The next Warfarin order was not entered until 3/28/25, and there was no documentation of a physician order or lab result for that date. Staff interviews confirmed that Warfarin administration requires close monitoring with lab draws and that missing doses increases the risk of blood clots. The Director of Nursing acknowledged that the Warfarin order was not continued during the missed period, and the resident did not receive the medication as prescribed. The facility's policy requires medications to be administered according to established procedures, which was not followed in this instance.
Resident Rights and Meal Service Deficiencies
Penalty
Summary
The facility failed to uphold resident rights by allowing a video containing identifiable images of a resident to be posted on a staff member's personal social media account. The video, intended to feature the Memory Care Director, inadvertently included the side profile of a resident with moderate cognitive impairment. The facility's Social Media Policy prohibits the use or disclosure of any resident identifiable information on social media, and the resident's photo consent did not authorize such use. Despite the Memory Care Director's claim of unawareness of the policy, the posting was unauthorized and raised concerns about resident dignity. Additionally, the facility did not ensure that residents seated at the same dining table were served their meals simultaneously, affecting their ability to eat together. During a Resident Council Group Meeting, residents expressed dissatisfaction with the staggered meal service, which sometimes resulted in a 45-minute delay between servings. Observations confirmed that residents were served at different times, with one resident waiting for silverware and missing parts of their meal due to a lack of clean dishes. The Dietary Supervisor was unaware of the issue with meal service timing and the shortage of clean dishes, despite being informed by an Activity Aide. The facility's Dining Room Meal Service policy did not specify that residents at the same table should be served together, contributing to the inconsistency in meal service. The residents' rights brochure emphasizes the facility's responsibility to provide services that meet residents' needs and choices, which was not upheld in this instance.
Failure to Prevent Cross-Contamination in Food Preparation
Penalty
Summary
The facility failed to ensure proper food preparation practices to prevent cross-contamination, affecting 15 residents on a pureed diet. During an observation, the Executive Chef, identified as V5, was seen preparing pureed foods without adhering to hand hygiene protocols. V5 used a gloved hand to handle meatballs, then removed the glove without washing hands, and continued to touch various surfaces and utensils, including the blender and containers, without performing hand hygiene. Additionally, V5 used bare hands to handle a thermometer, touching the probe without sanitizing it before inserting it into the food, and repeated this process with different food items. The Dietary Supervisor, V6, confirmed that handwashing or hand hygiene should be performed between tasks and that thermometers should be sanitized with alcohol before use to prevent cross-contamination. The facility's policies on handwashing and taking food temperatures emphasize reducing the risk of foodborne illness through proper hygiene and sanitization practices. However, these procedures were not followed during the preparation of pureed foods, leading to a deficiency in maintaining food safety standards.
Improper Oxygen Administration by CNAs
Penalty
Summary
The facility failed to adhere to professional standards of practice for the administration of oxygen therapy for a resident diagnosed with acute respiratory failure with hypoxia, sepsis, chronic diastolic congestive heart failure, and dysphagia. The resident's physician's orders specified continuous oxygen administration via nasal cannula at 2-4 liters per minute. However, during personal care, two Certified Nursing Assistants (CNAs) applied oxygen at 4 liters per minute, believing it was within their scope of practice and not requiring a physician's order. This action was contrary to the facility's policy, which mandates that only nurses are authorized to apply oxygen to ensure it is set according to the physician's orders. The Registered Nurse (RN) involved indicated that while nurses usually set and apply oxygen, CNAs could also perform this task, although they typically verify the liter flow with a nurse. The Director of Nursing (DON) clarified that oxygen administration is outside the CNAs' scope of practice, emphasizing that only nurses should apply oxygen to ensure compliance with physician's orders. The facility's policy on oxygen therapy devices supports this, stating that the application of oxygen should be verified against the physician's order, leaving room for professional judgment based on individual circumstances.
