Alden Estates Of Northmoor
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 5831 North Northwest Highway, Chicago, Illinois 60631
- CMS Provider Number
- 145888
- Inspections on file
- 30
- Latest survey
- January 26, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Alden Estates Of Northmoor during CMS and state inspections, most recent first.
A resident with multiple comorbidities, including DM, dementia, and a stage 3 sacral pressure ulcer, was found by a CNA during a scheduled shower to have new discoloration/bruising on the left side of the body. The CNA reported the finding to an LPN and documented it in CNA charting. The LPN confirmed seeing the bruise, involved the DON, and obtained a stat X-ray, later reporting negative results to the physician for a resident on long-term anticoagulation. However, the LPN did not document the bruising, assessment, change in condition, physician notification, or interventions in the resident’s electronic health record, and the only entry was a radiology note indicating results were relayed with no new orders, contrary to facility policy requiring documentation of new skin discoloration and related provider communication.
Surveyors found that staff failed to follow infection prevention practices, including a nurse entering an EBP room and providing high-contact care to a resident with an indwelling catheter and oxygen cannula without performing hand hygiene or using gown and gloves, and handling tubing dropped on the floor before placing it back on the resident. A CNA did not perform hand hygiene between handling a used cup for one resident and serving soup to another during meal service. Another resident’s urinary catheter drainage bag was observed resting on the floor rather than properly hung and contained. An LPN reused a white foam tray from a resident’s room and placed it on the medication cart without sanitizing it, despite facility expectations that such trays be sanitized between uses to avoid contaminating the cart.
A resident was admitted with Parkinson's disease and insomnia and later developed additional diagnoses including dementia, Alzheimer's disease, major depressive disorder, and anxiety disorder, with related issues addressed in the care plan and treatment with antidepressant medication. Despite these new serious mental illness diagnoses and a facility policy requiring PASRR screening upon changes in status, the resident did not receive an updated PASRR Level II, and existing PASRR documentation continued to show no qualifying diagnosis and no need for Level II review, while the MDS in iQIES indicated no PASRR with diagnosis.
A resident with multiple chronic conditions, including heart failure and asthma, had a physician order for Clotrimazole 1% solution to be applied to all toenails twice daily for onychomycosis. During a medication pass, an LPN was observed administering only oral medications and not applying any topical medication, yet documented on the medication administration record that the Clotrimazole had been given. In a later interview, the LPN admitted the topical medication was not administered and should not have been documented as given, and the DON confirmed that medications must not be documented if not administered, contrary to facility policy and the nurse job description requiring accurate administration and documentation of medications as ordered.
Two residents with orders for continuous O2 via nasal cannula, one with severe cognitive impairment and one cognitively intact, were repeatedly observed with their nasal cannulas and oxygen tubing lying uncontained on bed linens while they were away from their rooms and not using oxygen. In both cases, the oxygen concentrators remained connected to the unbagged tubing, despite posted Enhanced Barrier Precautions for one resident and facility policies and inservices requiring nasal cannulas and respiratory equipment to be stored in labeled plastic bags when not in use. Multiple staff, including an RN, LPN, unit manager/CNA, ADON, DON, and the Administrator, acknowledged that nasal cannulas should be contained and replaced if found uncontained, but the equipment for these two residents was not handled according to those expectations.
A resident with severe cognitive impairment was involved in an incident where a staff member used a racial slur while recounting a story. The DON was informed of the event and addressed the staff member's inappropriate language, but did not notify the resident's POA as required by facility policy. Facility records confirmed that the POA was not informed of the verbal abuse allegation.
The facility failed to report two separate allegations of abuse involving two residents to the State Agency within the required 24-hour timeframe. In one case, a cognitively intact resident reported a staff member making an obscene gesture, and in another, a resident with severe cognitive impairment was involved in an incident where an LPN used a racial slur. Both incidents were not reported promptly as required by facility policy and regulations.
The facility failed to follow proper food storage guidelines and their own policy for labeling and dating ready-to-eat food items. During an inspection, it was found that opened pre-sliced cooked turkey and buffet ham were not labeled with a 'use by' date, and a bottle of lemon juice was not stored in the refrigerator as required. These oversights have the potential to affect all 163 residents receiving food from the facility's kitchen.
A facility failed to follow its medication storage and labeling policy, as observed in a medication cart on the third floor. A nurse found three unlabeled white tablets in a plastic bag, which were not identified or properly stored. Interviews with the Assistant Directors of Nursing confirmed that unknown medications should be discarded, and the facility's policy requires medications to be stored in original containers and properly labeled.
The facility failed to adhere to standardized pureed diet recipes, affecting four residents. Observations showed that residents on pureed diets received only thin broth instead of properly blended soup. The dietary aide and chef confirmed the practice of straining solids from the soup, contrary to recipe instructions. The dietary supervisor and consultant dietitian stressed the importance of following recipes to ensure nutritional value, highlighting the potential nutritional risks for residents on pureed diets.
The facility failed to follow its policy on administering influenza and pneumococcal vaccines, resulting in several residents not being offered or provided with the necessary immunizations. Residents expressed a desire for the vaccines, but due to issues with the timing of vaccination clinics and inadequate investigation into medical histories, they were not administered. Staff acknowledged the oversight, which affected residents with chronic conditions who were eligible for the vaccines.
