Aliya Of Palos Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Palos Park, Illinois.
- Location
- 12220 South Will Cook Road, Palos Park, Illinois 60464
- CMS Provider Number
- 146053
- Inspections on file
- 36
- Latest survey
- November 24, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Aliya Of Palos Park during CMS and state inspections, most recent first.
A resident with multiple high-risk conditions, including dementia and impaired mobility, was not adequately supervised despite being identified as a high fall risk. The resident was left unsupervised in the common area while the assigned LPN was at the nurse's station and CNAs were assisting another resident, resulting in a fall and right hip fracture. Staff interviews confirmed that close monitoring was expected but not provided, and the facility's fall prevention policy was not effectively implemented.
A deficiency was cited when a facility area was not kept free from accident hazards and adequate supervision was not provided to prevent accidents, resulting in increased risk for residents.
Two residents experienced significant changes in condition—one with vomiting, diarrhea, and low blood pressure, and another with rising blood glucose levels—without timely assessment, intervention, or physician notification by staff. In both cases, staff did not follow care plans or facility policies for monitoring and reporting, resulting in hospitalizations for severe dehydration and uncontrolled diabetes.
The facility did not serve pureed bread to residents on pureed diets as required by the posted menu, affecting several individuals. Staff confirmed that pureed bread was not prepared or provided due to the lack of bread puree mix, despite having recipes available.
Two residents and their families experienced long call light response times, with delays of 45 minutes or more reported multiple times per week, and their concerns were not formally documented or addressed by the DON. The facility also inconsistently enforced a new policy banning personal refrigerators in resident rooms, removing one resident's fridge while allowing another to keep theirs, without providing clear communication or education to all affected parties.
A resident was found calling out for help while seated in a Geri chair, with the call light placed out of reach on the bed. A CNA/Restorative Aide confirmed the call light was not accessible and subsequently moved it closer. The DON stated that staff are required to ensure call lights are within reach, as outlined in facility policy.
Two residents were placed in a semi-private room with video monitoring without proper informed consent from the residents or their POA, despite one resident having moderate cognitive impairment and a POA in place. Documentation of consent was inconsistent, and staff did not ensure that written consent was obtained and properly recorded in the EMR.
A resident with multiple risk factors for skin breakdown was not provided with a comprehensive care plan or thorough skin assessment upon readmission from the hospital. Staff failed to document the presence and treatment of wounds, and preventive interventions such as heel protectors were not consistently recorded. Facility policies requiring comprehensive assessment and person-centered care planning were not followed, resulting in inadequate documentation and uncertainty about the resident's skin care interventions.
Two residents with significant risk factors for skin breakdown did not receive comprehensive skin assessments or consistent documentation of preventive interventions upon admission or readmission. One resident with multiple comorbidities and a history of pressure ulcers was not properly assessed for wound status, and preventive measures such as heel protectors were not documented. Another resident with a stage 3 sacral pressure ulcer was placed on a low air loss mattress that was not set according to their actual weight, contrary to policy and manufacturer instructions. These deficiencies reflect failures in following facility protocols for pressure ulcer care and prevention.
A resident was observed with an indwelling catheter, but the physician order lacked documentation of the diagnosis or reason for its use. The DON confirmed that such documentation is required, and facility policy states that orders must specify the diagnosis or indication for the catheter, which was not done in this instance.
Two residents with significant weight loss and decreased oral intake did not have their meal consumption accurately documented, with observed intake not matching charted records and multiple meal opportunities lacking documentation. Despite ongoing nutritional interventions and weekly monitoring by the interdisciplinary team, incomplete and inaccurate documentation hindered effective tracking of their nutritional status.
The facility did not ensure that two residents received face-to-face visits from their attending physicians within the required timeframes, as documented visits were either delayed or missing, contrary to the facility's physician services policy.
A resident with macular degeneration was not assisted in obtaining transportation to a retinal specialist appointment after declining to pay a high out-of-pocket cost. Facility staff did not offer alternative transportation options or the in-house eye doctor, and there was no documentation of education or efforts to reschedule the appointment, despite care plan and physician orders indicating the need for ongoing ophthalmology consults.
