Alden Estates Of Shorewood
Inspection history, citations, penalties and survey trends for this long-term care facility in Shorewood, Illinois.
- Location
- 710 W Black Road, Shorewood, Illinois 60404
- CMS Provider Number
- 146153
- Inspections on file
- 22
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Alden Estates Of Shorewood during CMS and state inspections, most recent first.
Staff failed to follow established infection prevention practices during incontinence care, medication administration, and care of a resident on enhanced barrier precautions. In multiple instances, CNAs handled urine- and blood-soiled linens, applied briefs and creams, adjusted bed controls, dressed residents, and exited rooms without changing gloves or performing hand hygiene as required by facility policy. Soiled linens were placed on the floor, and a resident remained on a urine-soiled mattress during care. Nurses administered insulin and other medications, checked vital signs, and managed a central IV line without performing hand hygiene before or after care, and one nurse did not don the required gown when providing high-contact care to a resident under EBP. These actions were inconsistent with the facility’s hand hygiene policy and posted EBP instructions.
A resident with multiple serious cardiac and renal diagnoses had conflicting information regarding code status across the EMR, orders, and care plan. The face sheet, EMR dashboard, and active physician orders all listed the resident as No CPR/DNAR, but the active care plan documented that the resident had not chosen any advance directives and was full code. No signed POLST or advance directive documents were uploaded in the EMR or available in the designated black folder at the nursing station, despite facility policy requiring this for residents with DNR status. A nurse reported she would follow the DNR order and withhold emergency interventions, while the resident, who was alert and decision-capable, stated he wanted to be resuscitated and confirmed he wished to be full code, demonstrating a failure to align documentation and orders with the resident’s expressed treatment preferences.
A resident with a history of falls, unsteady gait, and recent hospitalization-related weakness was care planned as a fall risk requiring assistance with ADLs. During a transfer from a chair to a wheelchair, a CNA, assisting the newly admitted resident for the first time, held the resident’s hand while the resident stood and transferred but did not apply a gait belt, despite having one in her pocket and acknowledging that CNAs are supposed to use it for transfers. The DON later confirmed that staff are required to use a gait belt with weight-bearing residents needing hands-on assistance, in accordance with the facility’s gait belt policy.
A resident with COPD, chronic respiratory failure with hypoxia, and a recent pneumonia hospitalization had physician orders and a care plan for continuous O2 at 2 L/min via nasal cannula. The resident was observed in a wheelchair with a nasal cannula connected to a portable O2 tank, and when the POA questioned whether O2 was infusing, staff found the portable tank empty despite being set at 2 L/min. Staff interviews revealed uncertainty about who transferred the resident from bed to wheelchair and who switched her from the concentrator to the portable tank, while the DON and CNAs stated that only nurses are responsible for connecting O2 equipment and that CNAs may only assist with transfers and adjust the cannula. Facility policy required RNs or LPNs to provide compressed O2 per MD orders, but the resident remained on an empty portable tank while ordered to be on continuous O2.
A resident receiving high-risk opioid therapy for neoplasm-related pain had a 12 mcg/hr fentanyl patch ordered to be applied and removed every 72 hours per the MAR and physician order. Staff documented application of a patch and a subsequent due removal but instead entered a code on the MAR that should have been supported by a progress note, which was missing. Another 12 mcg/hr fentanyl patch was later applied to the resident’s arm with no documentation that the original patch was removed. The DON confirmed the order was not followed and that documentation of removal was absent, and an NP reported that two fentanyl patches were found on the resident upon arrival to the ER. The resident had multiple serious diagnoses, including malignant neoplasms, neoplasm-related pain, pulmonary embolism, morbid obesity, and protein-calorie malnutrition.
A resident with a history of anemia and cancer diagnoses received Ribociclib chemotherapy during a period when it was ordered to be held, due to staff failing to update and follow new physician orders after an oncology appointment. The responsible LPN did not enter all the new orders, and the medication was administered despite clear instructions to pause treatment, contrary to facility policy.
