Aliya Of Homewood
Inspection history, citations, penalties and survey trends for this long-term care facility in Homewood, Illinois.
- Location
- 940 Maple Avenue, Homewood, Illinois 60430
- CMS Provider Number
- 145684
- Inspections on file
- 35
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Aliya Of Homewood during CMS and state inspections, most recent first.
The facility failed to follow its fall-prevention policy, resulting in multiple high-risk residents experiencing repeated falls and injuries. One resident with severe cognitive impairment and hemiplegia, assessed as needing maximal assistance and unable to transfer safely, fell twice from bed, including a fall causing a head laceration requiring staples, while care-planned interventions were limited to bed equipment and therapy staff were unaware of the recent falls and left the resident in a wheelchair with only line-of-sight supervision. Another resident with seizures, poor coordination, and a history of falls had multiple falls at the nurse’s station and in the room, including a facial laceration, while the post-fall risk assessment omitted prior falls, and staff could not clearly describe transfer methods or consistently mention care-planned frequent rounding. A third resident with a non–weight-bearing pelvic fracture and high fall risk fell while trying to reach the bathroom after admission; the non–weight-bearing order and fracture were not incorporated into the care plan, and staff were unsure of the resident’s weight-bearing status and fall precautions. A fourth resident with multiple sclerosis and legal blindness had a care-planned floor mat that was folded and positioned away from the bed due to an over-bed table, leaving the resident unprotected if rolling out of bed, which staff acknowledged on observation.
A resident’s post-fall risk assessment was completed inaccurately and left incomplete, with a key section on falls, accidents, and fractures left blank. The item regarding a history of falls, which should have included the current fall, was not selected, resulting in a documented fall risk score of 7 instead of the correct score of 17. During an interview, the DON acknowledged that omitting this section altered the score and that the resident should have been classified as high risk for falls. This failure occurred despite a facility policy requiring comprehensive fall risk evaluations on admission, readmission, quarterly, with significant change, and after each fall.
A resident admitted with a history of falls and a right pelvic fracture had physician orders for non-weight bearing to the right leg, but the baseline care plan developed within 48 hours did not include the pelvic fracture or non-weight bearing status. Instead, the resident was care planned only as high risk for falls due to reduced mobility and poor safety awareness, with general interventions such as low bed position, call light within reach, and staff assistance as needed. During surveyor interview, the DON confirmed that the non-weight bearing and specific transfer requirements were omitted from the baseline care plan, despite hospital records with these orders being available prior to admission.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in increased risk for resident accidents.
A resident with a history of stroke, left-sided weakness, and moderate cognitive impairment was not adequately supervised during a transfer when a CNA turned to retrieve a wheelchair, allowing the resident to reach for an item on the floor and fall, resulting in a head laceration and subdural hematoma. The resident's fall risk was underestimated due to errors in assessment, and known behaviors that increased fall risk were not sufficiently addressed during care.
A resident on Enhanced Barrier Precaution was prescribed Metronidazole without a documented stop date, contrary to the facility's Antibiotic Stewardship Program. The Infection Control Nurse and DON acknowledged the oversight, which violated the policy requiring documentation of dose, duration, route, and indication for all antibiotics.
A resident was prescribed Metronidazole without proper documentation and monitoring as required by the facility's Antibiotic Stewardship Program. The Infection Preventionist could not locate the infection assessment evaluation record, and the Director of Nursing acknowledged the need for ongoing monitoring. The resident had diagnoses including sepsis and a periprosthetic fracture, with an active order for Metronidazole starting in late September.
A facility failed to follow physician orders for a urinalysis, leading to a resident's hospitalization with a UTI and sepsis. Additionally, the facility did not conduct a comprehensive assessment for a resident in pain, resulting in a delayed diagnosis of a severe hip fracture. These deficiencies highlight the facility's failure to adhere to proper procedures for assessing and responding to changes in residents' conditions.
Two residents with severe cognitive impairments experienced multiple falls due to the facility's failure to implement effective individualized fall interventions. One resident sustained serious injuries requiring hospitalization, while another was left unsupervised for 13 minutes after a fall. The facility's interventions, such as floor mats and perimeter pillows, were inadequate in preventing falls, and immediate supervision and assessment were lacking.
A resident experienced significant pain in the left leg, later identified as an impacted transcervical fracture. Despite observations by a CNA and a nurse, the facility failed to notify the physician or emergency contact on the day of the incident, resulting in a delay in treatment orders for over 24 hours.
A facility failed to issue a refund of $19,950.00 within 30 days after a resident's death, as required by their internal policy. The delay was due to the absence of the corporate staff member responsible for processing refunds. This failure to adhere to the refund process policy resulted in a deficiency related to the misappropriation of resident funds.