Two residents did not receive their prescribed medications as ordered. One resident missed a scheduled dose of Midodrine due to unavailability, resulting in a significant delay in administration despite low blood pressure. Another resident did not receive a scheduled dose of steroid eye drops because the medication could not be given in the dining room, and the nurse chose to skip the dose. Both incidents were confirmed by documentation and staff interviews.
Expired ferrous sulfate tablets were found in a medication cart after their expiration date, and three bottles of oral liquid Lorazepam requiring refrigeration were improperly stored in a narcotic box. An LPN was unaware of the correct storage requirements, and a discontinued controlled medication remained in the cart instead of being disposed of as per policy.
Staff did not adhere to contact isolation protocols for a resident with an ESBL/VRE urinary tract infection, as required by facility policy and physician orders. On multiple occasions, staff entered the resident's room without the necessary PPE, including gowns and gloves, and there was confusion among staff regarding the resident's isolation status. The care plan also lacked documentation of the required contact isolation precautions.
A facility failed to complete a comprehensive metabolic panel (CMP) for a resident with complex medical conditions, despite multiple physician orders. The Director of Nursing was unaware of the missed lab draws until informed by the NP, and the facility could not present lab results for the specified dates. The issue was not with the contracted laboratory, indicating a failure in the facility's processes.
A resident with dementia and high fall risk fell and fractured her hip after being left unsupervised in a common area. Despite known impulsive behavior and poor safety awareness, the resident was unattended when a CNA left to perform rounds, and the nurse was busy with medication administration. The facility's fall prevention policy was not effectively implemented, leading to the incident.
The facility failed to supervise a high fall risk resident with Dementia, resulting in an unwitnessed fall and hip fracture. Another resident with Dementia fell from her wheelchair due to the absence of leg rests during transport, sustaining a forehead hematoma. Both incidents highlight non-compliance with the facility's fall prevention policy.
A resident with a history of falls and severe pain waited over 30 hours for a chest x-ray, which was delayed due to inadequate tracking and communication within the facility. The resident was eventually sent to the hospital and diagnosed with multiple rib fractures.
The facility failed to follow sanitizing guidelines by not sanitizing a knife and cutting board for the required 1 minute, as observed when a cook submerged them in sanitizer for only 1 second. This deficiency could affect 104 residents receiving an oral diet.
The facility failed to ensure mail was delivered to residents on Saturdays, affecting seven residents. During a resident council meeting, multiple residents stated that they do not receive mail on Saturdays and have to wait until Monday. An interview with the Life Enrichment/Activities staff revealed that Saturday's mail is placed in a locked administration office by the receptionist, and activity aides do not have access to this office. As a result, mail is only distributed to residents on Mondays.
The facility failed to follow their abuse policy by not immediately reporting a bruise of unknown origin on a resident to the immediate supervisor or the administrator. The bruise was noticed by staff members on different occasions prior to the official report, but it was not reported immediately as required by the facility's abuse policy.
The facility failed to notify a family member when a resident was sent to the hospital. The Director of Nursing confirmed that staff are expected to notify families of any change in condition, but a review of the resident's records showed no such notification was made.
A resident with aphasia had four hundred dollars stolen from his wallet due to the facility's failure to provide secure storage for personal items. The resident, who was alert but had communication challenges, reported seeing a staff member in his room but could not provide a complete description. Staff confirmed the resident had shown his money before it was stolen, and the facility did not offer secure storage options, suggesting families bring a lockbox instead.
Failure to Provide Adequate Supervision for High Fall Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and implement effective care plan interventions for a resident with multiple high-risk diagnoses, including delirium, dementia, and impaired mobility. The resident was identified as high risk for falls, with a fall risk score of 22.0, and had a recent history of falling. Despite care plan interventions requiring close monitoring in the common area, the resident was left unsupervised when the assigned LPN was charting at the nurse's station and two CNAs were occupied assisting another resident. During this lapse in supervision, the resident attempted to stand and walk, resulting in a fall and a right hip fracture. Staff interviews confirmed that the expectation was for high fall risk residents to be closely monitored in the common area, with staff in close proximity, not at the nurse's station. The LPN responsible for monitoring the resident was not present in the common area at the time of the fall, and staff acknowledged that the unit was understaffed to provide adequate supervision for the number of high-risk residents. The facility's fall prevention policy required identification and implementation of interventions for residents at risk for falls, but these were not effectively carried out, leading to the resident's injury.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. This lack of appropriate environmental safety measures and supervision directly contributed to the deficiency cited by surveyors.
