Aliya Of Highwood
Inspection history, citations, penalties and survey trends for this long-term care facility in Highwood, Illinois.
- Location
- 50 Pleasant Avenue, Highwood, Illinois 60040
- CMS Provider Number
- 145936
- Inspections on file
- 32
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Aliya Of Highwood during CMS and state inspections, most recent first.
The facility failed to provide adequate ADL assistance, including incontinence and hygiene care, to multiple dependent residents. One resident with significant physical and cognitive impairments was found lying on a saturated incontinence pad wearing two fully saturated briefs, with a strong urine odor and a reddened, excoriated peri area and buttocks; despite a care plan requiring barrier cream after each incontinent episode, no skin protectant was applied. Another resident, dependent on staff and transferred with a full-body lift, remained in a reclined wheelchair position placing pressure on the coccyx for several hours and was later found in a saturated brief smelling of urine, with a 1-cm open coccygeal area with exposed granulation tissue and no dressing present, despite staff stating the resident was changed every two hours. A third resident with hemiplegia and chronic conditions, who required substantial assistance with personal hygiene, was observed with long fingernails and a large amount of dark debris under the nails, contrary to the facility’s nail care policy and the DON’s expectation that nails be kept clean.
A resident with left wrist and pelvic fractures returned from an orthopedic follow‑up visit with her cast removed and a wrist brace reportedly provided, but the after‑visit summary only documented an OT referral and did not mention the brace or revised instructions. An RN observed the resident’s swollen wrist without any splint or brace in place, and the ADON was initially unaware that a brace had been issued. No timely nursing documentation of the follow‑up findings or new orthopedic recommendations was entered into the EMR, and updated orders for use of a Velcro wrist brace and related care were not added until two days after the appointment.
Two residents with existing pressure injuries and identified risk did not receive ordered pressure ulcer care and preventive measures. One resident with severe cognitive impairment and multiple heel pressure ulcers was repeatedly observed sitting in a recliner with direct pressure on the coccyx and heels, without heel offloading or a pressure-reducing pad, despite orders and a care plan to offload heels with heel boots or pillows. Another resident with a large stage 3 sacral pressure injury and an unstageable left great toe wound, both with daily treatment orders, was found with no dressings on either wound during care, while heels rested directly on the bed. Staff acknowledged expectations that treatments protect pressure injuries, and facility policy referenced the need for consistent wound monitoring and documentation, but offloading and dressing application were not consistently implemented.
Two residents experienced deficiencies in catheter-related care when staff did not adequately respond to severe new groin pain after a catheter change for a cognitively intact resident with a neurogenic bladder, and did not secure or properly position another resident’s indwelling catheter and drainage bag. In the first case, the resident repeatedly reported intense burning and razor blade-like pain in the groin and scrotum after the catheter change, staff administered tramadol but did not document the pain in the EMR or notify the provider despite facility policies on pain management and change in condition. In the second case, a resident was observed lying on unsecured catheter tubing that was taut from the weight of the drainage system, and a CNA briefly raised the drainage bag above bladder level, allowing urine to flow back toward the catheter, contrary to the facility’s catheter care policy requiring securement with a leg strap or similar device.
The facility failed to manage pain appropriately for two residents with significant medical conditions and PRN orders for analgesics. One resident with hemiplegia and a reddened perineal area reported back and arm pain and exhibited clear pain behaviors during incontinence care, yet received no PRN acetaminophen that day. Another resident with a pelvic fracture, bladder cancer, urinary drainage bags, and a large sacral wound showed abdominal pain, tensing, moaning, and verbal pain responses during peri-care, wound care, and limb movement, but was not given ordered PRN acetaminophen or hydromorphone on that day. These events occurred despite a facility pain management policy that defines pain as what the resident reports and calls for effective recognition and management of pain.
A deficiency was identified when a physician-ordered OTC medication, dextromethorphan 15 mg for TBI-related mood instability, was not available for a resident and was inaccurately documented on the MAR. An RN could not locate the medication during a morning med pass despite it having been ordered from the pharmacy days earlier. The DON stated that the pharmacy does not supply this OTC drug and that the facility is responsible for providing it, and that the nurse who entered the order should have received and reported a pharmacy message declining delivery. The MAR showed some doses signed as given and others marked as not available, and the facility’s medication ordering policy did not address how to obtain OTC medications.
A resident was observed with lidocaine pain patches left on a bedside table and self-applying them to both knees, while an RN confirmed that staff hand the patches to the resident for self-application. The MAR contained orders for lidocaine 5% patches to be applied to each knee, signed out by nurses as administered, but there was no physician order or interdisciplinary team determination authorizing self-administration of these patches and no corresponding self-administration assessment in the record. This conflicted with facility policies requiring secure medication storage and formal orders and assessments before allowing self-administration.
