All American Vlge Nrsg & Rhb
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 5448 North Broadway Street, Chicago, Illinois 60640
- CMS Provider Number
- 146198
- Inspections on file
- 19
- Latest survey
- May 23, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at All American Vlge Nrsg & Rhb during CMS and state inspections, most recent first.
Three residents were not protected from abuse, resulting in one losing a dental implant and tooth after being punched, and two others sustaining injuries during a physical altercation over a TV remote. Staff and medical records confirmed the incidents, which occurred despite facility policies prohibiting abuse and requiring resident safety.
The facility managed the personal trust funds of two residents without obtaining the required written authorization, as mandated by facility policy. One cognitively intact resident refused to sign the authorization and later exhibited aggressive behavior and was hospitalized after discovering the facility had assumed control of her funds without consent. The Business Office Manager confirmed that written authorization was not obtained for these residents.
A resident with moderate cognitive impairment and a history of mental illness was placed in a room with another resident known for severe cognitive impairment and repeated aggressive behaviors, including physical aggression toward others. Despite documented behavioral issues and a care plan indicating the need for separation, no specific interventions or monitoring were implemented after the room transfer. This resulted in a physical assault, with staff unaware of the rationale for the room assignment and the room not being located near the nurse station as believed.
The facility failed to properly label, date, and discard food items, and did not monitor refrigerator and freezer temperatures as required, potentially affecting 138 residents. Several food items lacked proper labeling, and temperature logs showed missing entries, indicating non-compliance with the facility's policies.
The facility failed to implement a plan to prevent Legionella growth in its water system, potentially affecting all 137 residents. The Maintenance Director admitted there is no plan or documentation for Legionella testing, despite having implemented such measures at previous employment. The facility's policy requires reducing Legionella risk, aligning with CMS directives for Medicare-certified facilities to maintain water management policies.
The facility failed to manage medications properly, including not documenting administration, not following inhaler instructions, administering late medications without notifying a doctor, and keeping a medication without an expiration date. These actions could lead to medication errors and affect therapeutic levels for residents.
The facility's call light system was found to be non-functional for eleven residents, as observed during a survey. When activated, the call lights did not illuminate or emit sound, preventing residents from requesting assistance. Staff, including CNAs and the DON, were unaware of the issue until the survey, despite recent maintenance attempts. The facility's policy mandates a functioning call light system, which was not met.
A facility failed to respect a resident's right to privacy and dignity when a CNA was found searching a resident's room and personal belongings without consent. The resident, who was cognitively impaired and had multiple health issues, was not present during the incident. The CNA admitted to being in the room during a lunch break, despite not being assigned to the resident, and acknowledged the violation of the resident's rights. The facility's policy mandates respect and dignity for residents, which was not upheld in this case.
A resident was found wearing a hospital wristband displaying personal health information, which was not removed upon readmission to the facility. This oversight was acknowledged by the DON and violated HIPAA regulations, as it exposed the resident's private information to unauthorized individuals.
A facility failed to update the PASARR screening for a resident, resulting in an expired assessment. The resident's SLP setting was deemed appropriate, but the initial screen and comprehensive assessment were not renewed within the 90-day validity period. Staff interviews revealed a lack of awareness and communication regarding the expiration, with the Business Office Manager and Social Services Director both unaware of the need for an update.
A facility failed to conduct a required Level I PASRR screening for a resident with mental illness, relying on an outdated OBRA-I Initial Screen. The resident was admitted before PASRR requirements, and the oversight was acknowledged by the Administrator and Business Office Manager, who was auditing charts to ensure compliance.
A facility failed to monitor a resident's ileostomy site every shift as ordered by the physician. The resident, with an intact cognition and diagnosed with an ileostomy, expressed concerns about the lack of care. The Treatment Administration Record showed multiple missed monitoring instances, and a nurse consultant confirmed these omissions. The facility's policy requires documentation of care, which was not consistently followed.
A resident with intact cognition received expired milk for breakfast, which was confirmed by a surveyor. The facility's policy requires checking expiration dates before serving, but this was not followed, leading to the incident. The Dietary Manager explained the procedure for handling milk, but the expired milk was still served, indicating a lapse in protocol.