Failure to Respond to Changes in Condition and Elevated Blood Glucose
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for two residents. One resident with multiple comorbidities, including chronic kidney disease and congestive heart failure, experienced several episodes of vomiting and diarrhea, as well as low blood pressure and altered mental status. Despite these changes in condition, staff did not implement adequate interventions to prevent dehydration, such as monitoring intake or providing supportive hydration. The resident's family repeatedly expressed concerns and ultimately insisted on hospital transfer, where the resident was diagnosed with colitis and severe dehydration due to norovirus. Documentation and interviews revealed that staff were aware of the resident's symptoms but did not escalate care or notify the physician in a timely manner, and there was a lack of comprehensive assessment and intervention for the resident's deteriorating condition. Another resident with Alzheimer's disease and type 2 diabetes had a significant increase in blood glucose levels, with readings rising from a baseline range of 143-246 mg/dL to 399 mg/dL and then 521 mg/dL over several days. Staff failed to notify the physician when the resident's blood sugar first exceeded their baseline and reached critical levels in the 300s, only acting after the blood sugar reached 521 mg/dL, at which point the resident was transferred to the hospital and diagnosed with uncontrolled diabetes and metabolic encephalopathy. The resident's care plan and facility policy required monitoring and physician notification for significant changes in blood glucose, but these protocols were not followed. Interviews with staff confirmed that there was no clear parameter for physician notification and that earlier intervention could have potentially prevented the hospital transfer. Both cases demonstrate a lack of timely assessment, monitoring, and communication with the physician regarding significant changes in residents' conditions. The facility's failure to follow established care plans and policies for monitoring, documenting, and responding to changes in condition resulted in adverse outcomes for both residents, including hospitalizations for severe dehydration and uncontrolled diabetes.
Failure to Provide Pureed Bread as Required by Menu
Penalty
Summary
The facility failed to follow the prescribed menu for residents on pureed diets, as observed during meal service. On the specified date, the menu included an oven roasted turkey with gravy, sweet potatoes, Brussel sprouts, dinner roll, chilled peaches, and beverages. However, all residents receiving pureed diets did not receive a bread or roll item with their meal, despite the menu and available recipes for pureed bread. Staff interviews confirmed that pureed bread was not provided because the facility did not have the bread puree mix, and it had not been prepared for some time, even though recipes were available. This deficiency affected all seven residents on pureed diets in the sample reviewed.
Failure to Address Call Light Delays and Inconsistent Refrigerator Policy Enforcement
Penalty
Summary
The facility failed to address concerns raised by a resident and their family regarding excessive call light response times and inconsistent enforcement of a new policy prohibiting personal refrigerators in resident rooms. One resident and their family reported that it often took 45 minutes or more for staff to respond to call lights, particularly on weekends, and that these concerns were communicated to the DON but not formally documented or addressed. The family was not offered an opportunity to complete a concern form, and the DON did not consider the conversation a formal complaint because the family did not use specific language indicating a concern. Additionally, the facility recently implemented a policy to remove personal refrigerators from resident rooms, citing safety concerns such as expired food and wandering residents accessing food not intended for them. However, this policy was not applied consistently, as one resident's refrigerator was removed while another resident still had a refrigerator in their room. Staff confirmed that some residents continued to have personal refrigerators because the facility had not yet educated all families about the new policy. There was no documentation that the affected resident or their family received education about the change. The facility's own policies require timely response to call lights and guidance for safe storage of personal food, but these were not followed as documented in the report. The lack of consistent communication, documentation, and enforcement of policies resulted in unequal treatment of residents and failure to honor their rights to dignity, self-determination, and communication.