A resident with multiple diagnoses, including cognitive impairment, was not treated with dignity during a dining observation. A CNA was observed standing over the resident while assisting with feeding, contrary to the facility's policy requiring staff to be seated at eye level to ensure comfort and dignity. The DON confirmed the importance of this practice, highlighting the need for staff to avoid making residents feel rushed during meals.
A nurse at the facility failed to follow professional standards by crushing and administering multiple medications together for a resident with Alzheimer's and other conditions. The facility's policy lacked specific guidelines for administering multiple crushed medications, and a pharmacist confirmed that each medication should be administered separately to avoid potential incompatibilities.
A resident with complex medical needs was left in a soiled incontinence brief for extended periods, leading to skin excoriation. Despite facility policies requiring two-hourly checks, staff inconsistencies resulted in delayed care, particularly during night shifts.
A resident with rheumatoid arthritis and hand contractures did not receive prescribed splint applications as per the care plan. Observations showed the resident without splints, despite a physician's order for their use twice daily. The Director of Nursing confirmed the active order and the importance of splints in preventing further contractures, but documentation showed non-compliance on several dates.
A facility failed to provide a spare tracheostomy tube at the bedside for a resident with chronic respiratory failure. The resident's care plan did not include an intervention for a spare trach tube, and staff were unaware of the trach tube's specifications. The facility lacked specific policies on tracheostomy care, contributing to the deficiency.
A resident with chronic pain conditions did not receive timely PRN pain medication, despite reporting constant neck and shoulder pain. The facility failed to update the resident's care plan to reflect her pain status, and the DON confirmed that pain assessments and interventions were not consistently performed as per policy.
The facility failed to properly account for and dispose of controlled medications, affecting two residents. One resident's Tramadol blister packet was compromised, and the nurse was unsure of the tablet's identity. Another resident's Oxycodone and Lorazepam records showed discrepancies in the remaining tablet counts. The Assistant Directors of Nursing confirmed that controlled substances should not be returned once packaging is broken, and discrepancies should be addressed immediately.
A facility failed to complete timely AIMS assessments for a resident receiving antipsychotic medication, Olanzapine, for unspecified psychosis. Despite the facility's policy requiring AIMS assessments upon admission and every six months, the last documented assessment was on 11/23/22. The Assistant Director of Nursing acknowledged the importance of these assessments in monitoring side effects, which were not conducted as required, posing a safety concern.
A resident with cognitive impairment was found with unexplained bruises and abrasions, which were not properly investigated or reported by the facility staff. Despite the resident's report of being hit, no incident report was completed, and the facility failed to adhere to its abuse policy, resulting in a deficiency.
Two residents in a LTC facility were left wet and soiled for extended periods due to inadequate incontinent care. One resident, who is cognitively intact, reported being wet since early morning, but the CNA did not verify her condition. Another resident, dependent on the facility for hygiene, was found in a saturated bed. The facility lacked a specific policy for incontinent care, contributing to the deficiency.
A resident with a tracheostomy was not supervised during meals as recommended by Speech Therapy, despite having a care plan indicating a swallowing problem. The resident, who is cognitively intact, was observed eating without supervision, and the facility's administrator was unaware of the need for meal supervision. The facility's policy on feeding residents was not followed, and the resident was not included on the feeders list.
The facility failed to follow its Fire Watch policy during a sprinkler system malfunction, resulting in inadequate staff training and communication with the fire department and state health agency. The administrator was unsure if in-service training was conducted, and documentation was lacking. The new Building Manager was not informed about Fire Watch procedures, and many staff members were not trained, leading to a deficiency in fire safety preparedness.
A resident, dependent on a mechanical lift for transfers due to a history of falls and other conditions, was transferred without the lift, resulting in a fall and minor injuries. Despite clear documentation and communication of the resident's transfer needs, a CNA manually assisted the resident, leading to the incident. This failure to adhere to established procedures compromised the resident's safety.
A facility failed to follow a care plan for a resident at risk for pressure injuries by not turning and repositioning her as required. Observations showed the resident was not moved between 9:23 AM and 11:34 AM, and she reported not being repositioned since the night shift. The resident, with a history of diabetes, vascular disease, and obesity, is dependent on assistance for mobility and is at moderate risk for pressure injuries.
Failure to Document New Skin Discoloration and Related Clinical Actions
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident who developed new skin discoloration/bruising on the left side of the body. A CNA reported that during a scheduled shower she observed new discoloration/bruising on the resident’s left side and immediately notified the LPN and documented her observation in her own CNA charting. The CNA stated she had not witnessed any fall or injury and that this was the first time she saw the bruise. The resident’s face sheet shows multiple diagnoses, including type 2 diabetes mellitus with diabetic polyneuropathy, dementia, and a stage 3 sacral pressure ulcer. The LPN confirmed being notified by the CNA after lunch and described seeing a bruise on the resident’s left side, below the armpit and next to the breast. The LPN stated she asked the DON to assess the resident, and after approximately 20 minutes the DON instructed her to order a stat X-ray. The LPN reported that the resident is on long-term blood thinner medication, tends to lean to the left side, and requires frequent repositioning, and that she notified the physician of the negative X-ray results. However, the LPN acknowledged that she did not document the bruising/discoloration, the assessment, the notification to the physician, or the interventions in the resident’s electronic health record, stating she was waiting for direction from the DON. The radiology note only documented that X-ray results were relayed to the physician with no new orders, and there was no documentation in the medical record regarding the new skin discoloration or the change in condition, despite facility policy requiring documentation and physician notification for any new skin discoloration.