Two residents did not receive the planned noon meal when staff ran out of turkey casserole due to heaping scoop portions that exceeded the documented 6 oz serving size. The cook and the administrator both plated meals at the steam table, and when the casserole was depleted, the cook substituted hot dogs with carrots for the last two plates instead of the scheduled entrée. One affected resident reported that a higher-level staff member later acknowledged the hot dog was given by accident; the resident stated he would have preferred the regular meal and was not informed of the shortage or offered an alternative choice. The administrator confirmed the resident was not told about the lack of turkey casserole and was not offered an item from the alternative menu, despite the facility’s menu specifying turkey casserole, chopped carrots, and bread pudding for that meal.
A resident did not receive food and supplements consistent with documented dietary preferences and orders. During a mealtime observation, the resident’s tray contained an uneaten turkey casserole, carrots, and a small cup of fluid, but no soup or health shake, despite the dietary sheet specifying a daily health shake, a serving of soup, and no casseroles. The resident reported that the wrong food was sent every day and that requested soup was not provided. An RN confirmed that no health shakes had been sent to the floor after checking multiple dietary carts, and the Dietary Manager acknowledged that soup was not available even though it was listed on the resident’s dietary sheet.
Staff failed to follow the facility’s transmission-based precautions policy for a resident on strict contact isolation for C. diff. A housekeeping staff member cleaned the resident’s room wearing only gloves and no gown, despite a contact isolation sign on the door. At the same time, a CNA assisted the resident and removed dirty laundry in a yellow cinch bag, not an isolation bag, and left the room without wearing any PPE. The ICP later confirmed that gloves and a gown were required upon entry to rooms of residents on contact isolation, and facility records and policy documented that such precautions, including in-room care to prevent cross contamination, were ordered for this resident.
A resident with hemiplegia, muscle weakness, and communication deficits, documented as 73 inches tall, was observed lying in a bed that did not accommodate his height, with bent knees and a foot extending off the wooden footboard. He reported that a longer bed would be more comfortable and demonstrated how his knees were forced upward when his feet were on the bed. The DON stated uncertainty about the availability of a longer bed, and the Administrator reported that staff were unaware of the resident’s desire for a longer bed and could not confirm whether anyone had noticed his feet hanging off the bed, despite a facility policy requiring evaluation and reasonable accommodation of individual needs and preferences.
Residents reported ongoing issues with access to properly sized incontinence supplies, often receiving incorrect sizes or insufficient quantities, leading to discomfort and undignified care. Staff confirmed supply restrictions and acknowledged problems with inventory management. Additionally, a resident with behavioral health needs repeatedly directed verbal abuse at others, with staff and other residents witnessing these incidents and facility leadership not consistently intervening. These failures resulted in a lack of dignity and respect for multiple residents.
Staff failed to follow Enhanced Barrier Precautions for two residents with chronic wounds, including not wearing required PPE such as gowns during high-contact care and not posting appropriate EBP signage. Both the DON and Infection Control Nurse confirmed the need for gloves and gowns for residents on EBP, and facility policy requires these precautions for high-risk care activities.
A facility failed to double lock controlled substances in a medication cart, leaving them unsecured during medication administration. An LPN left the cart unattended and out of sight while administering medications to residents, with the lockbox containing controlled substances unlocked. The DON confirmed the importance of double locking to prevent theft, as outlined in the facility's policy.
A resident was repeatedly found without access to water, displaying signs of dehydration such as dry lips and mouth. Despite no fluid restrictions or swallowing issues, the facility staff failed to ensure water was within reach, contrary to the care plan and hydration policy.
A facility failed to refer a resident with bipolar disorder for a Level II PASARR screening, despite a reasonable suspicion of mental illness. The resident, admitted in 2019, was on antipsychotic and antidepressant medications. The Social Services Director could not find documentation of the required screening or referral, and the facility's policy for completing PASARR screenings prior to admission was not followed.
A facility failed to assess and document treatment orders for a new wound on a resident with a history of venous stasis wounds and lymphedema. Despite the resident's report of a new sore, the nursing staff did not document the wound or obtain treatment orders promptly. The wound care nurse was unaware of the blister until it was brought to her attention, and the wound doctor was notified two days later. The facility's Skin Management policy was not followed, leading to a deficiency in care.
A resident with severe cognitive impairment and high fall risk was transported in a wheelchair without foot pedals by the Social Service Director, leading to a deficiency in safety measures. The resident's toes repeatedly hit the ground during transport, despite staff awareness of the need for foot pedals to prevent injury. A policy for safe wheelchair transport was requested but not provided.
A resident with severe cognitive impairment and multiple medical conditions received a water flush through a G-tube without prior verification of tube placement by a nurse. The facility's policy did not explicitly state the procedure for checking tube placement, contributing to the deficiency.
A facility failed to follow manufacturer instructions for an insulin pen, impacting a resident with type II diabetes. A nurse prepared the pen without attaching the needle during priming, contrary to guidelines, potentially affecting the insulin dose administered. The DON confirmed the correct procedure involves attaching the needle before priming to ensure accurate dosing.