Call Light Not Placed Within Resident's Reach
Penalty
Summary
A deficiency occurred when staff failed to follow the facility's Call Light Response policy by not ensuring that a resident's call light was within reach. During an observation, the resident was found in a Geri chair on the right side of the bed, calling out for help and requesting to be put back to bed, as well as looking for his dentures. The call light was observed to be placed on the upper head part of the bed, out of the resident's reach. This was confirmed by a CNA/Restorative Aide, who then moved the call light closer to the resident. The Director of Nursing later confirmed that staff are expected to place the call light within reach, especially after returning a resident from dialysis, in accordance with the facility's policy.
Failure to Obtain Proper Consent for Video Monitoring in Shared Room
Penalty
Summary
The facility failed to maintain the privacy and dignity of two residents by not properly obtaining informed consent for placement in a semi-private room where video monitoring was in use. Signage indicating video monitoring was observed on the residents' room doorway. The administrator stated that consent is obtained when a roommate is placed in a room with video monitoring, but documentation and interviews revealed inconsistencies in the consent process. For one resident, the social services staff provided a newly signed consent form after the original was given to the surveyor, and this new form was placed in the electronic medical record (EMR) only recently. There was also a lack of clarity regarding why the consent was not uploaded into the EMR at the appropriate time. One of the residents involved had a BIMS score indicating moderate cognitive impairment and had a power of attorney (POA) in place. The social services staff stated that verbal consent was obtained from the POA, but there was no documentation in the medical record to support this between the time of the voicemail left for the POA and a later note. The staff also indicated that they did not believe written informed consent from the POA was necessary for video monitoring, as it was not related to healthcare. This lack of proper documentation and failure to obtain and record informed consent from the appropriate decision-maker resulted in a breach of privacy and confidentiality requirements.
Failure to Develop and Document Comprehensive Skin Breakdown Prevention Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address and prevent skin breakdown for a resident with multiple risk factors, including diabetes, dementia, anemia, end stage renal disease, sacral pressure ulcer, and dependence on renal dialysis. Upon readmission from the hospital, the resident was not provided with a thorough skin assessment to document the size and appearance of existing wounds or dressings. The initial care plan did not include specific interventions to prevent further skin breakdown, and updates to the care plan were not documented until much later. Observations and interviews revealed that the wound nurse and LPNs were unclear about the presence and documentation of wounds on the resident's legs upon readmission. The wound nurse stated that she was not present at the time of readmission and relied on the admitting nurse's assessment, which only noted scars and not open wounds. There was no documentation or photographic evidence of the resident's skin condition at the time of readmission, and the use or frequency of preventive interventions such as heel protectors was not recorded. The treatment administration record did not show any treatments for the resident's legs on the day of readmission. Facility policies required comprehensive skin assessments and person-centered care planning, but these were not followed. The lack of clear documentation and timely assessment led to uncertainty about the resident's skin status and the interventions in place to prevent further breakdown. The wound doctor later confirmed the presence of pressure ulcers on both lower legs, distinguishing between scars and scabs, and noted that a pressure ulcer can develop in a short period. The failure to follow policy and document interventions affected the resident's care and did not meet regulatory requirements for comprehensive care planning.
Failure to Complete Comprehensive Skin Assessments and Ensure Proper Pressure Ulcer Prevention
Penalty
Summary
The facility failed to follow its own policies regarding comprehensive skin assessments and pressure ulcer prevention for two residents with skin impairments. Upon readmission from the hospital, one resident with multiple diagnoses including diabetes, dementia, end stage renal disease, and a history of pressure ulcers did not receive a comprehensive skin assessment to identify the size and appearance of wounds or dressings present. Documentation was lacking for the presence and frequency of preventive interventions such as heel protectors, and there was no evidence that a low air loss mattress was used according to manufacturer recommendations. The wound nurse and LPN provided conflicting accounts regarding the condition of the resident’s legs upon readmission, with the wound nurse identifying open pressure ulcers and the LPN documenting only scars. No skin pictures were taken at the time of readmission, and the treatment administration record did not show any treatments for the resident’s legs on the day of readmission. Another resident, admitted with a stage 3 pressure ulcer to the sacrum and identified as high risk for skin breakdown, was observed on a low air loss mattress. However, the mattress was not set according to the resident’s actual weight, as required by manufacturer guidelines and facility policy. The resident’s weight was significantly lower than the mattress setting, and although staff stated that checks are performed to ensure correct settings, the observation revealed a discrepancy. The care plan for this resident included interventions for pressure ulcer prevention, but the implementation did not align with the operational manual for the mattress. Facility policies required comprehensive, person-centered care planning and specific interventions for residents at risk for skin breakdown. The lack of documentation, incomplete assessments, and failure to ensure proper use of pressure-relieving equipment contributed to the deficiencies identified by surveyors. These actions and inactions resulted in the facility not providing appropriate pressure ulcer care and not preventing new ulcers from developing, as required by their own policies and procedures.