The facility failed to monitor antibiotic use for three residents, as the IP, new to the role, discovered there was no system in place to track antibiotic prescriptions. Some residents were prescribed antibiotics without end dates, contrary to the facility's policy on antibiotic stewardship, leading to a deficiency in monitoring and reviewing antibiotic use.
The facility's heating system failed due to water leakage from a rusted water heater tank, affecting all residents during cold temperatures. The Maintenance Director reported that the boiler control system was damaged, preventing the facility from maintaining the required temperature. Residents experienced discomfort, needing extra blankets and moving away from windows. The facility lacked a regular maintenance schedule for the heating system, and temperature logs were incomplete, contributing to the problem.
The facility failed to conduct comprehensive pre-employment background checks on new hires, including a supervisor and CNAs, before they began working. Required checks on offender registries were not completed, and documentation lacked initiation dates, potentially affecting resident safety.
A resident reported her designer eyeglasses were stolen, but the LTC facility failed to investigate or report the incident to the State Agency. Despite the resident's cognitive intactness and detailed account, staff did not take appropriate action. The LPN informed the DON, but no investigation followed. The Administrator later acknowledged the oversight, and a report was only made after surveyor involvement.
A resident with multiple health issues was transferred to a hospital due to lethargy and abnormal vital signs. However, the documentation of this event was improperly recorded under another LPN's credentials, who did not assess the resident. The LPN who documented the event used a colleague's access due to computer access issues, violating facility policies on secure and accurate record-keeping.
The facility failed to maintain an effective pest control program, resulting in mice and roaches in resident rooms and common areas. Residents reported seeing pests, and housekeeping confirmed the presence of droppings and live roaches. The pest control company only treated common areas unless directed to specific rooms, leading to ongoing pest issues and resident complaints.
Failure to Prevent Resident-to-Resident Abuse Resulting in Physical Harm
Penalty
Summary
The facility failed to protect three residents from abuse, resulting in significant physical harm. One resident with a history of schizoaffective and bipolar disorder, who was experiencing delusions and agitated behavior, entered another resident's room and punched them in the mouth. This incident caused the victim to lose a dental implant and a natural tooth, resulting in bleeding and distress. Multiple staff interviews and medical records confirmed the physical altercation and the extent of the dental injuries, which required further dental evaluation and treatment. In a separate incident, two roommates were involved in a physical altercation over a television remote. One resident attempted to retrieve the remote from the other, leading to a physical struggle in which one was kicked in the face and responded by punching the other in the head multiple times. Both residents sustained injuries: one had a laceration to the upper lip, and the other complained of a headache after being kicked in the head. Staff interviews and hospital records corroborated the sequence of events and the resulting injuries. The facility's own policies affirm the right of residents to be free from abuse, including physical harm inflicted by others. Despite these policies, the incidents described involved residents inflicting physical harm on each other, with staff only becoming aware after the events had occurred. The facility's monitoring and supervision were insufficient to prevent these abusive incidents, as evidenced by the residents' ability to engage in physical altercations resulting in injury.
Failure to Obtain Written Authorization for Management of Resident Trust Funds
Penalty
Summary
The facility failed to obtain proper written authorization to manage the personal trust funds of two residents. One resident, who was cognitively intact and able to express her wishes, refused to sign the authorization paperwork, stating she could manage her own finances. Despite this, the facility proceeded to manage her funds, including becoming the representative payee for her Social Security benefits without her consent. The resident became aware of this change after contacting Social Security and observing facility staff handling documents related to her finances. This led to significant agitation, aggressive behavior, and ultimately, the resident being hospitalized. Additionally, the facility managed another resident's funds without obtaining written authorization, as confirmed by the Business Office Manager, who stated that the majority of residents did not have such authorization on file. The facility's own policy required residents or their representatives to sign an authorization form before the facility could manage personal funds, but this procedure was not followed for these two residents.