Infection Control Lapses with EBP, Catheter Care, Hand Hygiene, and Medication Cart Sanitation
Penalty
Summary
Surveyors identified multiple failures in the facility’s infection prevention and control practices involving residents on Enhanced Barrier Precautions (EBP), residents with indwelling urinary catheters, and during meal and medication passes. One resident with severe cognitive impairment, bowel and bladder incontinence, and an indwelling urinary catheter was on EBP with a posted sign and a PPE cart containing gowns and gloves outside the room. Despite this, a registered nurse entered the resident’s room without performing hand hygiene or donning gown and gloves, then provided high-contact care including assisting the resident from the bathroom to bed, touching the resident’s hands, arms, and urinary catheter, and handling the resident’s nasal cannula. During this care, the nurse dropped the nasal cannula tubing on the floor and then placed it back on the resident without changing it or performing hand hygiene, and exited the room after scratching their own face, again without hand hygiene. The nurse later acknowledged that residents with catheters or wounds are placed on EBP and that PPE and hand hygiene should be used during high-contact care, and admitted not following these practices. Surveyors also observed failures in hand hygiene during meal service. A CNA removed a used cup from in front of one resident, discarded it in the trash, and then immediately obtained a bowl of soup and placed it in front of another resident without performing hand hygiene between residents. The CNA later stated that the first resident had put soup in the juice cup, that she discarded the cup for that reason, and that she did not sanitize her hands between residents but should have, acknowledging that hand hygiene is part of being sanitary. Additionally, the facility’s own hand hygiene policy required hand hygiene with alcohol-based hand rub immediately prior to touching a resident, when caring for a resident, after touching a resident or the resident’s environment, and after removal of gloves and PPE, and required soap and water after contact with body fluids or contaminated surfaces. Further infection control lapses were observed related to urinary catheter management and medication cart sanitation. One resident with a urinary catheter was observed in bed with fall mats on both sides and the catheter drainage bag on the floor containing approximately 400 ml of yellow urine; the bag was affixed to a non-movable part of the bed frame but was touching the floor and was not in a privacy bag. Nursing staff, including an LPN and the RN, confirmed that catheter bags should be hung on a non-movable part of the bed, not touching the floor, and that they should be in a privacy bag, with the LPN noting that the bag should drain to gravity and not sit on the floor to prevent backflow of urine which can cause urinary tract infection. In another instance, an LPN placed a reusable white foam tray on a resident’s dresser, then removed it and placed it on top of the medication cart without cleaning it. The LPN stated the tray is disposable but used throughout the shift and that he should have wiped it off before bringing it out of the resident’s room. The DON stated that such trays can be reused only if sanitized between uses and that the medication cart would be considered contaminated when a used, unsanitized tray is placed on it. The facility’s policies and job descriptions further outlined expectations that were not followed in these events. The Enhanced Barrier Precautions documents required everyone to clean hands before entering and when leaving the room and required staff to wear gloves and gowns for transferring, assisting with toileting, and urinary catheter care for residents with indwelling medical devices. The EBP policy specified that gown and gloves must be used prior to high-contact care activities such as dressing, transferring, providing hygiene, assisting with toileting, and device care, and that hand hygiene should be performed prior to entering and exiting the room when not providing high-contact care. The staff nurse job description required nurses to ensure nursing procedures and protocols are followed in accordance with established policies, and the DON job description required the DON to assure all nursing procedures and protocols are followed and to make daily rounds to ensure appropriate procedures are being followed. Despite these written expectations, surveyors observed multiple instances where staff did not perform required hand hygiene, did not use PPE during high-contact care for residents on EBP, allowed a urinary catheter bag to rest on the floor, and failed to sanitize reusable trays before placing them on the medication cart.
Failure to Update PASRR After New Serious Mental Illness Diagnoses
Penalty
Summary
The facility failed to conduct an appropriate PASRR evaluation for a resident who developed new diagnoses of serious mental illness after admission. The resident was admitted with diagnoses of Parkinson's disease and insomnia and later received additional diagnoses of dementia in other diseases classified elsewhere, Alzheimer's disease, major depressive disorder, and anxiety disorder. The resident’s face sheet reflected these new diagnoses, and the care plan documented a focus on antidepressant medication related to depression, anxiety, dementia, elopement due to cognitive impairment, and insomnia. Despite these changes, the resident did not have a PASRR Level II reflecting the new mental health diagnoses. Record review showed that the resident’s PASRR Level II determination dated April 4, 2024, documented an exclusion from PASRR due to no diagnosis and no Level of Care (LOC), and a subsequent PASRR Level I review dated February 5, 2025, indicated that no Level II was required due to resolved symptoms. The Minimum Data Set in iQIES indicated no PASRR with diagnosis, and the resident’s BIMS score was 14, indicating intact cognition. During interview, the Social Services Director stated that all residents must have a PASRR Level I on admission, that she reviews PASRR results and requests a Level II or new Level I if discrepancies are found, and acknowledged that the resident had a change in diagnosis requiring a Level II PASRR. The facility’s PASRR policy stated that residents will be screened prior to admission and upon any change in status for known or suspected serious mental illness, developmental disability, or intellectual disability.