Lack of Documented Diagnosis for Indwelling Catheter
Penalty
Summary
Surveyors found that the facility failed to document a diagnosis or indication for the use of an indwelling catheter for one resident. During observations, a resident was noted to have an indwelling catheter in place. Review of the resident's physician order sheet showed an order for the catheter, specifying the size and balloon volume, but the section for diagnosis or reason for the catheter was left blank. The Director of Nursing confirmed that a diagnosis should be documented on the physician order to indicate the reason for the indwelling catheter. The facility's own policy also requires that physician orders specify the diagnosis or indication for use, but this was not followed in this case.
Failure to Accurately Document Meal Intake for Residents with Weight Loss
Penalty
Summary
The facility failed to accurately document meal intake for two residents who were being monitored for nutrition. Observations showed that both residents consumed only 25% of their lunch meal, yet documentation in the point of care system indicated that one resident had consumed 76-100% of the meal. Staff interviews confirmed that CNAs are responsible for documenting meal intake after each meal and are expected to notify nursing staff if a resident eats very little or nothing. However, the Director of Nursing was unable to provide complete meal intake documentation for the past three months for either resident, and review of records showed missing documentation for multiple meal opportunities. Both residents had documented histories of significant weight loss over several months, with one resident experiencing a decrease from 181 to 146.6 pounds and the other from 93 to 80 pounds. The registered dietitian and interdisciplinary team had initiated weekly weights and nutritional interventions, including supplements and appetite-stimulating medication, due to ongoing weight loss and decreased oral intake. Despite these interventions, the lack of accurate and complete meal intake documentation hindered effective monitoring and response to the residents' nutritional needs.
Failure to Ensure Timely Physician Face-to-Face Visits
Penalty
Summary
The facility failed to ensure that residents received face-to-face visits from their attending physicians within the required timeframes, as outlined in the facility's physician services policy. Specifically, one resident was admitted and did not have a documented face-to-face physician visit until 20 days after admission, with no further visits recorded, despite subsequent hospitalizations and returns. Another resident had only sporadic face-to-face visits documented, with significant gaps between visits and no evidence of compliance with the required frequency. The attending physician stated that he is present in the facility several times a week and documents visits in the electronic medical record, but the records reviewed did not support that the required visits occurred as per policy. The facility's policy requires a physician to see Medicare residents at least every 30 days and all other residents at least every 60 days, with documentation of each visit in the medical record.