A facility failed to provide wound treatment as ordered for a resident with a stage 4 pressure ulcer. The Wound Care Nurse/ADON found that the resident's dressing was not changed as scheduled, with the last change occurring four days prior, despite orders for every other day treatment. An LPN confirmed that wound care should follow the doctor's orders.
A facility failed to investigate an abuse allegation when a resident reported that his roommate used a racial slur against him. The incident was reported to a registered nurse and the police, and the accused resident was moved to a different room. However, the facility administrator did not conduct an investigation, contrary to the facility's abuse policy, which mandates prompt investigation of all abuse allegations.
A resident with multiple diagnoses refused medication administration, leading to a failure in protocol when the nurse left the medication at the bedside. Despite the resident's refusal, the Medication Administration Record was inaccurately signed as if the medication was given. The ADON acknowledged the error, noting that the facility's policy requires staff to ensure medication is taken, which was not adhered to in this instance.
The facility failed to provide necessary wound care for two residents with nonpressure wounds. One resident with necrotizing fasciitis had undressed wounds despite daily care orders, while another with Hidradenitis Suppurativa missed multiple wound care treatments. The facility lacked a policy for nonpressure wound care.
Failure to Provide Adequate ADL, Incontinence, and Hygiene Care
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance with activities of daily living (ADLs), including incontinence and hygiene care, to residents who were dependent on staff. One resident with hemiplegia, hemiparesis, muscle weakness, cognitive communication deficit, and abnormal posture required substantial/maximal assistance with personal hygiene and was dependent on staff for toileting hygiene. This resident was found lying in bed on an incontinence pad with a large yellow wet area and a darker yellow ring, wearing two incontinence briefs that were completely saturated with urine and emitting a strong urine odor. When the CNA removed the briefs and provided incontinence care, the resident’s peri area and buttocks were reddened and excoriated, and the resident moaned and said “ouch” multiple times during cleansing. Despite a care plan directing staff to apply barrier cream after each incontinent episode for moisture-associated skin damage, no skin protectant was applied before a new brief was placed. Another resident, who was dependent on staff and used a reclining wheelchair and full-body mechanical lift, was observed sitting for hours in a reclined position that placed pressure directly on the coccyx, without engaging activity. When CNAs later transferred this resident to bed, the incontinent brief showed dark blue wetness indicator lines and was saturated with dark yellow urine, and the resident smelled of urine. Examination of the coccyx revealed a 1-centimeter open area with exposed granulation tissue, surrounding pallor, and mottled redness, with no dressing found in the bed or brief. A CNA stated that this resident is changed every two hours and is laid down after lunch, but also reported that the last incontinence change had occurred when the resident was gotten up at breakfast, indicating a gap of several hours without incontinence care. A third resident with hemiplegia, repeated falls, aphasia, and chronic kidney disease required substantial/maximal assistance with personal hygiene. This resident was observed with a splint on the left hand and long fingernails on the right hand, with a large amount of dark substance under the fingernails. When asked, the resident agreed to have the nails cleaned and cut. The care plan indicated the resident required assistance with daily care needs related to hemiplegia, and the facility’s nail care policy required removal of dirt from under fingernails and performance of nail care on shower days and as needed. The DON stated that residents’ hands should be washed before meals and that he would expect residents’ nails to be clean, but the resident’s observed nail condition showed that this assistance with hygiene had not been provided as required.
Failure to Timely Clarify and Implement Orthopedic Brace and Wrist Care Orders
Penalty
Summary
Failure to provide appropriate treatment and care according to orders, resident preferences, and goals occurred when the facility did not obtain or clarify new orthopedic recommendations following a resident’s follow‑up appointment and did not timely update the medical record. The resident had a history of fractures of the left hand, distal radius and ulna of the left wrist, and superior and inferior pubic ramus fractures of the left pelvis, with prior instructions to use a left wrist splint and a platform walker to avoid weight bearing through the left wrist. During a morning medication pass, an RN observed that the resident’s left arm cast had been removed after an orthopedic follow‑up visit and noted that the left wrist remained slightly swollen. The resident and her husband reported that a brace had been provided and that they were told it could be worn whenever the resident wanted, but at that time the resident was not wearing the brace and there was no documentation in the electronic medical record regarding new orthopedic instructions or the brace. The after‑visit summary for the follow‑up appointment documented only an occupational therapy referral and did not mention a brace or revised instructions for wrist support or weight bearing. The ADON initially stated he was unaware of any brace sent with the resident after the appointment, and by the end of that day there were still no nursing notes in the EMR describing the orthopedic follow‑up findings or any new recommendations. A late entry progress note later documented that the splint had been removed and an OT referral given, but the original lack of timely documentation and clarification meant that the resident’s care orders, including use of a Velcro wrist brace and clarification of weight‑bearing status, were not updated in the EMR until two days after the follow‑up visit.