Inaccurate Documentation and Omission of Prescribed Topical Medication
Penalty
Summary
The deficiency involves the failure to administer and accurately document a prescribed topical medication for a resident. The resident had multiple medical diagnoses, including hypertensive heart and chronic kidney disease with heart failure, chronic diastolic heart failure, asthma, and major depressive disorder. A physician’s order dated 09/18/2025 directed that Clotrimazole External Solution 1% be applied to all toenails of both feet twice daily for three months for onychomycosis. On 12/02/2025 at 9:13 a.m., a surveyor observed an LPN administer oral medications to the resident but did not observe the LPN administer any topical medications. Despite this, the surveyor observed the LPN document that medications, including the topical Clotrimazole, had been given. Record review showed that the medication administration audit record for that date and time contained documentation by the LPN that the Clotrimazole External Solution 1% was administered. In a subsequent interview, the LPN stated that he did not administer the topical medication during the observed medication pass and acknowledged that he should not have documented the medication as given when it was not administered, stating that medications should not be documented if not given because it can cause a medication error. The DON also stated that medication should not be documented if it is not administered. Facility policy on medication administration required that drugs be administered in accordance with written physician orders, and the staff nurse job description required adherence to facility policies and nursing procedures, including preparing and administering medications as ordered and reviewing medication records for accuracy and completeness.
Uncontained Nasal Cannulas and Oxygen Tubing When Not in Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure nasal cannulas and oxygen tubing were properly contained when not in use, as required by facility policy and staff expectations. For one resident, R11, who had diagnoses including hypertensive heart disease with heart failure, cardiomyopathy, atrial fibrillation, dementia, and dependence on supplemental oxygen, the care plan and physician orders documented a need for continuous oxygen at 2 L/min via nasal cannula and staff assistance with oxygen use. Despite this, surveyors observed R11’s nasal cannula and tubing lying on top of the bed sheets, not contained in a plastic bag, while the oxygen concentrator remained turned on and connected to the uncontained tubing. R11 was not in the room at the time and was later observed in the dining room without oxygen in place. Multiple observations on the same day confirmed that R11’s nasal cannula and tubing remained uncontained on the bed, even though an Enhanced Barrier Precautions (EBP) sign was posted on the door. When the surveyor and an RN (V16) entered the room, the RN confirmed that the tubing and nasal cannula were lying on the bed and acknowledged that they should always be contained in a plastic bag when not in use. The RN initially stated that the tubing and cannula should be contained and changed weekly, then later stated that they had made a mistake. Other staff, including a unit manager/CNA (V22), the Administrator (V1), and the DON (V2), stated that nasal cannulas and oxygen tubing should be stored in labeled plastic bags when not in use, replaced if found uncontained, and handled with appropriate hand hygiene and, in EBP rooms, with gowns and gloves. A similar situation was observed for another resident, R98, who had diagnoses including COPD, chronic respiratory failure with hypoxia, emphysema, pulmonary embolism, and dependence on supplemental oxygen, with physician orders for continuous oxygen at 2 L/min via nasal cannula. Surveyors observed R98’s nasal cannula sitting on the bed, attached to tubing and an oxygen concentrator, not in use by the resident and not contained in a bag, while the resident was in the dining room without oxygen in place. An LPN (V3), the ADON (V36), and the DON (V2) each stated that nasal cannulas should be stored in plastic bags when not in use and replaced if found uncontained. Facility policies on respiratory equipment and oxygen therapy devices, as well as inservice records, documented that respiratory equipment, including nasal cannulas, should be stored in storage bags when not in use and that staff are responsible for following these procedures to prevent contamination.
Failure to Notify Resident's Representative of Verbal Abuse Allegation
Penalty
Summary
The facility failed to notify a resident's representative of an allegation of verbal abuse involving a racial slur made by a staff member. The incident was reported to the Director of Nursing (DON) by a Certified Nursing Assistant, who stated that an LPN had used inappropriate language referencing a racial slur while recounting an interaction with the resident. The DON acknowledged that the language was inappropriate and addressed it with the staff member involved. However, the DON did not inform the resident's Power of Attorney (POA) about the incident at the time, stating that she did not believe notification was necessary since the allegation was not directed toward the resident. Upon further review, the DON recognized that the incident constituted an allegation of verbal abuse and that facility policy required notification of the resident's representative. The resident involved had diagnoses including dementia, age-related osteoporosis, and a history of falls, with a documented Brief Interview for Mental Status (BIMS) score indicating severely impaired cognition. The facility's records, including progress notes and the initial reportable event documentation, did not show any evidence that the POA was notified of the verbal abuse allegation. The facility's abuse policy specifically requires informing the resident's representative of any report of potential mistreatment and ongoing investigations, which was not followed in this case.