Deficiencies in Weight Monitoring, Wound Care, and Skin Care
Penalty
Summary
The facility failed to obtain daily weights for a resident with congestive heart failure (CHF), which is crucial for monitoring fluid status and preventing exacerbation. The resident's care plan and physician's orders required daily weights, with a notification to the physician if the resident gained more than 5 pounds in a week. However, the resident's weight was not recorded on several days, and a significant weight gain was noted without proper follow-up. Staff interviews revealed a lack of adherence to the weight monitoring protocol, which is essential for managing the resident's CHF. Another deficiency involved a resident with a surgical wound from a hip fracture repair. The facility failed to perform timely dressing changes and proper wound assessments as per the physician's orders. The resident reported that the dressing had not been changed since admission, and the nurse responsible for the dressing changes did not document any assessments or measurements of the wound. The facility also lacked appropriate dressing supplies, which contributed to inadequate wound care. Additionally, the facility did not provide adequate skin care for a resident with reddened skin. During incontinence care, the resident's scrotum was found to be reddened and painful, but the nurse did not apply the prescribed ointment to the affected area. The incident was not documented in the progress notes, and there was a lack of communication between the CNAs and the nurse regarding the resident's skin condition. This oversight in skin care could potentially lead to further skin integrity issues for the resident.
Failure to Maintain Proper Catheter Care and Education
Penalty
Summary
The facility failed to maintain a resident's indwelling urinary drainage bag in a manner that prevents contamination and ensures it is kept below the level of the bladder. During observations, the resident was seen with the catheter drainage bag resting on the footrest of her motorized wheelchair, which was not covered completely, and the urine appeared cloudy with sediment. The resident expressed that the drainage bag often slips out and that she was not informed about the importance of keeping the bag off the footrests or below the bladder level to prevent infection. Additionally, when the resident was in the dining room, the drainage bag was attached to the armrest of the wheelchair, again not below the bladder level. The resident's medical history includes acute kidney failure, chronic kidney disease, and other significant health conditions. The facility's records, including progress notes and care plans, did not document any education provided to the resident regarding proper catheter care and infection control measures. The facility's policy on indwelling catheters requires that the drainage bag be placed below the bladder level to facilitate drainage and minimize urine stasis, but this was not adhered to in the resident's care.
Infection Control Deficiencies in Dressing Change and EBP Signage
Penalty
Summary
The facility failed to perform a dressing change for a resident with a surgical incision in a manner that prevents cross-contamination. A registered nurse (RN) applied saline to three wounds on a resident's right hip and used the same gauze to dab each incision without changing the gauze or performing hand hygiene between incisions. This practice was contrary to the facility's policy, which requires using a clean gauze for each incision to prevent infection and cross-contamination. The resident, identified as R242, had a history of a right hip fracture and surgical procedure to repair it, among other diagnoses. Additionally, the facility failed to ensure that enhanced barrier precaution (EBP) signage was consistently posted on or near the doorway of a resident's room who had an IV midline. The resident, identified as R130, had multiple diagnoses, including chronic obstructive pulmonary disease and dependence on supplemental oxygen. Despite having an active order for EBP due to the IV midline, the signage was not consistently present, as observed by surveyors on multiple occasions. The facility's policy requires EBP for residents with indwelling medical devices, regardless of their multidrug-resistant organism status. The infection preventionist and assistant director of nursing acknowledged the inconsistency in EBP signage, attributing it to a room change and census update issues. The lack of consistent EBP signage and the improper dressing change procedure highlight deficiencies in the facility's infection prevention and control practices, potentially increasing the risk of cross-contamination and infection among residents.
Failure to Provide 1:1 Supervision Leads to Fatal Choking Incident
Penalty
Summary
The facility failed to provide 1:1 supervision for a resident during mealtimes after the resident experienced a choking episode. This lack of supervision resulted in the resident experiencing a second choking episode, which led to cyanosis, low oxygen levels, and subsequent hospitalization. The resident ultimately expired in the hospital due to complications from aspiration pneumonia and choking on food. This deficiency was identified as an Immediate Jeopardy situation. The resident in question had a medical history that included Parkinson's disease, dementia, dysphagia, congestive heart failure, and muscle weakness, with a moderate cognitive impairment. After the initial choking incident, the resident's nurse practitioner ordered 1:1 supervision during meals until a speech therapy evaluation could be conducted. However, this order was not communicated effectively to the staff, and the necessary supervision was not provided, leading to the second choking incident. Interviews with staff revealed a lack of awareness and communication regarding the resident's need for 1:1 supervision. The nurse practitioner had given orders for slow feeding and 1:1 supervision, but these were not entered into the medical record or communicated to the oncoming staff. As a result, the resident was left unsupervised during meals, which contributed to the fatal choking incident. The facility's failure to implement and communicate the necessary interventions for the resident's safety was a critical factor in the deficiency.