Failure to Offload Heels and Maintain Ordered Dressings for Pressure Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary pressure ulcer care and preventive measures for two residents with existing pressure injuries and identified risk. For one resident with severe cognitive impairment and dependence for all footwear tasks, surveyors observed on multiple occasions that the resident was seated in a reclining chair with direct pressure on the coccyx and both heels resting on the leg rest, without heel offloading or a pressure-reducing pad in the chair. The wound nurse confirmed the resident had a Stage 4 pressure ulcer and an unstageable pressure ulcer on the left heel and two unstageable pressure ulcers on the right heel, and stated the resident should wear pressure-reducing heel boots in bed and in the chair. The LPN reported the pressure reduction boots were in the closet, and the physician’s orders and care plan both directed that the heels be offloaded with heel boot protectors or pillows. The facility’s skin management policy did not include guidance for offloading pressure ulcers. For a second resident admitted with multiple diagnoses and assessed as at risk for pressure injuries, orders were in place for daily wound treatments to a sacral wound and a left great toe wound. During incontinence care, surveyors observed a large sacral wound with a dark central area and red surrounding tissue, with no dressing in place; the CNA stated she did not know when the dressing came off. Later, the wound nurse assessed the resident, who exhibited pain responses during sacral wound care, and confirmed an unstageable wound on the left great toe, also without a dressing in place, while the resident’s heels were directly on the bed. Wound documentation showed a Stage 3 sacral pressure injury measuring 10 cm by 10 cm and an unstageable pressure injury on the left big toe. The DON stated that treatments to pressure injuries are intended to add protection and that he expects treatments to be in place, and the facility’s skin management policy emphasized the need for a system to assure consistent implementation of monitoring and documentation protocols.
Failure to Address Catheter-Related Pain and Maintain Proper Catheter Positioning
Penalty
Summary
The deficiency involves the facility’s failure to appropriately assess and respond to a resident’s significant increase in groin pain following a urinary catheter change, and failure to maintain proper positioning and securement of another resident’s indwelling urinary catheter and drainage bag. One resident, cognitively intact and with a history of neurogenic bladder requiring an indwelling catheter, reported severe burning and razor blade-like pain in the groin and scrotal area beginning after a catheter change. Over several days, the resident repeatedly stated that the pain was intense, interfered with eating, and that he felt no one was paying attention to it, although he acknowledged receiving pain medication that only partially helped. Nursing staff, including an RN, were aware of the resident’s ongoing groin pain and were administering tramadol, and the DON and ADON knew he was in pain and had an upcoming urology appointment. However, they were unsure whether the physician had been notified, and it was later confirmed that no one had contacted the physician about the new or increased pain following the catheter change. The resident’s EMR contained no documentation of his pain complaints despite staff awareness and administration of pain medication. The resident’s care plan for indwelling catheter use included monitoring for signs and symptoms of UTI and notifying the MD of abnormal findings, and the facility’s pain management policy defined pain as what the resident says it is and allowed for notifying the health care provider of new or changed pain, but these provisions were not followed in relation to his reported catheter-associated pain. A second resident with an indwelling urinary catheter was observed lying on their side with the catheter exiting through the back of an incontinent brief, unsecured, and with the drainage tubing suspended off the bed so that the weight of the tubing held the catheter taut. When staff repositioned the resident up in bed, the catheter stretched, and the tubing remained under the resident’s leg. A CNA then lifted the urinary collection bag above the level of the bladder, causing urine in the collection tubing to flow back toward the catheter. The CNA acknowledged the resident should not be lying on the catheter tubing and that the securing device had come loose, noting that the securing device is applied by a nurse. The facility’s indwelling catheter care policy required securing and anchoring the catheter with a leg strap or other device, which was not done in this instance.
Failure to Provide PRN Pain Management During Care and Wound Treatment
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate pain management for residents who required such services, specifically affecting two residents reviewed for pain management. One resident was admitted with hemiplegia, hemiparesis, muscle weakness, abnormal gait, cognitive communication deficit, dysphagia, and abnormal posture. His care plan, initiated in December and updated in January, included participation in a personal pain management program, education on pain management including non-pharmacological approaches, and pain management as needed. An order was in place for acetaminophen 325 mg, two tablets by mouth every four hours as needed for mild pain. On one observed day, this resident reported back pain and an inability to move his right arm while lying in bed. Shortly afterward, a CNA provided incontinence care and lifted the resident’s right arm to change his shirt, during which the resident hollered, moaned, and stated that his right arm hurt. The CNA apologized and continued care, removing the resident’s soiled incontinence brief. The resident’s perineal area was noted to be very reddened, and when the CNA wiped the area with a towel, the resident moaned, moved side to side, and complained that his perineal area hurt. The Medication Administration Record for that day shows the resident did not receive any pain medication, although he did receive pain medication the following day for pain rated 7 out of 10. The second resident involved was admitted with diagnoses including a right pubis fracture, malignant neoplasm of the bladder, major depressive disorder, right hip pain, anxiety disorder, and osteoarthritis. Orders were in place for acetaminophen 325 mg, two tablets by mouth every six hours as needed for pain, and hydromorphone 0.5 ml by mouth every eight hours as needed for pain. During an observed peri-care episode, CNAs removed the resident’s incontinence brief and noted a moderate amount of blood, believed to be from the rectum. When asked about pain, the resident patted her abdomen. The resident had two urinary drainage bags from the back area and a large, uncovered sacral wound. During wound care by an LPN/Wound Care Nurse, the resident tensed and moaned, and when asked afterward if the sacral area hurt, she nodded yes. When her right lower extremity was lifted, she said “Ow.” The Medication Administration Record for the month shows she had received acetaminophen and hydromorphone on earlier dates for high pain scores but did not receive any pain medication on the day of the observed pain behaviors, despite the facility’s pain management policy emphasizing recognition, management, and monitoring of residents’ pain.