The facility failed to manage medications properly, with residents found with medications at their bedside without physician orders. One resident had an inhaler from home, another had eye drops without an order, and a third had pain relief cream and ointment. Additionally, a resident was left with a medication cup containing pills, and another had eye drops and cream not prescribed to them. The facility's policy requires orders for bedside medications, which was not followed.
The facility failed to justify the necessity of antibiotics for four residents, as they did not meet the criteria for prescription. The Director of Nursing/Infection Preventionist admitted that the McGeer tool was not completed for tracking antibiotic use, leading to unnecessary prescriptions. The facility's policy to optimize antibiotic use was not adhered to, resulting in deficiencies.
The facility failed to conduct performance evaluations for five CNAs, affecting all 79 residents. The Business Office Manager, V9, admitted to not completing the evaluations, which were supposed to be done after corporate rate changes. The Director of Nursing clarified that V9 was not responsible for these evaluations, which should have been conducted by the CNA supervisor. A review of personnel files showed that none of the five CNAs had received annual performance reviews for several years, contrary to the facility's policy.
A resident's PICC line transparent sterile dressing was not changed as ordered by the physician due to a lack of available supplies in the facility. The Director of Nursing and registered nurses confirmed that the dressing changes were not performed or documented as required, leading to a deficiency in providing appropriate PICC line care.
Failure to Follow Hand Hygiene, PPE, and Linen-Handling Practices
Penalty
Summary
The deficiency involves multiple failures to follow the facility’s infection prevention and control practices, particularly related to hand hygiene, glove use, handling of soiled linens, and adherence to enhanced barrier precautions. One resident with chronic kidney disease, knee pain, hypertension, and muscle weakness was found lying in bed on an incontinence pad and linens soiled with urine and blood, with additional bed linens on the floor. A CNA, already wearing gloves, removed the soiled incontinence pad and placed it on the floor, then continued to cover the resident with clean linens, adjust the bed controls, and hand the resident the call light while wearing the same soiled gloves. The CNA then placed the soiled linens and pad into a plastic bag taken from the resident’s trash bin, contrary to the DON’s expectation that staff remove gloves, perform hand hygiene between dirty and clean tasks, and avoid placing linens on the floor. Another resident with stage 4 chronic kidney disease, type 2 diabetes mellitus, severe morbid obesity, and polyneuropathy required extensive assistance with personal hygiene and toileting. During incontinence care, a CNA wore gloves while wiping urine from the resident’s buttocks and groin and tucking a soiled bedsheet under the resident, then applied a clean brief and cream to the buttocks without changing gloves. After removing one soiled glove, the CNA took a clean glove from her pocket and another from the bathroom, donned them without performing hand hygiene, and continued to apply cream to the groin, remove the soiled bedsheet, and finish securing the brief. The CNA then put on the resident’s socks and shorts while the resident remained on a urine-soiled mattress, placed a mechanical lift sling under the resident, removed gloves, and handled the trash bag with soiled linens and exited the room without performing hand hygiene, contrary to the facility’s hand hygiene policy and the DON’s stated expectations. Additional deficiencies were observed during medication administration and care of a resident on enhanced barrier precautions. A nurse administered insulin to one resident and then prepared and administered two types of insulin to another resident without performing hand hygiene before or after either medication pass. For a resident on enhanced barrier precautions with a central IV line, a nurse checked vital signs without gloves and without hand hygiene before or after, then prepared and administered oral and IV medications wearing only gloves and without performing hand hygiene. This was inconsistent with the facility’s hand hygiene policy, which requires alcohol-based hand rub before resident contact, between soiled and clean body sites, and after glove removal, and with the EBP posting on the resident’s door, which instructed staff to clean hands upon entering and leaving the room and to wear gown and gloves for high-contact care involving devices such as central lines.