Removal Plan
- Education with all nursing staff on the facility's Diet Consistency/Texture Change Protocol policy and 1:1 supervision for meals.
- Review of all residents who are at risk for aspiration, choking, and/or noted with swallowing difficulty.
- Education of all nursing staff on ensuring interventions to prevent further choking episodes based on root cause analysis/assessment.
- Monitoring of all residents who are high risk for aspiration/choking at all meals by managers, nurses, and CNAs.
- Review of policies and procedures on choking, diets, change in condition, and physician orders with the medical director.
- Implementation of a Quality Assurance Audit tool for monitoring resident change in ability to swallow and/or requiring 1:1 supervision.
- Audit of residents at high risk for aspiration/choking.
- Review of QA Audit results by the Facility QAPI team to determine necessary changes.
- Emergency QA meeting with the Interdisciplinary Care Team and Medical Director to discuss residents at risk for choking, diet downgrades, and in services for physician orders and shift to shift report.
Failure to Implement Diet Order Leads to Resident's Death
Penalty
Summary
The facility staff failed to implement a physician's order for a resident's downgraded diet to mechanical soft, which resulted in the resident experiencing a second choking episode. The resident, who had diagnoses including Parkinson's disease, dementia, dysphagia, congestive heart failure, and muscle weakness, was initially ordered to receive a mechanical soft diet after a choking incident. However, this order was not entered into the resident's medical record, and the resident continued to receive regular food, leading to another choking episode. The nurse practitioner had specifically instructed the nursing staff to provide the resident with a mechanical soft diet and 1:1 supervision during meals until a speech therapy evaluation could be conducted. Despite these instructions, the nurse on duty did not enter the order into the medical record, nor did they communicate the new dietary requirements during the shift-to-shift report. As a result, the resident was served regular food, which led to choking on sausage that was not ground up. The failure to implement the physician's order and communicate the necessary dietary changes resulted in the resident being hospitalized and subsequently passing away from complications of aspiration pneumonia and choking on food. The facility's policies on verbal orders and diet consistency changes were not followed, contributing to the immediate jeopardy situation identified by the surveyors.
Removal Plan
- Education by Director of Nursing with all nursing staff on the facility's Diet Consistency/Texture Change Protocol policy and physician orders.
- Review of all residents at risk for aspiration, choking, and/or noted with swallowing difficulty.
- Physician orders audited by Director of Nursing or Assistant Director of Nursing or designee.
- Shift to shift report audited by Director of Nursing and Assistant Director of Nursing to ensure completion.
- Facility DON and Administrator reviewed policies and procedures on shift-to-shift report and physician orders with the medical director.
- Quality Assurance Audit tool used for monitoring implementation of physician orders, with audits done for 5 residents.
- Audit of shift-to-shift report completed for 10 residents.
- Results of QA Audits reviewed by the Facility QAPI team to determine any necessary changes.
- Emergency QA meeting held by the Administrator with the Interdisciplinary Care Team and Medical Director to discuss residents at risk for choking, diet downgrades, and in-services for physician orders and shift-to-shift report.
Failure to Ensure Safe Service of Hot Liquids
Penalty
Summary
The facility failed to ensure the safe service of hot liquids, resulting in a resident sustaining burns. The incident occurred when a server spilled coffee on a table, which then dripped onto the resident's left forearm and inner thigh, causing first and second-degree burns. The resident, who had a history of right-sided weakness following a stroke and other medical conditions, was unable to move quickly enough to avoid the spill. The resident's cognitive status was intact, and he required partial to moderate assistance for eating. The facility did not have a clear process for managing the temperature of hot liquids, and staff were not adequately trained to handle and serve hot beverages safely. Observations revealed that coffee temperatures were not consistently checked before serving, and there was no established safe temperature range for serving hot liquids. The coffee machines used by the facility did not display temperatures, and staff were unaware of the appropriate temperature limits to prevent burns. Interviews with staff indicated a lack of awareness and training regarding the safe handling of hot beverages. The dietary supervisor and servers were not informed of the necessary actions to take if coffee temperatures were too high. Additionally, the facility's policy did not specify a maximum safe temperature for hot liquids, and there was no protocol for cooling hot beverages before serving them to residents. This lack of clear guidelines and training contributed to the incident and posed a risk to all residents in the facility.