Failure to Assist Resident with Transportation for Medically Necessary Eye Appointment
Penalty
Summary
A resident with macular degeneration and impaired vision was not assisted by facility staff in obtaining transportation to a retinal specialist appointment, as ordered by the physician and recommended by an ophthalmologist. The resident reported having to cancel the appointment due to the high cost of transportation and stated that no alternative options, such as seeing the in-house eye doctor, were offered. Staff interviews confirmed that only one transportation company was contacted, and when the resident declined to pay the out-of-pocket cost, no further alternatives or education about other options were provided. Documentation did not reflect any education given to the resident regarding transportation responsibilities or any efforts to arrange alternative transportation. The facility's policy requires staff to arrange transportation for outside appointments unless the family chooses to do so, and to reschedule missed appointments at the earliest time. However, staff did not document any attempts to reschedule the appointment or offer other solutions after the resident declined to pay for the transportation. The care plan indicated the need for ongoing ophthalmology consults, but there was no evidence that the facility followed through with these interventions for the resident after the initial appointment was missed.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to administer prescribed medications as ordered for two residents. One resident with a diagnosis of hematuria did not receive the scheduled 9AM dose of Midodrine 5mg, a medication used to increase blood pressure, because the medication was not available in the pyxis or cycle med roll. The nurse identified the missing medication, contacted the pharmacy, and notified the physician, but the medication was not administered until 10:59AM, nearly two hours after the scheduled time. The resident's blood pressure was documented as low prior to the scheduled dose, and the delay was confirmed through nursing notes and the medication administration record. Another resident with macular degeneration did not receive the scheduled 9AM dose of prednisolone acetate ophthalmic suspension 1% eye drops, which are ordered four times daily to relieve eye pressure. The nurse did not administer the medication because the resident was in the dining room, and facility policy did not allow medication administration in that setting. The nurse subsequently decided to skip the 9AM dose and planned to administer the next scheduled dose early. The medication administration record confirmed the 9AM dose was not given, and the resident reported feeling increased pressure in the eyes due to the missed dose.
Failure to Remove Expired Medications and Improper Storage of Lorazepam
Penalty
Summary
The facility failed to ensure proper medication management in several instances. During a review of the medication cart, a 12-count card of ferrous sulfate 325mg tablets with an expiration date of 03/2025 was found in the cart after the expiration date had passed. The nurse responsible for the cart admitted that expired medications should be removed immediately and that it is the nurse's responsibility to check for expired medications before the morning medication pass, but confirmed that this check had not been performed. The expired medication was only removed after it was pointed out during the review. Additionally, three bottles of oral liquid Lorazepam, which require refrigeration according to the manufacturer’s label, were found stored in the narcotic box of a medication cart instead of in the refrigerator. The LPN present was unaware of the storage requirements, and only after consultation with the ADON was it confirmed that the medication should be refrigerated. Furthermore, a bottle of Lorazepam for a resident whose order had been discontinued was still present in the medication cart, contrary to facility policy that requires discontinued medications to be disposed of the same day. The facility’s policy and the medication insert both specify the need for proper storage and prompt removal of expired or discontinued medications.
Failure to Follow Contact Isolation Protocols for Resident with ESBL/VRE Infection
Penalty
Summary
Staff failed to follow the facility's transmission-based precautions policy for a resident with a documented ESBL/VRE urinary tract infection who was under contact isolation. On two separate occasions, staff entered the resident's room without donning the required personal protective equipment (PPE). One CNA entered the room with only a surgical mask, did not wear gloves or a gown, and did not perform hand hygiene before entry, despite signage indicating contact isolation. The CNA handled items in the room and assisted the resident with a meal before exiting and using hand sanitizer. The CNA stated they were unaware of the type of isolation required for the resident. A nurse also entered the same resident's room wearing only gloves, omitting the gown as required by the posted contact isolation sign. The nurse was unable to confirm the resident's current isolation status and stated confusion regarding whether the resident was on contact isolation or enhanced barrier precautions. The infection prevention nurse later confirmed that the resident was on contact isolation and that staff are expected to don gown, mask, and gloves prior to entry. The resident's care plan did not address contact isolation, despite physician orders and infectious disease notes specifying the need for such precautions.
Failure to Complete Comprehensive Metabolic Panel as Ordered
Penalty
Summary
The facility failed to follow physician orders to complete a comprehensive metabolic panel (CMP) for a resident diagnosed with multiple complex conditions, including Ogilvie syndrome, cerebral palsy, and severe intellectual disabilities. The physician orders, dated from 10/15/24 to 10/30/24, specified the need for a CMP and other lab tests to be conducted on specific dates. However, these tests were not completed as ordered, and the facility was unable to present lab results for the CMP on the specified dates. The Director of Nursing (V2) was initially unaware of the missed lab draws until informed by the Nurse Practitioner, and upon review, it was found that the specimen collected was insufficient to run the test. The resident's care plan required skilled services, including lab monitoring, due to their complex medical history and current health status. Despite the facility's policy on physician orders, which includes the administration of drugs and diagnostic orders upon a clean, complete, and signed order, the CMP was not completed. The Director of Nursing confirmed that the issue was not with the contracted laboratory, indicating a failure within the facility's processes to ensure the completion of necessary diagnostic tests as per physician orders.