Failure to Timely Report Allegations of Abuse to State Agency
Penalty
Summary
The facility failed to report allegations of abuse to the State Agency within the mandated 24-hour timeframe for two residents. In the first instance, a cognitively intact resident with a history of dementia and other medical conditions expressed distress to a unit manager, requesting to speak with administration. The unit manager relayed the concern to the assistant administrator, who was occupied at the time. Later, it was reported that a nurse had made an obscene gesture toward the resident, which the unit manager recognized as potential mental abuse and again reported to the assistant administrator. Despite this, the initial report to the State Agency was not submitted until more than 24 hours after the facility became aware of the allegation. In the second case, the Director of Nursing was informed by a CNA that an LPN had used a racial slur while recounting an incident involving a resident with severe cognitive impairment. The DON investigated and spoke with the LPN, who admitted to repeating the story but claimed the language was not directed at the resident. The DON initially decided not to report the incident to the State Agency, believing it did not constitute reportable abuse. However, the initial report was eventually submitted several days after the allegation was made, again exceeding the required reporting timeframe. Both incidents demonstrate that the facility did not adhere to its own abuse policy, which requires immediate reporting of abuse allegations to the State Agency within 24 hours. The policy emphasizes the importance of timely and accurate reporting to ensure resident safety and compliance with regulatory requirements. The delays in reporting were confirmed through staff interviews and review of documentation, with both initial reportables submitted well after the mandated period.
Failure to Follow Food Storage Guidelines
Penalty
Summary
The facility failed to adhere to proper food storage guidelines and their own policy regarding the labeling and dating of ready-to-eat food items. During an inspection, it was observed that the facility did not label opened pre-sliced cooked turkey and buffet ham with a 'use by' date, which is required to ensure food safety. The Dietary Supervisor confirmed that these items should have been labeled with a delivery date, an opened or prepared date, and a use by date, and should be used within seven days of being opened. Additionally, a bottle of lemon juice was found without an opened or use by date and was not stored in the refrigerator as per the manufacturer's guidelines, which was acknowledged by the staff as a mistake. The facility's policy, titled 'Labeling & Dating,' mandates that ready-to-eat time/temperature control for safety foods be stored in the refrigerator at 41 degrees Fahrenheit for no more than seven days to reduce the risk of foodborne illness. The facility also provided a document outlining food expiration guidelines, which specifies different storage durations for various types of fully cooked ham. The deficiency in following these guidelines and policies has the potential to affect all 163 residents receiving food from the facility's kitchen, although the report does not specify any direct impact on the residents at the time of the survey.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to adhere to its medication storage and labeling policy, as observed in the third floor's Team A medication cart. During an inspection, a nurse identified as V6 was responsible for this cart, which contained medications for 24 residents. In one of the top drawers, three white round tablets were found in a clear plastic bag without any labeling to identify the medication or its intended recipient. V6 admitted to not knowing the origin of the tablets or who placed them in the bag, acknowledging that this practice was against the facility's policy and that the tablets should have been discarded. Further interviews with the Assistant Directors of Nursing, V4 and V30, confirmed that the facility's policy requires unknown medications to be discarded in the sharps' container. They emphasized that no medication should be stored separately or saved on the side, as nurses have access to an electronic dispensing system for additional medications. The facility's policy, dated January 2022, mandates that medications be stored in their original containers and properly labeled, with any damaged or outdated medications being removed and disposed of according to procedure.
Failure to Follow Pureed Diet Recipes
Penalty
Summary
The facility failed to follow standardized pureed recipes during food preparation, affecting four residents on pureed diets. Observations revealed that residents on pureed diets were served thin broth instead of properly blended pureed soup. The dietary aide confirmed that the pureed soup typically consisted only of broth. The chef admitted to straining the solids from the regular soup and serving only the liquid to residents on pureed diets, contrary to the recipe instructions that required blending the soup to a pureed consistency. The dietary supervisor emphasized the importance of following recipes to ensure nutritional value, while the consultant registered dietitian highlighted the potential nutritional risks for residents on pureed diets. The dietitian noted that residents on pureed diets should receive the same nutritional content as those on regular diets, except in pureed form. The failure to blend the soup as per the recipe meant that residents missed out on essential nutrients, potentially impacting their nutritional intake. The report documented specific diet orders for the affected residents, all requiring pureed textures.
Failure to Administer Influenza and Pneumococcal Vaccines
Penalty
Summary
The facility failed to adhere to its policy on Influenza and Pneumococcal Immunizations, resulting in several residents not being offered or provided with the necessary vaccines. Resident R145, who is alert and oriented, reported not being offered the influenza and pneumococcal vaccines despite expressing a desire to receive them. The resident's medical records confirmed that the influenza vaccine was not offered, and the pneumococcal vaccine was deemed ineligible without proper investigation into the resident's qualifying medical conditions. Resident R158, admitted in July, was informed that flu shots were not administered until October. However, by the end of October, the resident had not received the influenza vaccine and expressed concern due to existing heart problems. The resident's records indicated that the influenza vaccine was not offered because it was not in season, and the pneumococcal vaccine was also not offered. Similarly, Resident R93, who is moderately cognitively impaired, was not offered the influenza vaccine for the current season nor the pneumococcal vaccine, despite having received the influenza vaccine the previous year. Resident R124, who is alert and oriented, received the influenza vaccine in October after requesting it since March. However, the resident had consented to the pneumococcal vaccine in March and had not received it by the end of October. The facility's staff, including the Assistant Director of Nursing and the Director of Nursing, acknowledged the oversight in offering and administering the vaccines, citing issues with the timing of vaccination clinics and a lack of thorough investigation into residents' medical histories to determine vaccine eligibility. Resident R150, who has multiple chronic conditions, was also not offered the pneumococcal vaccine despite expressing a desire to receive it and having an active order for it in their medical records.