Removal Plan
- All residents were reviewed for conditions that may make them more at risk for the unsafe handling and distribution of hot beverages. Care Plans and assessments updated as needed.
- All dietary and nursing staff were educated on safe handling of hot beverages, safe vessels to hold hot beverages, temperature checking of coffee prior to serving, and notification to appropriate vendors of equipment malfunction.
- The coffee vendor was called to verify that all coffee makers are functioning properly and are producing coffee at the lowest safe temperature that the machine can brew.
- The facility Administrator and IDT reviewed policies and procedures on serving hot beverages and food to residents, including At Risk Food Temperature Policy, Hot Water Temperature Policy, Incidents & Accidents, Coffee Machines Owner's Manual, and developed A Cool Liquid Program.
- The Administrator and Assistant Administrator completed a QA audit tool for the Dietary Department to ensure that taking temperatures of hot beverages is occurring prior to the serving of coffee each meal.
- Coffee shall be served for the general population between 120-140 degrees and below 120 degrees for the at risk population.
- The results of the QA Audits shall be reviewed by the Facility QAPI team to determine any necessary changes.
- An Emergency QA meeting was held by the Administrator with the IDT and Medical Director to review the removal plan.
- The QA Committee shall meet and review the results of the QA audits. Changes to the policy and procedure shall be made as indicated by the QA results.
- This will be monitored by the Administrator and Assistant Administrator.
Failure to Track and Manage Burn Wounds
Penalty
Summary
The facility failed to ensure proper wound care and tracking for a resident who sustained burns from spilled coffee. The incident involved a resident with a history of right side weakness following a stroke, among other medical conditions, who was burned on the left forearm and inner thigh. The wound care nurse, V8, did not perform measurements on the resident's burns, as they were initially not open, and failed to track the progress of the wounds effectively. Despite the resident's complaints of pain and the worsening condition of the thigh wound, the facility did not have a clear policy for burn care, and the wound care provider had not seen the resident until several days after the incident. The resident's care plan, initiated after the burns occurred, indicated an increased risk for delayed wound healing due to the resident's need for assistance with care, impaired mobility, and other medical conditions. The resident's electronic medical records and progress notes lacked documentation of wound measurements, which are essential for assessing the severity and tracking the healing process. The wound care nurse acknowledged the absence of measurements and was unable to provide an explanation for how the wounds were being monitored without them. The wound care nurse practitioner, V33, confirmed that the resident had not been seen by the wound care provider until after the consult was entered, which was several days post-incident. V33 noted that the burns appeared to be second-degree and emphasized the importance of taking measurements to determine the severity and track the progress of the wounds. The facility's existing policy on skin alterations did not specifically address burn care, contributing to the oversight in the resident's treatment and care.
Failure to Administer Physician-Ordered Medication
Penalty
Summary
The facility failed to ensure that a physician-ordered medicated cream, Nystatin, was applied to a resident, identified as R2, as prescribed. R2 was admitted with multiple diagnoses including metabolic encephalopathy, absence epileptic syndrome, Type 2 Diabetes, paraplegia, and morbid obesity, and was assessed to have no cognitive impairment. The electronic Medication Administration Record (eMAR) for September 2024 indicated that the application of Nystatin Cream was documented as 'see other progress notes' on several occasions, specifically on 9/17/24, 9/19/24, and 9/20/24. Progress notes from 9/18/24 and 9/19/24 indicated that the cream was in the process of being delivered or ordered from the pharmacy, suggesting a delay in administration. R2 expressed concerns about not receiving the Nystatin cream, stating that it ran out and took over a day to be reordered and delivered. The facility's policy requires medications to be reordered when a 2-day supply remains, to prevent lapses in therapy. However, this policy was not adhered to, resulting in R2 missing several doses. The resident reported feeling neglected due to the lack of medication and requested to speak with the Director of Nursing. The facility's failure to reorder the medication in a timely manner led to a deficiency in providing the necessary pharmaceutical services to meet the resident's needs.