Inconsistent Advance Directive Documentation and Orders for a Resident
Penalty
Summary
The facility failed to ensure that one resident’s advance directive documentation, physician order, and care plan were consistent and accurately reflected the resident’s treatment wishes in the event of a medical emergency. The resident was admitted with multiple significant diagnoses, including acute kidney failure, acute on chronic diastolic congestive heart failure, and ventricular premature depolarization. The face sheet, EMR dashboard, and active order summary all indicated a No CPR/Do Not Attempt Resuscitation (DNAR) status. However, the active care plan stated that the resident had not chosen any advance directives due to personal preference and identified the resident’s code status as full code. Review of the EMR revealed no uploaded advance directive forms or signed POLST to support the DNR order. During interviews, the Social Service Director (SSD) confirmed that, according to facility policy, signed POLST and/or advance directive documents for residents with DNR status should be uploaded into the EMR and an actual signed copy should be kept in a black folder at the nursing station. The SSD found that neither an uploaded document nor a physical copy was available for this resident. A registered nurse, when asked about the resident’s code status, stated she would rely on the EMR dashboard and active orders, which showed DNR, and that no emergency action would be taken if the resident were found unresponsive. The nurse also confirmed there were no supporting advance directive documents in the EMR or black folder and acknowledged the contradiction between the DNR order and the full code care plan. When the SSD directly asked the resident, who was alert and able to make decisions, the resident stated he wanted to be resuscitated and confirmed he wished to be full code, further demonstrating the inconsistency between the resident’s expressed wishes, the orders, and the care plan, contrary to the facility’s advance directive policy and procedure.
Failure to Use Gait Belt During Transfer of High Fall-Risk Resident
Penalty
Summary
The deficiency involves staff failure to follow the facility’s gait belt policy during the transfer of a resident identified as being at risk for falls. The resident had multiple diagnoses, including a history of falling, polyosteoarthritis, other chronic pain, and hypertension. A fall risk assessment documented that the resident was at risk for falls, had an unsteady gait, and had experienced one to two falls in the prior three months. The resident’s fall care plan and ADL care plan, both initiated on the same date as the observation, identified a risk for falls and functional performance deficits due to weakness from a recent hospitalization, with interventions directing staff to assist the resident with ADL tasks as needed. On the morning of the observation, the resident was seated in a chair in their room when a CNA, who stated it was her first time assisting this newly admitted resident, prepared to transfer the resident from the chair to a wheelchair. The CNA positioned the wheelchair close to the resident’s chair and asked the resident to stand. The resident stood while the CNA held the resident’s hand to assist with the transfer. Although the CNA had a gait belt in her pants side pocket and acknowledged that CNAs are supposed to use a gait belt when assisting residents with transfers, she did not place the gait belt around the resident’s waist during this transfer. Later that day, the DON confirmed that CNAs are required to use a gait belt when transferring residents and that the CNA should have used a gait belt with this resident, consistent with the facility’s written policy stating that a gait belt will be used with weight-bearing residents who require hands-on assistance.
Failure to Ensure Continuous Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide ordered continuous oxygen therapy to a resident with multiple respiratory-related diagnoses. The resident had COPD, chronic respiratory failure with hypoxia, and a recent hospitalization for pneumonia, and the physician’s order and care plan required continuous oxygen at 2 L/min via nasal cannula. On observation, the resident was seated in a wheelchair with a nasal cannula connected to a portable oxygen tank, and an oxygen concentrator was also present in the room. When the resident’s POA questioned whether oxygen was infusing, staff checked the portable tank and found the gauge in the red zone, and the RN confirmed the tank was empty despite being set at 2 L/min. The resident reported that an aide had gotten her out of bed to the wheelchair but could not identify who or when, and the RN stated that whoever got the resident up had switched her from the concentrator to the portable tank. Subsequent interviews showed uncertainty among staff about who transferred the resident and who switched the oxygen source. The PTA reported therapy had not gotten the resident up that morning, and the DON stated that interviews with CNAs indicated none of them had transferred the resident and that the resident might have gotten herself up, as her daughter had previously commented that she was getting stronger and able to get out of bed on her own. CNAs and the DON stated that only nurses are responsible for disconnecting oxygen from the floor concentrator and connecting it to a portable tank, and that CNAs only assist with transfers and may adjust or reapply the nasal cannula. Facility policy specified that oxygen via compressed gas must be provided per physician orders by an RN or LPN, with CNAs/rehab aides limited to adjusting or reapplying the cannula or mask. Despite these orders and policies, the resident was found on an empty portable oxygen tank while ordered to be on continuous oxygen.