Failure to Prevent Resident-to-Resident Abuse Due to Inadequate Care Planning and Monitoring
Penalty
Summary
The facility failed to establish an environment that promotes resident sensitivity, safety, and prevention of mistreatment, resulting in an incident of abuse between two residents. One resident with schizoaffective disorder, bipolar disorder, and moderate cognitive impairment was placed in a room with another resident who had a history of severe cognitive impairment, schizoaffective disorder, bipolar type, anxiety disorder, and repeated aggressive behaviors toward staff and other residents. Despite multiple documented incidents of aggression and behavioral concerns for the second resident, including physical aggression, verbal outbursts, and the need for antipsychotic medication, there was no documented care plan or intervention specifically addressing abuse prevention for the first resident after the room transfer. The care plan for the aggressive resident indicated a need for separation from others as needed due to behavioral symptoms, but this intervention was not implemented when the two residents were placed together. Staff interviews revealed a lack of awareness regarding the rationale for the room assignment and an absence of specific interventions to prevent abuse following the transfer. The aggressive resident's care plan also called for ongoing assessment for aggression, but there was a gap in aggression assessments between the date of the care plan intervention and the actual abuse incident. On the day of the incident, the resident with moderate cognitive impairment was physically assaulted by the aggressive resident, resulting in injuries to his ribs and head. Staff responded after hearing commotion, but the incident occurred quickly and without prior intervention. The room where the incident occurred was not located near the nurse station, contrary to staff belief that it was, and there was no evidence that enhanced monitoring or other preventive measures were in place at the time of the incident.
Failure to Properly Label and Monitor Food Storage
Penalty
Summary
The facility failed to ensure proper labeling, dating, and discarding of food items, as well as monitoring of refrigerator and freezer temperatures, which could potentially affect 138 residents. During an inspection, several food items in the reach-in refrigerator and dry foods/spice pantry were found without open dates, use by dates, or with unreadable labels. For instance, a container of nacho jalapeno peppers had an open date of 02/08/25 and an expiration date of 03/20/2025, but was not discarded as required. Other items, such as giardiniera mild pepper mix and sweet relish, lacked proper labeling, making it difficult to determine their freshness and safety for consumption. Additionally, the facility did not adhere to its policy of monitoring refrigerator and freezer temperatures twice daily. Temperature logs for the reach-in refrigerator, walk-in refrigerator, and walk-in freezer showed no entries for evening temperatures from 04/01/2025 to 04/08/2025, and no morning temperature entries for 04/09/2025. The Dietary Service Director acknowledged that the cooks were only checking temperatures once per day, contrary to the policy that requires three checks per day. This lack of monitoring could compromise the safety and quality of stored food items.
Failure to Implement Legionella Prevention Plan
Penalty
Summary
The facility failed to implement a plan to prevent the growth of Legionella bacteria in its water system, which has the potential to affect all 137 residents residing in the facility. During an interview, the Maintenance Director/Housekeeping Director, who has been working at the facility for approximately five months, admitted that there is no plan in place to check the facility's water system for Legionella. He also stated that he could not find any previous documentation indicating that the facility's water system had been tested for Legionella. Despite having implemented Legionella water testing at his previous employment, he has not done so at this facility. The facility's policy, dated 2023, outlines the need to reduce Legionella risk in the facility water systems to prevent cases and outbreaks of Legionnaires' Disease and other waterborne pathogens. The Centers for Medicare & Medicaid Services (CMS) requires Medicare-certified healthcare facilities to develop and maintain water management policies and procedures to reduce the risk of growth and spread of Legionella. The facility's failure to have a documented water management program in place is a direct violation of this directive, as it lacks measures to minimize the risk of Legionella and other opportunistic pathogens in building water systems.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to properly manage pharmaceutical services, resulting in several deficiencies. A Licensed Practical Nurse (LPN) did not document the administration of medications for a resident, which could lead to medication errors such as double dosing. Another LPN administered an inhaler to a resident without following the pharmacy's instructions to wait between puffs, potentially affecting the medication's absorption and effectiveness. Additionally, a resident's medications were administered late without notifying the doctor, which could disrupt therapeutic levels necessary for managing the resident's illnesses. Furthermore, during a review of the medication cart and room, a bottle of Ferrous Sulfate was found without an expiration date, raising concerns about its efficacy and safety. The Director of Nursing acknowledged that medications without expiration dates should be removed to prevent potential adverse effects. The facility's Medication Administration Policy emphasizes timely administration and proper documentation, which were not adhered to in these instances, leading to the identified deficiencies.