Failure to Provide and Accurately Document Ordered OTC Medication
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician-ordered medication was available and accurately documented as administered for a resident. During a morning medication pass, an RN was unable to locate the ordered dextromethorphan tablets, which had been ordered from the pharmacy several days earlier. The DON later explained that dextromethorphan is an OTC medication that the facility, not the pharmacy, is responsible for providing, and that the floor nurse who entered the order should have received and reported a pharmacy message indicating the medication would not be delivered. The resident’s January MAR showed an order for dextromethorphan 15 mg at bedtime for 3 days for TBI-related mood instability, with doses signed out as given, and a second order for dextromethorphan 15 mg twice daily for the same indication, with only the first dose signed out as given and subsequent doses marked as not available. The facility’s medication ordering policy did not address procedures for obtaining OTC medications, and no additional pharmacy policies were provided.
Improper Storage and Unauthorized Self-Administration of Pain Patches
Penalty
Summary
Surveyors identified a deficiency in the facility’s handling of medication storage and administration for one resident using lidocaine 5% pain patches. During observation, the resident was found lying in bed with medication patches on her bedside table, which she stated were for knee pain and that she would apply when ready. During the same interaction, she placed both patches below each knee herself and reported that she always applies and removes them on her own. A subsequent interview with an RN confirmed that nurses give the patches to the resident and that the resident applies them herself. Record review showed active MAR orders for lidocaine 5% external patches to be applied topically to the left and right knees for pain management, with nurses signing these medications as given. However, there was no physician order authorizing self-administration of the lidocaine patches and no corresponding self-administration assessment for these patches in the electronic medical record. The only self-administration assessment on file, dated several months earlier, pertained to a different medication. This practice conflicted with the facility’s own policies, which require medications to be stored securely and accessible only to authorized staff, and which state that self-administration must be determined by the interdisciplinary team and supported by a specific order after assessing the resident’s ability to self-administer.
Failure to Follow Planned Menu and Portion Sizes Resulting in Substitute Entrées Without Resident Choice
Penalty
Summary
The deficiency involves the facility’s failure to follow the planned noon meal menu and portion sizes, resulting in two residents not receiving the scheduled turkey casserole meal. During observation of the noon meal service, the cook used a white 6 oz scoop to plate turkey casserole and chopped carrots while staff verbally requested meal textures. The administrator went behind the steam table and also began plating, using heaping scoop portions that created a mound over the flat of the scoop. As the last room cart was being plated, the cook scraped the metal tray to fill the scoop and ran out of turkey casserole, despite believing the correct serving ladle was used. Staff informed the cook that two more plates were needed, and the cook plated hot dogs with carrots for those two meals instead of the planned entrée. The dietary manager later confirmed that the facility ran out of turkey casserole and that two residents did not receive the regular meal, stating that the scoop sizes had been too large and should have been flat. One of the affected residents reported receiving a tray with a hot dog, believing it was the normal meal being served, and stated that a female staff member with long black hair, described as someone higher up, later told him they had accidentally given him the hot dog. The resident said he would have preferred the regular meal and felt he should have been given a choice of an alternative and informed that the facility had run out of the planned meal. The administrator confirmed that this resident was not informed of the shortage of turkey casserole and was not offered a choice from the alternative menu. The facility’s diet spreadsheet menu documented the turkey casserole portion size as 6 oz, with 4 oz soft chopped carrots and bread pudding as part of the planned meal.
Failure to Honor Resident Dietary Preferences and Ordered Supplements
Penalty
Summary
The facility failed to provide a resident with food that accommodated documented preferences and ordered supplements. On 01/12/2026 at 1:02 PM, the resident was observed lying in bed with the head of the bed at a 20-degree angle and an over-bed table holding an uneaten turkey casserole, uneaten carrots, and one 120 milliliter cup of fluid, with no health shake and no soup present. At that time, the resident reported that every day the facility sent the wrong food, that the facility never served the food on the menu, that soup had been requested but not provided, and that the resident could not eat the food that was sent. At 1:10 PM, an RN stated that dietary usually sent health shakes on the cart with the milk and, after checking four dietary carts on different hallways, reported that the kitchen had not sent any health shakes to the floor. At 1:20 PM, the Dietary Manager reviewed the resident’s dietary sheet and stated that the facility did not have soup and that health shakes were on the carts with the milk. The resident’s dietary sheet dated 01/12/2026 documented ordered supplements and preferences including “HEALTH SHAKE – 1 each,” “SOUP – 1 serving,” and “NO CASSEROLES,” which did not match the meal and items actually provided to the resident at the time of observation. These observations, interviews, and record review show that the resident did not receive the ordered health shake and soup and was instead served a casserole contrary to the documented preference of no casseroles, demonstrating a failure to accommodate the resident’s food and drink preferences as specified in the dietary sheet.