Failure to Remove Fentanyl Patch as Ordered Resulting in Duplicate Opioid Patches
Penalty
Summary
A deficiency occurred when staff failed to follow physician orders and the facility’s medication administration policy requiring drugs to be given in accordance with written orders. The physician order and MAR for one resident in November 2025 directed that a 12 mcg/hr fentanyl patch be applied transdermally every 72 hours for pain management and removed per schedule. Documentation showed a patch was applied on 11/26/25 at 5:25 PM and was due to be removed 72 hours later on 11/29/25 at 4:19 PM. Instead, a “9” was entered on the MAR on 11/29/25 at 3:22 PM, which should have been accompanied by a progress note, but no such note was found. The resident’s care plan identified them as receiving high-risk opioid medication and directed staff to administer pain strategies and medications per MD order and MAR/TAR. On 11/30/25 at 6:00 AM, another 12 mcg/hr fentanyl patch was documented as applied to the resident’s right arm, with no documentation that the original patch had been removed. The DON later confirmed that the order indicated the patch should have been removed on 11/29/25, that the physician order was not followed, and that there was no progress note or MAR prompt showing removal of the old patch. A nurse practitioner reported that when the resident arrived at the emergency room on 12/1/25, the ER nurse found two 12 mcg/hr fentanyl patches on the resident. The resident’s diagnoses included multiple serious conditions such as neoplasm-related pain, malignant neoplasms of bone and bone marrow, secondary neoplasms, pulmonary embolism, morbid obesity, protein-calorie malnutrition, neuromuscular bladder dysfunction, and pressure-induced deep tissue damage.
Failure to Update and Follow Physician Orders After Oncology Appointment
Penalty
Summary
The facility failed to update and follow all physician orders after a resident's outpatient oncology appointment. The resident, who had diagnoses including iron deficiency anemia, malignant neoplasm of the breast, and secondary malignant neoplasms of the bone and bone marrow, was seen by an oncology nurse practitioner and doctor, who provided written orders to hold the chemotherapy medication Ribociclib for one week and to resume it on a specified date. The physician order sheet included instructions for weekly CBC, daily Letvozole, a specific start date for the next Ribociclib cycle, and an evaluation by radiation oncology. Despite these orders, the medication administration record showed that the resident continued to receive Ribociclib during the period it was supposed to be held. Interviews with facility staff revealed that the nurse responsible for the resident after the appointment did not enter all of the new physician orders into the system, only entering the order for weekly CBC. The nurse acknowledged not entering the order to hold Ribociclib, despite being aware of the written instructions. Another nurse attempted to administer Ribociclib during the hold period and was informed by the resident that it should not be given until the specified date. The facility's policy requires that all medication orders be documented and followed, but this was not done in this case, resulting in the resident receiving chemotherapy against the physician's orders.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure proper medication management for residents, as evidenced by several observations and interviews. One resident, R10, was found with an Atrovent inhaler from home on her bedside table, despite having no physician's order for its use or for it to be at the bedside. The resident, who has chronic obstructive pulmonary disease and acute respiratory failure, stated that the inhaler is usually kept in her purse, which she could not locate. The facility's policy requires an order for medications to be stored at the bedside, which was not followed in this case. Another resident, R127, was found with eye drops on her bedside table, labeled with her name but without a corresponding physician's order. The resident, diagnosed with glaucoma, was cognitively intact, as indicated by her BIMS score. The Director of Nursing confirmed that no residents should have medications at the bedside without an order. Similarly, R19 had a pain relief cream and vaporizing ointment on her over-bed table, which she used without a physician's order. The LPN assigned to R19 was unaware of any residents being assessed to keep medications at the bedside. Additionally, R57 was found with a medication cup containing seven pills left at his bedside, which he did not take in the presence of a nurse. The LPN admitted to leaving the medications unattended, contrary to the facility's policy that requires nurses to ensure residents take their medications. R65 was found with eye drops and cortisone cream in her room, neither of which had a physician's order. The resident stated that the eye drops were not hers, and a family member suggested they belonged to a previous resident. The facility's failure to adhere to its medication management policies resulted in these deficiencies.