Inconsistent PPE Usage in COVID-Positive Resident Rooms
Penalty
Summary
The facility failed to ensure proper Personal Protective Equipment (PPE) was worn by staff entering the rooms of COVID-positive residents, specifically for two residents who were on Transmission Based Precautions. Observations and interviews revealed inconsistencies in PPE usage among staff members, with some wearing only surgical masks instead of the required N95 masks and face shields. The facility's policy, revised earlier in the year, mandates the use of N95 respirators, eye protection, gowns, and gloves for staff entering rooms of residents with confirmed or suspected COVID-19 infection. Interviews with residents and staff highlighted concerns about the inconsistency in PPE usage. One resident expressed worry about the lack of mask-wearing by some staff, particularly as they were immunocompromised due to chemotherapy. Another resident noted that during their quarantine period, not all staff wore the same level of PPE. A dietary aide confirmed the use of a gown, gloves, and a surgical mask, but mentioned that wearing an N95 mask or face shield was optional, contrary to the facility's policy. The Infection Preventionist stated that staff are expected to wear a gown, gloves, an N95 mask, and a face shield, indicating a discrepancy between policy and practice.
Failure to Prevent Fall in Dementia Resident
Penalty
Summary
The facility failed to prevent a fall for a resident with known dementia-related behaviors, resulting in a significant injury. The resident, who had a history of impulsive behavior and was at risk for falls, was receiving ADL care when the incident occurred. During a shower, the resident became anxious and attempted to leave while a CNA was adjusting her footwear. The back of the resident's shoe was folded over, and as the CNA tried to fix it, the resident stepped away and fell, resulting in a fractured left hip. Prior to the fall, the resident was able to ambulate with a walker and only required verbal cues to use it. The resident's care plan indicated a risk for falls and emphasized the need for proper footwear and the use of a walker. Despite these precautions, the CNA did not ensure the resident was seated while adjusting the shoe, contributing to the fall. The resident's POA expressed concern about the lack of proper precautions during the incident. Following the fall, the resident was unable to walk independently and required surgical intervention for the hip fracture. The facility's Director of Nursing acknowledged the expectation for CNAs to be aware of fall risks and precautions, noting that the CNA involved was familiar with the resident's needs.
Failure to Ensure Resident Safety in Recliner
Penalty
Summary
The facility failed to ensure a resident was safely positioned in a wheeled recliner, leading to the resident falling out of the chair and sustaining a subdural hematoma. The resident, who had a history of traumatic subdural hemorrhage, dementia, major depressive disorder, and generalized anxiety disorder, was identified as being at risk for falls. Despite this, the resident was placed in a high back wheeled recliner near the nurses' station without adequate supervision. The resident was observed to be restless and anxious, and staff reported increased agitation and behaviors prior to the incident. The resident was found on the floor with a lump on the back of her head and was subsequently diagnosed with a subdural hematoma at the hospital. The investigation revealed that a CNA had placed the resident in the recliner and then walked away to assist another resident. The recliner tipped over, causing the resident to fall and hit her head. The LPN on duty did not witness the fall but found the resident on the ground with a head injury. The CNA involved in the incident no longer works at the facility, and there were discrepancies in staff accounts regarding the use of a wheelchair in conjunction with the recliner. The facility's Fall Management Program emphasizes proactive measures to identify and assess residents at risk for falls, but these measures were not effectively implemented in this case.