Failure to Ensure Required PPE Use for Resident on Contact Isolation
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the use of personal protective equipment (PPE) for a resident on contact isolation. On 1/12/26 at 12:51 PM, a housekeeping staff member (V17) was observed cleaning the room of resident R91, whose door displayed a sign indicating "Contact isolation." During this activity, V17 was only wearing gloves and was not wearing a gown as required by the facility’s transmission-based precautions policy for contact isolation. At the same time, a CNA (V19) was in the same room assisting R91 and removing the resident’s dirty laundry, which was placed in a yellow cinch bag rather than an isolation bag. The CNA carried the laundry from the resident’s room to the soiled utility room without wearing any PPE, including gloves or a gown. On 1/13/26 at 1:05 PM, the facility’s infection control preventionist nurse (V18) stated that staff should wear gloves and a gown upon entering the room of a resident on contact isolation. Facility records showed that R91 was on strict contact isolation precautions due to C. diff, with orders indicating that all needs were to be rendered in the room to prevent cross contamination. An isolation list provided by the facility documented that R91 was on contact isolation for C. diff with a start date of 1/10/26 and a potential stop date of 1/20/26. The facility’s transmission-based precautions policy dated 1/1/25 specified that for contact precautions, hand hygiene and gloves upon entry to the room were required, and a gown was required.
Failure to Provide Bed Accommodating Resident’s Height
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate an individual resident’s need for a bed suited to his height. The resident was admitted with diagnoses including hemiplegia and hemiparesis, muscle weakness, cognitive communication deficit, aphasia, and dysphagia, and his record showed a height of 73 inches. During observation, he was seen lying in bed with the head of the bed slightly elevated, his knees bent, and his left foot extending off the wooden foot end of the bed. When asked about his comfort, he reported that he was 6 feet 2 inches tall and that a longer bed would be more comfortable. He demonstrated that when he placed his feet on the bed, his knees were forced upward, and there was only a small amount of mattress above his head. In interviews, the DON stated he was not sure if a longer bed was available for this resident. The Administrator later reported that staff did not know the resident wanted a longer bed and could not say whether any staff had noticed that his feet were hanging off the foot of the bed. These findings occurred despite the facility’s Accommodation of Needs policy, which states the facility will evaluate and make reasonable accommodations for each individual’s needs and preferences, except when health and safety would be at risk.
Failure to Ensure Resident Dignity and Adequate Incontinence Supply
Penalty
Summary
The facility failed to ensure residents' dignity and rights by not providing incontinence supplies in the correct sizes and quantities, as well as by not preventing undignified interactions between residents. Multiple residents without cognitive impairment reported ongoing issues with access to appropriately sized incontinence briefs and pull-ups, with some residents forced to use incorrect sizes or go without supplies for extended periods. Staff interviews confirmed that supply distribution was restricted, with diapers stored in locked areas and limited quantities provided per shift, leading to shortages. The central supply and administrative staff acknowledged ongoing problems with supply management, including attempts to control inventory due to concerns about hoarding, but residents continued to report unmet needs. Additionally, the facility failed to prevent or address undignified verbal interactions among residents. Several residents and staff described incidents where one resident, with a history of mental illness and behavioral symptoms, verbally harassed and insulted other residents, including making derogatory comments about their weight and threatening statements. These behaviors were witnessed by other residents and staff, and in some cases, were not reported to or addressed by facility leadership. The affected residents generally reported feeling safe, but the incidents were recurrent and known to staff. The facility's policies regarding resident rights and dignity were requested but not provided during the survey. The combination of inadequate supply management for incontinence products and insufficient intervention in resident-to-resident verbal abuse resulted in a failure to uphold residents' rights to dignity, self-determination, and respectful treatment.
Failure to Implement Enhanced Barrier Precautions and PPE Use for Residents with Chronic Wounds
Penalty
Summary
The facility failed to ensure proper implementation of Enhanced Barrier Precautions (EBP) for two residents with chronic wounds. In one instance, a CNA provided morning care to a resident on EBP, including changing an incontinent brief, transferring the resident, and changing bed linens, while only wearing gloves and not a gown as required. The CNA acknowledged awareness of the EBP protocol and the need to wear both gown and gloves to prevent cross-contamination. The resident's care plan documented the need for EBP due to infection prevention standards. In another case, a resident with a surgical wound requiring daily dressing changes and recent antibiotic treatment did not have the required EBP signage or orange dot indicator outside the room. The DON confirmed the resident was on EBP and that the sign may have been removed during a room change or cleaning. Both the DON and Infection Control Nurse stated that staff should wear gloves and gowns when providing care to residents on EBP, and facility policy specifies the use of gown and gloves for high-contact care activities for residents at high risk of MDRO transmission.