Failure to Justify Antibiotic Use in LTC Facility
Penalty
Summary
The facility failed to utilize an appropriate standardized tool or system to justify the necessity of antibiotics at the time they were ordered for four residents. Resident 43 was prescribed Nitrofurantoin for a UTI despite not meeting the criteria for antibiotic prescription, as her only symptom was increasing confusion, which was her baseline. Similarly, Resident 65 was given Bactrim for a UTI without presenting any symptoms, and Resident 66 received Nitrofurantoin for a UTI with only increased confusion as a symptom, which was also her baseline. Resident 4 was on Cephalexin and Ciprofloxacin for prophylactic treatment without proper justification. The Director of Nursing/Infection Preventionist (V2) acknowledged that the McGeer tool, which is used for tracking antibiotic use, was not completed for any residents on antibiotics for November 2024. The facility's policy emphasizes optimizing antibiotic use to prevent resistance and adverse effects, but the lack of adherence to this policy led to unnecessary antibiotic prescriptions. The facility's failure to communicate resident assessment information and apply the McGeer criteria contributed to these deficiencies.
Failure to Conduct CNA Performance Evaluations
Penalty
Summary
The facility failed to complete performance review evaluations for five Certified Nursing Assistants (CNAs), affecting all 79 residents. The Business Office Manager, V9, admitted to not conducting the evaluations, which were supposed to be done following corporate rate changes for CNAs. V9, who started in April 2023, was attempting to assist the supervisors by taking on the task of performance evaluations but forgot to complete them. The Director of Nursing, V2, clarified that V9 was not responsible for CNA evaluations, which should have been conducted by the CNA supervisor, V10, or the previous supervisor, V11, who left the facility in October 2024. A review of personnel files revealed that none of the five CNAs had received annual performance reviews for several years. V4, hired in 2021, lacked reviews for 2022, 2023, and 2024. V5, hired in 2021, had no reviews for 2022, 2023, and 2024, with only one review in 2021. V6, employed since 2014, had only one review in 2019, missing evaluations for multiple years. V7, hired in 2022, had no review for 2023, and V8, employed since 2017, lacked reviews from 2018 to 2024. The facility's policy mandates annual performance evaluations from the original hire date or following a position change, to be completed by the employee's department supervisor and reviewed by the Administrator.
Failure to Change PICC Line Dressing as Ordered
Penalty
Summary
The facility failed to change a resident's PICC line transparent sterile dressing as ordered by the physician. The resident, who was admitted with multiple diagnoses including mechanical complication of an internal right knee prosthesis and infection, had a PICC line in her right arm. The physician's orders required the dressing to be changed within 24 hours of admission and then weekly. However, the treatment administration record (TAR) and medication administration record (MAR) showed no documentation that the dressing was changed as ordered from April 25 through April 30, 2024, and from May 9 through May 14, 2024. Progress notes also lacked documentation of the dressing changes during these periods. Interviews with the Director of Nursing and registered nurses confirmed that the dressing changes were not performed due to a lack of available supplies in the facility, and there was no follow-up to ensure the supplies were delivered and the dressing changes were completed as ordered. The Director of Nursing reviewed the resident's medical records and confirmed that the PICC line dressing was not changed within 24 hours of admission and was not changed for the scheduled weekly change on May 9, 2024. The registered nurses involved stated that they were unable to perform the dressing changes due to the unavailability of supplies and were unsure if or when the supplies were delivered. This lack of adherence to physician orders and failure to document the dressing changes as required led to the deficiency in providing appropriate PICC line care for the resident.
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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