Failure to Implement and Communicate Effective Fall-Prevention Measures for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and fall-prevention interventions for multiple residents at high risk for falls. The facility’s own fall incident log showed 42 falls in a two‑month period. For one resident with anxiety, restlessness, agitation, hemiplegia, and hemiparesis, functional assessments documented a need for substantial/maximal assistance with bed mobility and that transfers were not attempted due to medical or safety concerns, yet this resident experienced two falls within days. After the first fall, the resident reported trying to go to the bathroom, and the incident report identified confusion, gait imbalance, and incontinence as predisposing factors, with a winged mattress added as an intervention. After the second fall, the resident was found on the floor outside the floor mats with a head laceration requiring staples, and staff documented that the resident was always attempting to get out of bed. Despite this, the care plan only reflected bed‑related interventions (wing mattress, ultra‑low bed, floor mats) and did not include supervision details, and therapy staff were unaware of the recent falls and left the resident in a specialty wheelchair in the therapy gym with only line‑of‑sight supervision while the therapist’s back was turned. Another resident with seizures, lack of coordination, muscle wasting/atrophy, and a history of falling had multiple falls documented at the nurse’s station and in the room. The resident’s post‑fall risk assessment failed to include a history of falls and/or fracture in the past six months, which would have increased the fall risk score. Incident reports described the resident having a seizure and falling from a wheelchair at the nurse’s station with a head injury, later documentation at the hospital describing an abrasion and hematoma, and subsequent falls where the resident was found on the floor after attempting to go to another room, including a fall at the nurse’s station resulting in a laceration to the eyelid. The care plan identified the resident as high risk for falls with interventions such as staff assistance as needed and frequent rounding, but nursing staff interviewed only cited low bed, floor mats, soft helmet, and call light within reach, and did not mention frequent rounding. One LPN was not sure how the resident was to be transferred from bed to wheelchair, and another RN described the resident falling face down from a chair at the nurse’s station and sustaining a laceration to the eye, while documentation of the side of injury was inconsistent between facility and hospital records. A third resident with Parkinson’s disease, muscle wasting/atrophy, cognitive communication deficit, diabetes, chronic kidney disease, hypertension, benign prostatic hyperplasia, history of falling, and a recent right pelvic fracture with a non‑weight‑bearing order to the right leg was admitted after a fall at home. Functional assessments showed impairment in range of motion and a need for partial/moderate assistance with toileting and substantial/maximal assistance with transfers, with walking not attempted due to safety concerns. The fall risk assessment scored the resident as high risk, but the care plan did not include the non‑weight‑bearing status or the fractured pubis as a factor, and interventions were limited to low bed, call light and frequently used items within reach, and staff assistance as needed. The resident fell while trying to get to the bathroom, was found on the floor with a knot and redness on the head, and was sent to the hospital, where he was admitted for a fall and non‑acute pelvic fracture. The DON later confirmed that the non‑weight‑bearing order was not on the care plan, and a nurse reported that CNAs were transferring the resident with one‑person assist and that she was unsure of the resident’s weight‑bearing status or specific fall precautions. A fourth resident with legal blindness, multiple sclerosis, weakness, restlessness, and agitation had a care plan identifying high fall risk with floor mats as an intervention while in bed. The resident’s functional assessment showed a need for substantial/maximal assistance with rolling and that transfers were not attempted due to medical or safety concerns. During observation, the floor mat intended to protect the resident was folded and angled away from the bed, with an over‑bed table stored under the bed preventing proper placement of the mat. An LPN acknowledged that the mat should be bedside and that, in its current position, if the resident rolled out of bed between the beds, the resident would land on the floor. The ADON had to enter the room, move the over‑bed table, and reposition the mat correctly. Across these residents, staff interviews revealed lack of awareness of recent falls, uncertainty about transfer requirements and weight‑bearing status, incomplete or inaccurate fall risk assessments, and failure to implement or consistently apply care‑planned fall‑prevention interventions, including supervision and environmental safeguards, contrary to the facility’s fall prevention and management policy that requires identification of residents at risk, completion of fall risk evaluations, and modification of care plans after each fall.
Incomplete and Inaccurate Post-Fall Risk Assessment
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall prevention and management policy and to ensure accurate and complete fall risk assessments for a resident reviewed for falls. For one resident (R4), a post-fall risk assessment dated 1/2/26 was incomplete because section G, which addresses falls, accidents, and fractures, was left blank. Specifically, the item asking whether there was a history of falls and/or fracture in the past six months, including the current fall incident, was not selected, even though the assessment was conducted after a fall and should have included the current incident. As a result, the resident’s fall risk score was documented as 7 (at risk) instead of 17 (high risk), as later acknowledged by the DON when interviewed by the surveyor. The facility’s fall prevention and management policy, reviewed in March 2026, requires that a fall risk evaluation be completed on admission, readmission, quarterly, with significant change, and after each fall, but this post-fall assessment was not accurately completed in accordance with that policy. The surveyor’s interview with the DON confirmed that leaving section G unchecked would alter the calculated score and that the correct score, if accurately assessed, should have been 17, which would classify the resident as high risk for falls. This demonstrates that the resident’s post-fall risk assessment was both incomplete and inaccurate, directly contradicting the facility’s stated procedures for identifying and evaluating residents at risk for falls.