Non-Functioning Call Light System in Resident Rooms
Penalty
Summary
The facility failed to provide a functioning call light system for eleven residents, as observed during a survey. On multiple occasions, when the call light was activated in various resident rooms, the light above the door did not illuminate, and no audible sound was heard. This issue was confirmed by both the Certified Nursing Assistants and the Director of Nursing, who acknowledged that the call light system is essential for residents to request assistance, especially in emergencies. Despite the presence of a call light in each room, the system was not operational, preventing residents from effectively communicating their needs to the staff. The Director of Nursing and other staff members were unaware of the malfunctioning system until it was pointed out during the survey. It was noted that someone had been working on the system the previous week, but the issues persisted, with no sound being emitted from the system. The facility's policy requires a functioning call light system, yet the survey revealed that the system was not meeting this requirement, as evidenced by the lack of response when the call lights were activated.
Violation of Resident's Right to Privacy and Dignity
Penalty
Summary
The facility failed to honor a resident's right to be treated with respect and dignity by searching a resident's room and personal property without the resident's knowledge and consent. This incident involved a male resident with multiple diagnoses, including hemiplegia, cerebral infarction, schizoaffective disorder, glaucoma, lack of coordination, unsteadiness on feet, heart failure, and malignant neoplasm of the prostate. The resident was cognitively impaired, as indicated by a BIMS score of 11/15. On the specified date, a Certified Nursing Assistant (CNA) was observed sitting on the resident's bed with his hand inside the resident's nightstand, while another CNA was sitting at the foot of the bed. The resident was not present in the room at the time. The CNA admitted to being in the room during his lunch break and acknowledged that he should not have been inside the resident's room without the resident's knowledge, especially since he was not assigned to care for the resident that day. The Director of Nursing confirmed that staff members should not be in residents' rooms during their breaks and should not search through residents' personal belongings without permission. The facility's policy emphasizes treating residents with respect and dignity, which was violated in this instance.
Resident Privacy Violation Due to Hospital Wristband
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's personal and medical information. A resident, identified as R33, was observed sitting in the dining room wearing a white hospital wristband that displayed his full name, date of birth, age, and medical record number. This wristband was placed on him during a hospital stay and was not removed upon his return to the facility, thereby exposing his private health information to anyone who could see it. The Director of Nursing (DON) acknowledged the oversight when it was brought to their attention and confirmed that the wristband should have been removed upon the resident's readmission to the facility. The facility's policy on Health Information Management mandates that all resident-identifiable information be kept confidential and only disclosed to authorized individuals. The failure to remove the wristband resulted in a violation of the Health Insurance Portability and Accountability Act (HIPAA), as it allowed unauthorized access to the resident's personal health information.
Failure to Update PASARR Screening for Resident
Penalty
Summary
The facility failed to initiate a new Pre-Admission Screening and Resident Review (PASARR) for a resident, referred to as R79, who was reviewed for PASARR in a sample of 27 residents. R79's documentation indicated that an SLP (Supportive Living Program) setting was deemed appropriate, and the initial screen and comprehensive assessment were valid for up to 90 days. However, the facility did not update the PASARR screening within this timeframe, resulting in an expired assessment. Interviews with facility staff revealed a lack of awareness and communication regarding the expiration of R79's PASARR screening. The Business Office Manager, who had been in the role for only 11 days, was responsible for inputting resident information into the PASARR system but was unsure of R79's screening results. The Social Services Director, responsible for updating PASARR screenings, was not aware of the expiration and had not received any notification about it. The facility's policy mandates that the transferring facility is responsible for ensuring the correct PASARR paperwork is in place, but this was not adhered to in R79's case.
Failure to Conduct PASRR Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to initiate a new Level I Pre-Admission Screening and Resident Review (PASRR) for a resident with a known mental illness, identified as R40. R40 was admitted to the facility with diagnoses including schizoaffective disorders, bipolar disorder, and major depressive disorder. Despite these diagnoses, the facility did not have a current PASRR screening for R40, as the resident was admitted before PASRR screenings were required. The facility relied on an outdated OBRA-I Initial Screen from 2004, which indicated a reasonable basis for suspecting mental illness. During the survey, the Administrator (V1) acknowledged the absence of a PASRR screening for R40 and mentioned that a request for the screening was made only recently. The Business Office Manager (V20), who had been in the position for just 13 days, confirmed that the facility had not conducted a PASRR screening for R40, as it was overlooked during the transition to the current requirements. V20 was in the process of auditing resident charts to ensure compliance with state requirements for PASRR screenings, but R40's screening had not been completed at the time of the survey.