Failure to Double Lock Controlled Substances in Medication Cart
Penalty
Summary
The facility failed to ensure that controlled substances were double locked in a medication cart, as required by regulations. During an observation of medication administration, it was noted that the staff member, identified as V5, did not lock the medication cart when entering residents' rooms to administer medications. This occurred on multiple occasions, specifically when V5 was administering medications to residents R16, R56, and R17. During these times, the medication cart was left unattended and out of V5's line of sight, with the controlled substance lockbox within the cart being unlocked and accessible without a key. The facility's Director of Nursing, identified as V2, acknowledged that the medications in the controlled substances box are prone to abuse and theft, emphasizing the importance of double locking these medications. The facility's Medication Administration policy, dated January 2023, explicitly states that the medication cart should never be left open and unattended. Despite this policy, the controlled substances for residents, including narcotic pain medications and anti-anxiety medications, were not secured as required, posing a risk of theft or misuse.
Failure to Provide Adequate Hydration to Resident
Penalty
Summary
The facility failed to provide adequate hydration to a resident, identified as R56, who was observed on multiple occasions without access to water. On the first observation, R56 was found in bed with dry lips and no water available in the room. The resident expressed thirst and consumed an entire cup of water when it was eventually provided by a nurse. Subsequent observations revealed similar conditions, with no water within reach, despite the resident's evident signs of dehydration such as dry lips and mouth. R56's medical records indicated no fluid restrictions or swallowing issues, and the care plan emphasized the importance of keeping water within reach and monitoring for dehydration signs. Despite this, the facility staff failed to ensure water was accessible, as evidenced by the resident's repeated expressions of thirst and physical signs of dehydration. The facility's hydration policy mandates routine monitoring and provision of fluids, which was not adhered to in this case, leading to the deficiency.
Failure to Complete PASARR Level II Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure a resident with a reasonable suspicion of mental illness was referred for a Level II PASARR screening. The resident, who had been diagnosed with bipolar disorder and had a history of suicidal ideations, was admitted to the facility in 2019. Despite the initial screening indicating a reasonable suspicion of mental illness, the facility did not complete the necessary referral for a Level II PASARR screening. The resident's care plan included antipsychotic and antidepressant medications, and he exhibited mood problems related to his bipolar disorder. Interviews with facility staff revealed that the Social Services Director, who was not in her current role at the time of the resident's admission, was unable to find documentation of the Level II PASARR screening or any referral made to the appropriate agency. The facility's policy required the completion of Level I and II screenings prior to admission, but the documentation was missing. The Director of Nursing confirmed that she was not involved in the PASARR screenings, indicating a lack of clarity in the roles and responsibilities for ensuring compliance with PASARR requirements.
Failure to Assess and Document New Wound
Penalty
Summary
The facility failed to assess and document treatment orders for a new wound on a resident with a history of venous stasis wounds and lymphedema. The resident, who has moderate cognitive impairment, reported a new sore on his right leg, but the electronic wound round reports did not reflect any open or active wounds. Despite the resident's concerns about the new sore, the nursing staff did not document the wound or obtain treatment orders in a timely manner. The wound care nurse was unaware of the new blister until it was brought to her attention, and the wound doctor was not notified until two days after the wound was discovered. The Director of Nursing and a Registered Nurse acknowledged awareness of the blister but failed to document the new order or perform an assessment. The facility's Skin Management policy emphasizes the importance of consistent documentation and assessment, which was not adhered to in this case.
Failure to Safely Transport Resident in Wheelchair
Penalty
Summary
The facility failed to safely transport a resident in a wheelchair, leading to a deficiency in ensuring a hazard-free environment and adequate supervision to prevent accidents. On the specified date, a resident, identified as R83, was observed being pushed in a wheelchair by the Social Service Director (V6) without foot pedals attached. During the transport, R83, who was wearing running shoes, attempted to lift his feet but was unable to consistently keep his right foot off the ground, causing his toes to hit the floor multiple times. This incident occurred despite R83's known high fall risk and severe cognitive impairment, as documented in his facility assessment and admission evaluation. Interviews with staff, including a Registered Nurse (V7) and the Director of Nursing (V2), confirmed that R83 was at high risk for falls and required foot pedals on his wheelchair during transport to prevent injury. The staff acknowledged that the absence of foot pedals could lead to potential harm, as R83 had a tendency to put his feet down. Despite the facility's awareness of the resident's condition and needs, a policy for safely transporting a resident in a wheelchair was requested but not provided, indicating a lapse in procedural adherence and safety measures.