Resident Dignity Compromised During Feeding
Penalty
Summary
The facility failed to treat a resident, identified as R17, with respect and dignity during a dining observation. R17, who was admitted with multiple diagnoses including multiple sclerosis, pseudobulbar affect, and dysphagia, was observed sitting in a wheelchair, alert but confused, during a lunch service. A Certified Nursing Assistant (CNA), identified as V26, was seen standing over R17 while assisting with feeding, which is contrary to the facility's policy that requires staff to be seated at eye level with residents during feeding to ensure dignity and comfort. The Director of Nursing (DON), identified as V3, confirmed that staff should be seated at eye level with residents during feeding to avoid making them feel rushed and to maintain their dignity. R17's medical records indicated a need for total assistance with eating, and the facility's policy on feeding, dated September 2020, emphasized the importance of staff positioning themselves conveniently and comfortably for both the resident and themselves. The incident was noted during a dining observation on the second floor, where two other residents were also present at the same table.
Failure to Follow Standards in Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards of practice during medication administration for a resident diagnosed with Alzheimer's disease, dementia, muscle wasting and atrophy, weakness, age-related physical debility, and adult failure to thrive. The resident had orders for Aspirin, Ferrous Sulfate, Jardiance, and Sertraline, with instructions that medications could be crushed if the manufacturer allowed or given in liquid form if the resident was unable to take them intact. During an observation, a nurse prepared the resident's morning medications by crushing all four tablets together and mixing them with applesauce before administering them to the resident. The facility's policy on medication administration emphasizes safe administration as prescribed, but its policy on crushing medications lacks specific guidelines for administering multiple crushed medications. A pharmacist at the facility stated that each medication should be crushed and administered separately with the liquid or food it is mixed with. An article from the American Association of Post-Acute Care Nursing supports this practice, noting that crushing and combining medications can lead to physical and chemical incompatibilities, potentially altering the therapeutic response.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, identified as R66, who is dependent on staff for toileting assistance. R66, who has a complex medical history including chronic obstructive pulmonary disease, heart failure, and diabetes, was observed to be alert and oriented but reported being left in a soiled incontinence brief for up to six hours. During an observation, R66 was found in a soiled brief with reddened and excoriated buttocks, indicating a lack of timely care. The resident expressed that she often had to urinate multiple times in her brief before being changed, and noted that care was delayed, especially during the night shift. Staff interviews revealed inconsistencies in the provision of care. V11, an LPN, stated that rounding and incontinence care should occur every two hours, but the assigned CNA was sent home, leaving R66's care to another CNA, V13. V14, another CNA, confirmed that incontinence care was provided earlier in the day but acknowledged that R66's skin was already raw and reddened. The Director of Nursing, V3, reiterated the facility's policy of two-hourly rounding and care to prevent skin conditions. The facility's care plan for R66 emphasized the need for assistance with toileting to maintain skin integrity, which was not adhered to, resulting in the deficiency.
Failure to Apply Hand Splints as Prescribed
Penalty
Summary
The facility failed to follow the care plan and apply splints to both hands of a resident with limited range of motion as prescribed by the doctor. The resident, who was admitted with multiple diagnoses including rheumatoid arthritis and contractures in both hands, was observed multiple times without the prescribed splints in place. The physician's order required the application of splints to the resident's hands for two hours in the morning and two hours in the afternoon, which was not consistently documented as being done. The Director of Nursing confirmed that the splints were intended to prevent further contractures and maintain current mobility, and that there was an active order for their application. However, the task record for the resident showed that the splints were not documented as applied on several dates. The facility's policy required that splint or brace assistance be planned, monitored, evaluated, and documented, which was not adhered to in this case.