Failure to Prevent Fall in High-Risk Resident
Penalty
Summary
The facility failed to implement effective fall interventions for a resident, resulting in the resident walking unassisted, falling, and sustaining a left hip fracture. The resident, primarily Spanish-speaking with dementia, exhibited poor safety awareness, impulsive behaviors, and an unsteady gait, requiring one-person assistance and an assistive walking device. Despite being identified as a high fall risk, the resident was left unsupervised in a common area when a CNA left to provide care for another shift, leading to the fall. Interviews with staff revealed that the resident was known to be impulsive, often attempting to get up and walk without assistance, and becoming combative when redirected. The CNA responsible for supervising the resident had informed a nurse of her intention to leave the common area to perform rounds, but the nurse was occupied with medication administration and did not ensure continued supervision. Consequently, the resident was found on the floor by the nurse after a fall. The resident's admission and fall risk evaluations confirmed her high risk for falls, with a score significantly above the threshold. The facility's fall prevention policy emphasizes the importance of identifying at-risk residents and implementing preventative strategies, yet the resident's care plan was not adequately adjusted to prevent the fall. The incident was reported to the state, and the resident was hospitalized with a left hip fracture requiring surgical intervention.
Failure to Supervise High Fall Risk Residents and Use Appropriate Equipment
Penalty
Summary
The facility failed to supervise a resident identified as a high fall risk, who has a diagnosis of Dementia, Syncope, and a history of falls. This resident, while sitting unattended in the dining room, experienced an unwitnessed fall from her wheelchair, resulting in a left hip fracture. The incident occurred when no staff was present in the dining room to monitor the resident, despite her care plan indicating a high risk for falls and the need for supervision. The resident was later found on the floor by a CNA, and emergency services were called to transport her to the hospital for evaluation and treatment of the fracture. Another resident, diagnosed with Dementia, Alzheimer's disease, and Anxiety, fell from her wheelchair while being transported without leg rests. The resident was holding her feet up off the ground, but her foot eventually dropped and gripped the floor, causing her to fall forward and sustain a right forehead hematoma. The CNA who was pushing the wheelchair confirmed that leg rests were not used during the transport, despite their availability and the resident's care plan indicating the need for such equipment to prevent falls. Both incidents highlight the facility's failure to adhere to its fall prevention and management policy, which aims to maximize residents' well-being by identifying those at risk for falls and implementing preventive strategies. The lack of supervision and failure to use appropriate equipment directly contributed to the falls and subsequent injuries of the two residents involved.
Failure to Provide Timely X-Ray Services
Penalty
Summary
The facility failed to have a system to track requests for diagnostic services, resulting in a significant delay in providing timely x-ray services to a resident. The resident, who had a history of syncope, unsteadiness on feet, orthostatic hypotension, restless leg syndrome, unspecified dementia, and anxiety disorder, reported a fall and subsequent pain in his left side. Despite the resident's report of severe pain and a physician's order for a chest x-ray, the x-ray was not performed within the expected 24-hour timeframe, leading to the resident being transported to the hospital after waiting over 30 hours for the x-ray service. The hospital diagnosed the resident with multiple rib fractures upon arrival. The facility's documentation and communication regarding the x-ray order were inadequate, contributing to the delay. The nurse on duty notified the doctor and received an order for a chest x-ray, but the x-ray service did not arrive within the expected time. The resident and his family repeatedly inquired about the x-ray, and the facility staff made follow-up calls to the x-ray company, but the technician did not arrive until after the resident had already been sent to the hospital. The facility's Director of Nursing (DON) and the x-ray technician confirmed that the x-ray should have been completed within 24 hours, and there was no documentation of follow-up communication from the facility to ensure the x-ray was performed in a timely manner. The resident's physician order sheets did not document any order for a chest x-ray, further indicating a lack of proper tracking and communication within the facility. The hospital records confirmed the resident's pain and the delay in receiving the x-ray, ultimately diagnosing the resident with acute left lateral seventh and eighth rib fractures. The facility's in-service packet for x-ray services stated that non-stat orders should be performed the same day, but this protocol was not followed in this case.