Failure to Include Non-Weight Bearing Status in Baseline Fall Care Plan
Penalty
Summary
The facility failed to follow its baseline care plan policy and did not ensure that required diagnoses and interventions related to fall risk were included in a newly admitted resident’s baseline care plan. The resident was admitted with diagnoses including a history of falling and a right pelvic fracture, with physician orders specifying non-weight bearing to the right leg. Despite these documented conditions and orders, the baseline care plan developed within the first days after admission identified the resident as high risk for falls only in relation to reduced mobility and poor safety awareness, and did not include the right pelvic fracture or the non-weight bearing status of the right leg. The baseline care plan interventions focused on general fall prevention measures such as keeping the bed in the lowest position, placing frequently used items and the call light within reach, and having staff assist as needed. These interventions did not address the specific non-weight bearing and transfer requirements associated with the resident’s right pelvic fracture. During an interview, the DON reviewed the baseline care plan and confirmed that the non-weight bearing right leg and pelvic fracture were not included, even though the hospital records with the non-weight bearing order had been received prior to admission. This omission occurred despite the facility’s written policy requiring that the baseline care plan, developed within 48 hours of admission, include necessary information such as fall risk to properly care for the resident.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Provide Adequate Supervision During Transfer Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with a history of traumatic subdural hemorrhage, aphasia, left-sided hemiplegia, glaucoma, and cognitive communication deficit was not adequately supervised during a transfer. The certified nursing assistant (CNA) was providing morning care and had positioned the resident on the side of the bed in preparation for transfer. While the CNA turned to retrieve the wheelchair, the resident reached for an item on the floor, lost balance, and fell forward, striking their head on the nightstand and then the floor. The incident was witnessed by the CNA, who reported being one to two feet away and momentarily distracted while setting up the wheelchair in front of the resident. The resident sustained a laceration to the left side of the forehead with moderate bleeding and was subsequently hospitalized. Medical evaluation revealed a small subdural hematoma and a small hemorrhagic contusion to the left frontal lobe. The resident was admitted for monitoring and further evaluation, including imaging studies that confirmed the injuries. The resident's care records indicated a history of left-sided weakness and moderate cognitive impairment, requiring substantial assistance with bed mobility and transfers. The care plan and therapy notes documented the resident as a fall risk due to impaired mobility, cognitive deficits, and a history of stroke. Review of the facility's fall risk assessments revealed inconsistencies and errors in scoring, with one assessment incorrectly indicating the resident was not at high risk for falls. The resident's care plan prior to the incident included interventions for fall prevention, but the supervision provided during the transfer was insufficient to prevent the fall. Staff interviews confirmed that the resident had a known behavior of reaching for objects, which was not adequately addressed during the transfer process.
Deficiency in Antibiotic Stewardship Documentation
Penalty
Summary
The facility failed to ensure that a resident's antibiotic regimen was properly documented and managed according to their Antibiotic Stewardship Program. A resident, identified as R103, was on Enhanced Barrier Precaution and reported taking an antibiotic for an infection since their admission in September 2024. However, the prescribed antibiotic, Metronidazole, lacked a documented stop date, which is a requirement under the facility's policy. The Infection Control Nurse, V4, and the Director of Nursing, V2, both acknowledged that the antibiotic should have included a start and stop date, along with an indication for use, and that the doctor should have been informed if the duration was not indicated. The Licensed Practical Nurse, V14, who regularly works on the unit where R103 resides, confirmed that the physician's order for Metronidazole did not include a stop date. The facility's policy mandates that the dose, duration, route, and indication of every antibiotic prescription must be documented in the medical record for every resident. This oversight in documentation and communication regarding the antibiotic regimen for R103 represents a deficiency in the facility's adherence to its own Antibiotic Stewardship guidelines, which are aligned with CDC and CMS standards.
Failure in Antibiotic Monitoring for a Resident
Penalty
Summary
The facility failed to implement ongoing monitoring of antibiotics as part of its Antibiotic Stewardship Program, affecting one resident in a sample of 23. During an interview, the Infection Preventionist (V4) stated that she reviews antibiotic prescriptions weekly and conducts an infection assessment evaluation before starting antibiotic use. However, she was unable to locate the infection assessment evaluation record for a resident (R103) who was prescribed Metronidazole 500mg every 12 hours for a bacterial infection without a stop date. This indicates a lapse in the documentation and monitoring process required by the facility's policy. The Director of Nursing (V2) expressed that the expectation for the antibiotic stewardship program is to ensure ongoing monitoring of antibiotics. The resident in question was admitted with diagnoses including sepsis and a periprosthetic fracture, and had an active physician order for Metronidazole starting on 9/26/24. The facility's policy, reviewed in February 2024, mandates that the dose, duration, route, and indication of every antibiotic prescription be documented in the medical record. Additionally, the policy requires the use of specific criteria for initiating antibiotic usage, which was not adhered to in this case.