Failure to Provide Spare Tracheostomy Tube at Bedside
Penalty
Summary
The facility failed to provide a spare tracheostomy tube at the bedside for a resident, R14, who was reviewed for tracheostomies. R14's medical records indicated a diagnosis of chronic respiratory failure with hypoxia and an order for tracheostomy care, specifying the type and size of the trach tube. During an observation, surveyors found that R14, who was alert and oriented, did not have a spare trach tube at the bedside. A nurse, V6, who regularly cared for R14, was also unaware of the type or size of the trach tube and confirmed the absence of a spare trach tube after searching the resident's room and supply areas. The Director of Nursing, V3, acknowledged the lack of a specific policy on tracheostomy care and confirmed that the facility's respiratory therapist, V7, stated that a spare trach tube should be available at the bedside for emergencies. R14's comprehensive care plan noted the potential for complications due to the tracheostomy but did not include an intervention to keep a spare trach tube at the bedside. The facility's clinical practice guidelines for comprehensive care plans and tracheostomy care did not address the need for a spare trach tube, contributing to the deficiency identified by the surveyors.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to adequately manage and address the pain management needs of a resident, identified as R35, who was experiencing constant neck and shoulder pain. Despite being on scheduled pain medication and having a PRN (as needed) order for Tylenol #3, the resident reported not receiving the PRN medication when needed. Observations on two consecutive days revealed that the resident was in pain and had not been offered the PRN medication until the surveyor intervened. The resident's care plan, which should have been updated to reflect her current pain status, goals, and preferences, was not revised accordingly. The Director of Nursing (DON) acknowledged that nurses are expected to assess pain every shift and provide both pharmacological and non-pharmacological interventions as needed. However, the review of the resident's electronic health record and Medication Administration Record (MAR) indicated that the pain management strategies were not consistently implemented. The facility's pain management policy requires regular pain evaluations and the use of a pain rating scale, but these measures were not effectively applied in R35's case, leading to unmanaged pain and discomfort.
Failure to Properly Account for and Dispose of Controlled Medications
Penalty
Summary
The facility failed to properly account for and dispose of controlled medications, leading to potential loss or diversion. This deficiency was observed during a narcotic reconciliation of one out of four medication carts, affecting two residents. One resident had a medical diagnosis of chronic pain syndrome and osteoarthritis, with an order for Tramadol HCl 50 mg to be taken as needed for pain. The surveyor found a compromised blister packet for this medication, with a piece of transparent tape over the back of the number ten slot, and the nurse was unsure if the tablet inside was Tramadol. The nurse acknowledged that the tablet should have been discarded in the sharps container with another nurse as a witness. Another resident, diagnosed with polyosteoarthritis, adjustment disorder with anxiety, and receiving palliative care, had orders for Lorazepam and Oxycodone HCl. The surveyor found discrepancies in the controlled drug records for these medications. The Oxycodone blister packet had four tablets remaining, while the record indicated there should be three. Similarly, the Lorazepam bottle had two tablets left, but the record showed there should be three. The nurse admitted to administering a dose of Lorazepam earlier and possibly signing the wrong record. Interviews with the Assistant Directors of Nursing confirmed that controlled substances should not be returned once their packaging is broken, and discrepancies should be addressed immediately.
Failure to Complete Timely AIMS Assessment for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to adhere to its policy regarding the timely completion of the Abnormal Involuntary Movement Scale (AIMS) Assessment for a resident, identified as R26, who was receiving antipsychotic medication. R26 was admitted with multiple diagnoses, including unspecified dementia and psychosis, and was prescribed Olanzapine for unspecified psychosis. The facility's policy required AIMS assessments to be conducted upon admission and then quarterly, annually, or upon significant change or readmission for residents on antipsychotic medications. However, the AIMS assessment for R26 was not completed in a timely manner, with the last documented assessment being on 11/23/22, despite the requirement for a reassessment every six months. The Assistant Director of Nursing, who also serves as the Psychotropic Nurse and Infection Preventionist, acknowledged the importance of the AIMS assessment in monitoring potential side effects of psychotropic medications, such as involuntary movements. The failure to complete the AIMS assessment as required could result in unrecognized side effects, posing a safety concern for the resident. The facility's policy, dated 09/2020, emphasized ongoing monitoring for side effects and the necessity of a baseline AIMS assessment for residents receiving antipsychotic medications. Despite this policy, the facility did not complete the required AIMS assessment for R26 as part of the last quarterly Minimum Data Set (MDS) on 10/22/24, leading to a deficiency in care.
Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate and report an injury of unknown origin for a resident, identified as R1, who was part of a sample of four residents. R1, an elderly resident with a history of hypertensive heart disease, spinal stenosis, type 2 diabetes, and generalized anxiety disorder, was found with two greenish bruises on the right side of his forehead and an abrasion on his nose. Despite R1's moderate cognitive impairment, he reported that a female had hit him with a phone, but he did not provide further details or report the incident to the staff. The Director of Nursing (V2) acknowledged that the bruising was noted by staff, and the overnight CNA reported that R1 had bumped his head during care. However, no incident report was completed by V2 or the Administrator (V1), who also failed to document the incident despite being informed. The Administrator questioned R1 and his roommates, but no further investigation was conducted. The CNA who attended to R1 during the night shift reported that R1 was almost on the floor and had bumps on his head, but she did not know how the injuries occurred. The facility's failure to properly investigate and report the incident was further highlighted by the lack of documentation and follow-up by the nursing staff. The hospice RN and other staff members noted R1's lethargy and unexplained head injuries, leading to his transfer to the hospital for evaluation. The facility's abuse policy mandates immediate reporting and investigation of potential mistreatment, which was not adhered to in this case, resulting in a deficiency in handling the incident appropriately.