Failure to Follow Sanitizing Guidelines
Penalty
Summary
The facility failed to follow sanitizing guidelines and manufacturer's instructions by not sanitizing a knife and cutting board for the required 1 minute. This deficiency was observed when a cook sanitized a knife and cutting board by submerging them in the sanitizer for only 1 second. Both the Regional Dietary Manager and the Dietary Manager confirmed that items should be sanitized for 1 minute according to the manufacturer's guidelines and facility policy. This failure has the capacity to affect 104 residents receiving an oral diet at the facility.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to ensure mail was delivered to residents on Saturdays, affecting seven out of seven residents reviewed for residents' rights in a sample of 26. During a resident council meeting, multiple residents stated that they do not receive mail on Saturdays and have to wait until Monday. An interview with the Life Enrichment/Activities staff revealed that Saturday's mail is placed in a locked administration office by the receptionist, and activity aides do not have access to this office. As a result, mail is only distributed to residents on Mondays. The facility's document on resident rights indicates that residents have the right to unimpeded, private, and uncensored communication by mail, phone calls, and with visitors, unless restricted by a physician for safety reasons.
Failure to Immediately Report Bruise of Unknown Origin
Penalty
Summary
The facility failed to follow their abuse policy by not immediately reporting a bruise of unknown origin on a resident to the immediate supervisor or the administrator. The resident, who was admitted with diagnoses including hypertension, depressive disorder, hemiplegia, and respiratory failure, had a bruise on her hand reported by her sister. The resident stated that a staff member caused the bruise by squeezing her hand during care. The nurse documented the incident and notified the administration immediately. However, the investigation revealed that the bruise was noticed by staff members on different occasions prior to the official report, but it was not reported immediately as required by the facility's abuse policy. One CNA noticed the bruise on the resident's hand but did not report it because she was unsure of its cause and the resident did not respond when asked about it. Another CNA confirmed that the resident had a bruise on her hand and mentioned it to the nurse, but the incident was not reported immediately. The facility's abuse policy mandates that any suspicious bruises or abnormalities of unknown origin must be reported to the administrator or an immediate supervisor immediately, which was not followed in this case.
Failure to Notify Family of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the family of a resident's change of condition. Specifically, a resident was sent to the hospital, and the family member was not informed. During an interview, the family member stated that they were not informed about the resident's hospitalization. The Director of Nursing confirmed that staff are expected to notify the family of any change in the resident's condition, even in emergencies. A review of the resident's progress notes and assessments did not show any notification made to the family member. The facility's policy on Change in Resident Condition requires communication with the resident and their responsible party to be documented in the resident's medical record or other appropriate documents.
Failure to Provide Secure Storage for Resident's Money
Penalty
Summary
The facility failed to ensure a resident identified as at risk for abuse was free from misappropriation of property by not providing a secure location for the resident to store his money. This resulted in the resident having four hundred dollars stolen while in the facility. The resident, diagnosed with aphasia following a cerebral infarction, was assessed to be alert and reported the theft. The resident stated that his wallet, containing the money, was left on the window sill in his room. The resident saw a staff member in his room but was unable to provide a complete description due to his communication challenges. The facility did not provide any means for residents to secure their personal items, and the resident's family was not informed about the need for a lockbox. Staff interviews revealed that the resident had been showing his money to others before reporting it stolen. The facility's administrator confirmed that they do not provide secure storage for residents' personal items and suggested that families bring a lockbox if needed. The social service staff and other CNAs corroborated the resident's report of missing money and noted that the resident had a significant amount of cash in his wallet. The facility's abuse policy affirms the right of residents to be free from misappropriation of property, but in this case, the lack of secure storage led to the resident's loss of money.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