Failure to Assist Resident to Bathroom in Timely Manner
Penalty
Summary
The facility failed to maintain a resident's dignity by not assisting the resident to the bathroom in a timely manner, resulting in the resident becoming incontinent of stool. The resident, who was alert, oriented, and normally continent of stool, had to wait 35 minutes for assistance after activating the call light. By the time staff arrived, the resident had already had an accident, which was embarrassing for her. This incident was not isolated, as the resident had experienced a similar situation a few days earlier due to delayed assistance from staff. The resident's progress notes indicated that she was admitted to the facility for therapy after fracturing her hip. Interviews with the Certified Nursing Assistants (CNAs) and the Director of Nursing (DON) confirmed that the resident was usually continent of stool and should have received timely help to prevent incontinence. The facility's policy was to respond to call lights within 3-8 minutes, but the facility lacked a system to track the exact times when call lights were activated and responded to. This deficiency highlights a failure in the facility's response system, leading to a loss of dignity for the resident.
Failure to Provide Alternative Call Light for Resident with Hand Impairments
Penalty
Summary
The facility failed to accommodate a resident's need for an alternative call light. The resident, a [AGE] year old female with osteoarthritis and chronic gout, had range of motion impairments and a contracture in her left hand, making it difficult for her to use the standard call light. Despite informing the staff about her difficulties on the first few days of her admission, no alternative call light was provided. The resident had to rely on her roommate to push the call light button for her, as she was unable to do so herself due to her hand strength issues. This was confirmed by both the resident and her roommate, as well as a Certified Nursing Assistant (CNA) who acknowledged the resident's history of not being able to use the call light. The Director of Nursing (DON) stated that an alternative call light, such as a soft touch call light, should be provided if a resident has difficulties using the standard call light. However, this was not done for the resident in question. The resident's care plan included an intervention to encourage the use of the call light for assistance, but no alternative call light was provided to accommodate her needs. This oversight led to the resident's discomfort and reliance on her roommate for assistance in using the call light.
Failure to Obtain Daily Weights for CHF Patients
Penalty
Summary
The facility failed to obtain daily weights for residents with congestive heart failure (CHF) as ordered by their physicians. Resident R93, who was admitted with multiple diagnoses including acute respiratory failure, lymphedema, Parkinson's disease, dementia, and acute on chronic diastolic CHF, had an order for daily weights following a hospitalization for acute hypoxemia respiratory failure. Despite this order, R93 was not weighed from April 9, 2024, to April 17, 2024. The nurse practitioner and medical doctor both noted the importance of daily weights for monitoring CHF, yet the facility did not comply with the order, leading to a lapse in monitoring R93's condition. Similarly, Resident R59, diagnosed with chronic diastolic CHF, had an active order for daily weights starting from March 9, 2024. However, the facility failed to record weights on multiple days, specifically on March 25, April 12, and April 15, 2024. The Director of Nursing confirmed that daily weights are crucial for CHF patients to monitor fluid shifts and weight changes, yet the facility did not adhere to this protocol. The facility's weight policy emphasizes the importance of regular weights to identify trends, but this was not followed in the cases of R93 and R59.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure a resident's medication was administered as ordered and not left at the bedside. On 4/22/24 at 10:14 AM, a resident had a medication cup with medication on his bedside table. The resident did not know what the medication was or how long it had been there. A Registered Nurse identified the medication as Carbidopa-Levodopa but was unsure when it was supposed to be administered, as she had given the resident his morning medications in the dining room. Another Licensed Practical Nurse confirmed that medications should never be left at the bedside because it cannot be ensured that the resident took them, and they could get lost, dropped, or not taken. The resident's Medication Administration Record indicated he was to receive Carbidopa-Levodopa three times a day, but there was no documentation allowing the resident to self-administer his medications.
Failure to Change Gloves and Perform Hand Hygiene
Penalty
Summary
The facility failed to change gloves and perform hand hygiene in a manner to prevent cross-contamination for two residents reviewed for infection control. Resident R3's care plan indicated functional bowel and bladder incontinence. During incontinence care, a CNA did not change gloves or perform hand hygiene after wiping stool from R3's front peri area and before touching clean surfaces. Similarly, Resident R109's care plan showed incontinence of both bowel and bladder. During incontinence care, two CNAs did not change gloves or perform hand hygiene after wiping urine from R109's front peri area and before placing a new incontinence brief. The facility's hand hygiene policy mandates hand hygiene after touching contaminated items, which was not followed in these instances.
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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