Failure to Verify G-Tube Placement Before Water Flush
Penalty
Summary
The facility failed to ensure the proper checking of a gastrostomy tube (G-tube) placement before administering water flushes for a resident with severe cognitive impairment and multiple medical conditions, including chronic respiratory failure, cerebral infarction, dysphagia, and the use of a tracheostomy tube. The resident's physician orders required a 200-milliliter water flush every four hours through the G-tube. However, during an observation, a registered nurse administered the water flush without verifying the tube's placement, which is a critical step to prevent potential complications such as aspiration. The Director of Nurses acknowledged that staff should verify the G-tube's placement before administering any substances, as failing to do so could result in the tube not being in the stomach, increasing the risk of aspiration. Although the facility's policy on enteral tube medication administration emphasizes safe and effective practices, it does not explicitly outline the procedure for checking tube placement. This oversight in practice and policy contributed to the deficiency identified during the survey.
Failure to Follow Insulin Pen Manufacturer Instructions
Penalty
Summary
The facility failed to adhere to the manufacturer's instructions for the use of an insulin pen, which was observed during the administration of insulin to a resident with type II diabetes. The resident had an active order for 5 units of rapid-acting insulin to be administered at meals, along with a sliding scale order for additional insulin based on blood sugar levels. On a specific occasion, a registered nurse prepared the insulin pen by dialing in and depressing 2 units of insulin twice without attaching the needle, contrary to the manufacturer's instructions. The nurse then attached the needle and selected 13 units of insulin for administration based on the resident's blood sugar reading. The manufacturer's instructions for the insulin pen specified that the needle should be attached before priming the pen, and the pen should be held vertically to expel air bubbles. The Director of Nursing confirmed that the purpose of priming the pen is to ensure the resident receives the full dose of insulin and that the needle should be attached prior to priming. The failure to follow these instructions could potentially result in the resident not receiving the correct dose of insulin.
Failure to Provide Ordered Wound Care
Penalty
Summary
The facility failed to provide wound treatment as ordered for a resident with a pressure ulcer. On a specific date, the Wound Care Nurse/Assistant Director of Nursing (ADON) noted that the resident should have received wound care and a dressing change to her coccyx wound two days prior, as the treatment was ordered every other day. However, the dressing in place was dated four days earlier, indicating a lapse in care. A Licensed Practical Nurse confirmed that wound care and dressing changes are supposed to be conducted according to the doctor's orders. The resident's care plan indicated an active stage 4 pressure ulcer on the sacrum, with treatment orders for cleansing, medication, and dressing changes every other day and as needed.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving two residents. On August 29, 2024, a resident reported to a registered nurse and the local police department that his roommate had used a racial slur against him. The police responded to the call, and the facility moved the accused resident to a different room. However, the facility administrator did not conduct an abuse investigation, as she did not consider the incident an abuse allegation. The facility's abuse policy requires prompt and aggressive investigation of all reports and allegations of abuse. Despite this policy, no investigation was conducted following the incident. Both residents involved were cognitively intact, as indicated by their Minimum Data Set assessments. The facility's failure to investigate the reported incident is a violation of its abuse policy and prevention program, which aims to ensure residents are free from abuse and mistreatment.
Failure in Medication Administration Protocol
Penalty
Summary
The facility failed to ensure proper medication administration for a resident diagnosed with delusional disorder, major depressive disorder, parkinsonism, cervical disc disorder, spinal stenosis, and a history of falling. On multiple occasions, the resident refused to take medications when offered by the nursing staff. The nurse initially attempted to administer the medication at 5:00 PM, but the resident was in the restroom and refused. A second attempt was made at 6:00 PM, which was also refused. At 8:30 PM, the resident took the medication cup from the nurse and placed it on the bedside table, instructing the nurse to leave it there. The Assistant Director of Nursing (ADON) witnessed this interaction but did not ensure the resident took the medication. The Medication Administration Record indicated that the medications were signed out as given, despite the resident not taking them in the presence of the nurse. The ADON confirmed that it was not acceptable to leave medications unattended, as it was unclear if the resident would take them. The facility's policy requires that staff verify medication administration by remaining with the resident to ensure the medication is swallowed. However, this protocol was not followed, and the resident's self-medication assessment was not completed, nor was there a doctor's order or care plan in place for self-administration.
Failure to Provide Necessary Wound Care
Penalty
Summary
The facility failed to provide necessary care and treatment to residents with nonpressure wounds, as evidenced by the cases of two residents. The first resident, R2, was admitted with infectious wounds on her buttocks and lower legs due to necrotizing fasciitis. Despite physician orders for daily wound care, observations revealed that R2's wounds were not dressed, and the resident reported that her dressings had not been changed for a couple of days. The wound nurse confirmed that wound care should be performed daily, and if unavailable, the floor nurse could also perform the treatments. The second resident, R3, had open wounds in the axilla and groin areas due to Hidradenitis Suppurativa. Physician orders required daily cleansing and application of wound care products, but the treatment administration record showed multiple days where no wound care was provided. The facility was unable to provide a policy on the care and treatment of nonpressure wounds when requested by the surveyors, indicating a lack of adherence to established care protocols.
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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