Failure to Monitor Ileostomy Site as Ordered
Penalty
Summary
The facility failed to adhere to physician orders by not monitoring a resident's ileostomy site every shift as required. The resident, who was admitted with an ileostomy and other medical conditions such as chronic obstructive pulmonary disease and bipolar disorder, had a care plan in place that included monitoring the stoma site for signs of infection or skin changes every shift. However, the Treatment Administration Record (TAR) for April 2025 showed multiple instances where the stoma site was not monitored as per the physician's order, including specific dates and shifts where the monitoring was missed. The resident expressed concerns about the lack of proper ileostomy care, and a nurse consultant confirmed that there were missed monitoring instances according to the TAR. The facility's policy on colostomy/ileostomy care requires documentation of care provided, including any signs of infection or skin issues, but this was not consistently followed. This deficiency was identified through observation, interview, and record review, highlighting a failure in the facility's compliance with the prescribed care plan for the resident.
Expired Milk Served to Resident
Penalty
Summary
The facility failed to ensure that residents are free from expired food, as evidenced by an incident involving a resident who received expired milk for breakfast. The resident, who has an intact cognitive status with a BIMS score of 15, reported receiving spoiled milk with an expiration date that had already passed. This incident was confirmed by the surveyor who inspected the milk carton and noted the expired date before it was discarded. The facility's policy requires staff to check expiration dates on food items before serving them to residents. However, in this case, the staff did not adhere to this policy, resulting in the resident receiving expired milk. The Dietary Manager explained the procedure for storing and checking milk, indicating that expired milk should be discarded and not served. Despite these procedures, the expired milk was still served to the resident, highlighting a lapse in the facility's adherence to its food safety protocols.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to monitor and review antibiotic use for three residents, leading to a deficiency in antibiotic stewardship. The Infection Preventionist (IP), who had been in the role for approximately one month, acknowledged that there was no system in place to track and trend antibiotic use prior to her involvement. On April 9, 2025, the IP generated the antibiotic tracking/monitoring list for the first time with the help of other staff members. The IP noted that some residents were prescribed antibiotics without an end date, which could lead to potential complications such as compromised immune systems and resistance to antibiotics. The facility's antibiotic order report from April 2025 revealed that three residents had ongoing antibiotic prescriptions without specified end dates. One resident had multiple antibiotic eye drops prescribed since December 2024 and March 2025, another resident had a topical ointment prescribed since March 2025, and a third resident had been prescribed antibiotic tablets since April 2025. The facility's policy on antibiotic stewardship, dated April 2024, emphasized the importance of appropriate use, including specifying the duration of antibiotic treatment to improve patient outcomes and minimize resistance. However, the lack of a tracking system and oversight led to the deficiency in monitoring antibiotic use effectively.
Heating System Failure Due to Poor Maintenance and Water Leakage
Penalty
Summary
The facility failed to maintain its mechanical heating equipment, resulting in inadequate heating during cold temperatures, which affected all 144 residents. The Maintenance Director, V3, reported that the boiler control system was damaged due to water leakage from the ceiling, which originated from a rusted water heater tank. This damage led to one of the boilers being non-functional, preventing the facility from maintaining the required temperature of at least 75 degrees Fahrenheit. The heating issue was particularly problematic in the east area of the building on the 2nd floor, where residents experienced discomfort due to the cold. Interviews with staff and residents revealed that the heating problem persisted for several days, with residents needing additional blankets and some even moving away from windows to stay warm. The Director of Nursing, V2, was informed of the cold conditions by a nurse on January 2, 2025, but there was no temperature log for that day. The facility's temperature logs were incomplete, only covering January 3 to January 6, 2025, and did not include all necessary hours. The Maintenance Director admitted that there was no regular maintenance schedule for the heating system, which contributed to the problem. Observations of the facility's heating system showed significant rust and dirt on the boilers, with liquid dripping from the ceiling onto the equipment. The water heater tank, installed in 2012, was identified as the source of the leak, with its bottom severely rusted and continuously leaking. Despite the facility's Extreme Weather Temperature Policy, which requires regular inspections and maintenance of heating systems, these procedures were not followed, leading to the heating system's failure and the residents' discomfort.