Failure to Follow Physician Orders and Conduct Comprehensive Assessments
Penalty
Summary
The facility failed to follow physician orders for a resident who was incontinent of urine and exhibited new onset lethargy. The physician had ordered a STAT chest x-ray, CBC, CMP, and urinalysis with culture and sensitivity. However, the facility did not notify the lab for urine collection, nor did they obtain a urine specimen for the resident. The nurse consultant and nurse practitioner confirmed that the staff should have collected the specimen or obtained an order for a straight catheter if necessary. This oversight resulted in the resident being hospitalized with a diagnosis of urinary tract infection and sepsis. Another deficiency involved a resident who was observed with his left leg/knee contorted under his wheelchair, exhibiting facial grimacing and yelling out in pain. Despite these signs, the nurse did not conduct a comprehensive body assessment or notify the medical doctor of the resident's change in condition. The resident was left in pain for twenty hours before an x-ray was ordered, which revealed a new acute transcervical left femoral neck fracture. The medical doctor stated that the nurse should have laid the resident down and completed a full body exam, including range of motion of the extremities, after observing the resident's pain. The report highlights the facility's failure to adhere to proper procedures for assessing and responding to changes in residents' conditions. In both cases, the lack of timely and appropriate action led to significant health issues for the residents, including hospitalization and a severe fracture. The facility's staff did not follow through with necessary medical assessments and communication with physicians, resulting in delayed treatment and care for the affected residents.
Failure to Implement Effective Fall Interventions
Penalty
Summary
The facility failed to implement effective individualized fall interventions for two residents, resulting in multiple falls. One resident, diagnosed with Alzheimer's Disease and dementia, was identified as a high fall risk. Despite this, the facility did not implement individualized preventive fall interventions after the resident's first fall. The resident sustained a second unwitnessed fall from bed, resulting in a comminuted displaced fracture of the bilateral nasal bones and a lip laceration, requiring hospitalization. The interventions in place, such as floor mats, were not effective in preventing falls, as confirmed by the restorative nurse. Another resident, under hospice care with severe cognitive impairment, experienced two fall incidents. The first fall led to the addition of perimeter pillows as an intervention. However, the second fall occurred despite the resident being rounded on 10 minutes prior. The resident was found on the floor by a family member and left unsupervised for 13 minutes before staff assistance was provided. The facility's policy requires immediate assessment and supervision of residents after a fall, which was not adhered to in this case. The facility's fall prevention and management policy emphasizes the need for individualized interventions based on root cause analysis after each fall. However, the interventions implemented for both residents were not sufficiently individualized or effective in preventing further falls. The lack of immediate supervision and assessment after falls further contributed to the deficiency in care provided to these residents.
Failure to Notify Physician of Resident's Acute Change in Condition
Penalty
Summary
The facility failed to notify a physician of an acute change in condition for a resident, as required by their change in condition policy. This failure affected a resident who was experiencing significant pain in the left leg, which was later identified as an impacted transcervical fracture. The resident was initially observed by a CNA and a nurse, who noted the resident's grimacing and resistance to moving the left leg. Despite these observations, the nurse did not notify the resident's physician or emergency contact on the day of the incident. The resident's condition was not communicated to the physician until after the resident was sent to the hospital the following day. The delay in notification resulted in a delay in treatment orders for over 24 hours. The facility's policy requires notifying the resident's physician and responsible party of any significant change in condition, which was not adhered to in this case. The resident's medical record lacked documentation of any notification to the doctor or family on the day of the incident.
Delayed Refund for Deceased Resident
Penalty
Summary
The facility failed to adhere to its internal refund process policy by not issuing a refund of $19,950.00 within 30 days following the death of a resident. The resident, who was under hospice private pay, was admitted to the facility and later expired there. According to the facility's policy, a refund should be processed within 30 days from the date of death or discharge. However, the refund was delayed due to the absence of the corporate staff member responsible for processing refunds, who had been let go. This delay affected the timely issuance of the refund check to the resident's family. The facility's internal refund process policy mandates that credit balances due to residents should be refunded within 30 days from the date of death or discharge. Additionally, the facility's Abuse Policy and Prevention Program emphasizes the residents' right to be free from misappropriation of property, which includes the wrongful use of a resident's belongings or money. Despite these policies, the facility did not meet the state compliance requirement, resulting in a deficiency related to the misappropriation of resident funds.
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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