Inadequate Incontinent Care for Residents
Penalty
Summary
The facility failed to provide adequate incontinent care for two residents, R3 and R4, resulting in them being left wet and soiled for extended periods. R4, who is cognitively intact and dependent on the facility for hygiene due to medical conditions, reported being wet since 6:00 AM and expressed frustration over the recurring issue. Despite R4's complaints, the CNA responsible for her care, V9, did not check her condition thoroughly, assuming she was dry based on her verbal response. The surveyor observed R4's saturated incontinence brief and bed sheet, indicating a lack of timely care. Similarly, R3, who is also dependent on the facility for perineal hygiene, was found in a saturated bed with a strong urine odor. The CNA, V16, acknowledged that R3 is a heavy bed wetter and should be changed more frequently than every two hours but was unable to do so due to having 12 residents assigned. The facility's unit manager and administrator confirmed that residents should be kept clean and dry to prevent skin issues, and that a resident stating they are not wet does not constitute refusing care. However, the facility lacked a specific policy related to incontinent care or ADLs, contributing to the deficiency.
Failure to Supervise Resident with Tracheostomy During Meals
Penalty
Summary
The facility failed to ensure that a resident with a tracheostomy, who was recommended by Speech Therapy to be supervised while eating, was monitored during meals. This resident, who is cognitively intact with a BIMS score of 15, was observed eating without supervision on multiple occasions. The resident expressed that no staff monitored them during meals and that they relied on a call light if they felt they might choke. The Speech Therapist had previously discharged the resident with a recommendation for occasional supervision during meals, but this was not being followed by the nursing staff. The facility's administrator was unaware of the Speech Therapist's recommendations for meal supervision, and the resident's care plan, which documented a swallowing problem related to dysphagia, was not being adhered to. The facility's policy on feeding residents was not followed, as there were no meal monitor sheets available for the resident. Additionally, the facility's feeders list, which documents residents requiring feeding assistance, did not include this resident, despite the documented need for supervision.
Fire Safety Deficiency Due to Inadequate Fire Watch Procedures
Penalty
Summary
The facility failed to adhere to its Fire Watch policy, which resulted in a deficiency related to fire safety procedures. The issue began when the water sprinkler system experienced a problem, causing low pressure after seven minutes of activation. This required the fire department to connect a water hose to assist with water pressure. The facility was on Fire Watch from 9/11/2024 to 9/17/2024, during which time the fire sprinklers were not functioning properly. Despite the critical nature of the situation, the facility did not provide an in-service training on Fire Watch procedures to all staff as required by their policy. The facility's administrator, V1, was unsure if an in-service was conducted and later confirmed that it was not done for all staff. The VP of Facilities Environmental Services and Life-safety, V5, and Corporate Maintenance, V4, indicated that only certain staff received in-service training, and there was no documentation to support this. The list of in-serviced staff was incomplete, missing many nursing staff and other departments that could be affected during a fire emergency. Additionally, the facility failed to notify the Fire Department and State Health Agency after the fire pump control was repaired and the system was restored. The new Building Manager, V9, who started during the Fire Watch period, was not informed about the Fire Watch procedures. The facility's Fire Watch policy requires that all department heads and designated staff be trained on Fire Watch procedures, and that a brief in-service be conducted at the beginning of each shift. The policy also mandates that the local fire department and State Health Department be notified in writing when the fire protection system is restored. These steps were not followed, leading to a deficiency in fire safety preparedness and communication.
Failure to Use Mechanical Lift Results in Resident Fall
Penalty
Summary
The facility failed to provide appropriate adaptive equipment during the transfer of a resident, resulting in the resident falling and sustaining a bruise and an abrasion on the knees. The incident involved a resident who was dependent on a mechanical lift for transfers due to a history of falling, morbid obesity, lack of coordination, and unsteadiness on feet. Despite these conditions, the resident was transferred without the use of a mechanical lift, which was against the established care plan and facility procedures. On the day of the incident, a CNA was responsible for transferring the resident to the shower room. The CNA did not use the mechanical lift as required, and instead, attempted to assist the resident manually. The resident's legs gave way, and the CNA assisted the resident to the floor, resulting in minor injuries. The CNA had been provided with a 'roster' at the beginning of the shift, which indicated that the resident required a mechanical lift for all transfers. However, the CNA did not adhere to this directive. Interviews with facility staff, including a Registered Nurse and a Physical Therapist, confirmed that the resident's transfer status was clearly documented and communicated. The failure to use the mechanical lift was attributed to the CNA's lack of judgment and failure to follow the established procedures. The incident highlighted a breakdown in communication and adherence to care protocols, which compromised the safety of the resident.
Failure to Reposition Resident at Risk for Pressure Injuries
Penalty
Summary
The facility failed to adhere to the care plan for a resident identified as at risk for pressure injuries, specifically by not turning and repositioning the resident as required. Observations on May 25, 2024, between 9:23 AM and 11:34 AM, revealed that staff did not assist the resident in turning or repositioning. The resident, who was observed lying on her back during this period, reported that she had not been moved or repositioned since the night shift and expressed discomfort due to her position. The resident also mentioned experiencing pain or pressure on her neck and back due to sliding down the bed. The resident's medical history includes Type 2 Diabetes Mellitus, peripheral vascular disease, diaper dermatitis, morbid obesity, and low back pain. The resident is cognitively intact with a BIMS score of 15 out of 15 but is dependent on assistance for mobility, as indicated by a mobility score of 1 out of 6. The resident's Braden scale score of 14 suggests a moderate risk for pressure injuries. The care plan specifies turning and repositioning every two hours, which was not followed, leading to the deficiency.
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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