Failure to Conduct Comprehensive Pre-Employment Background Checks
Penalty
Summary
The facility failed to perform comprehensive background checks on new employees before they began working, as required by the State Health Care Worker Registry. Specifically, the facility did not conduct searches on the six offender Website links on the State Health Care Worker registry for several employees, including a Housekeeping/Laundry/Maintenance Supervisor and three Certified Nursing Assistants. These employees were hired and started working without the necessary background checks being completed, which could potentially affect all residents at the facility. The Business Office Manager admitted to checking some registries only after being prompted by the surveyor, and there was no documentation of when the background checks were initiated. The Administrator acknowledged the importance of these checks to ensure the safety of residents and staff by preventing the hiring of individuals with criminal backgrounds. The personnel files reviewed lacked dates for the initiation of background checks, and several required registry searches were not performed, indicating a systemic failure in the facility's pre-employment screening process.
Failure to Report and Investigate Misappropriation of Resident Property
Penalty
Summary
The facility failed to report and investigate an allegation of misappropriation of property involving a resident's eyeglasses. The resident, who is cognitively intact with a BIMS score of 13 out of 15, reported that her designer eyeglasses were stolen from her room. Despite the resident's insistence and detailed description of the missing glasses, the facility did not take appropriate action to investigate or report the incident to the State Agency. The resident expressed frustration over the lack of response from the facility, stating that she had informed everyone about the missing glasses. Interviews with facility staff revealed a lack of communication and action regarding the resident's allegation. The LPN acknowledged being informed by the resident and notified the DON, but no further investigation or report was made. The DON, who was covering for the Administrator, claimed unawareness of the allegation and did not report it to the State Agency. The CNA stated that any allegations should be investigated and reported, but this was not done. The Administrator later acknowledged that the allegation should have been reported and investigated as misappropriation of property. The facility's records showed no report was submitted to the State Agency for this incident until after the surveyor's involvement.
Improper Documentation Practices in Resident's EMR
Penalty
Summary
The facility failed to ensure that a nurse followed established procedures for documentation in a resident's electronic medical record (EMR). This deficiency affected one resident, who had multiple diagnoses including hyperlipidemia, schizoaffective disorder, and legal blindness, among others. The resident was noted to have lethargy and abnormal vital signs, prompting a transfer to a local hospital. However, the documentation of this event was improperly recorded under the credentials of a nurse who did not assess the resident. The incident occurred when a Licensed Practical Nurse (LPN), identified as V9, used another LPN's (V8) electronic access to document in the resident's chart because V9 could not access the computer system. V8 admitted to allowing V9 to use her credentials, acknowledging that it was not professional practice and could lead to liability issues. V9 confirmed using V8's access and stated that she informed the Director of Nursing (DON) about the situation, although the DON denied being informed by V9. The facility's policies clearly state that only licensed personnel should document in a resident's medical record and that sharing access credentials is against professional practice. The Director of Nursing emphasized that nurses are educated not to share their passwords and should have contacted her or the Assistant Director of Nursing for assistance. The facility's documentation policies and job descriptions reinforce the importance of accurate and secure record-keeping, which was not adhered to in this case.
Inadequate Pest Control Measures Lead to Resident Complaints
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of mice and roaches in resident rooms and common areas. Multiple residents reported seeing mice in their rooms and common areas, with one resident noting that they had seen mice both during the day and at night. The presence of mouse droppings and live roaches was confirmed by housekeeping staff, who observed these pests in various locations, including under sinks and along baseboards. The facility's pest control measures were inadequate, as evidenced by the continued presence of pests despite the use of glue boards. The Maintenance Director acknowledged that the pest control company only treated common areas unless specifically directed to address resident rooms with known pest activity. However, there was a lack of communication and follow-up to ensure that pest control services were extended to affected resident rooms, even after evidence of pest activity was reported. The pest control company confirmed that they relied on the facility to inform them of specific areas requiring treatment. The facility's grievance binder and pest control service reports indicated that no specific resident rooms were treated for pests during the inspection period. This lack of targeted pest control intervention contributed to the ongoing pest issues, as residents continued to experience pest sightings and expressed concerns about living conditions.
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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