Alpine Care Of Evanston
Inspection history, citations, penalties and survey trends for this long-term care facility in Evanston, Illinois.
- Location
- 500 Asbury Street, Evanston, Illinois 60202
- CMS Provider Number
- 145011
- Inspections on file
- 29
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Alpine Care Of Evanston during CMS and state inspections, most recent first.
A resident with blindness, history of falls, prior subdural hemorrhage, and documented need for substantial/maximal assistance with toilet transfers was admitted and identified by the DON as high fall risk, but was scored as low risk on the fall evaluation and had no documented fall care plan beyond a bed alarm. Family had informed staff that the resident required constant monitoring due to blindness. During a day when clinical students were present, a CNA and student assisted the resident to the bathroom where he urinated on the floor and was difficult to redirect, then returned him to his wheelchair and left. Later, the CNA assigned a student to assist with feeding; the resident requested the bathroom, and the student took him there and left him alone while seeking help to clean urine, without proximate staff supervision. The resident was then found on the bathroom floor with a puddle of urine, stating he slipped and fell, and hospital imaging later showed a subdural hemorrhage.
A cognitively intact resident with Meniere's Disease, PTSD, and metabolic acidosis reported that an LPN responded angrily to her repeated requests for assistance and medication, slammed a medication cup onto the bedside table, and used profanity while referring to her as a problem, which a CNA described as rude and unprofessional. The same resident stated that a CNA assisted her to a bedside commode without verbal guidance, did not use a gait belt, and left the room despite her request that he remain nearby. During a care plan meeting in the resident’s room, the Administrator allegedly told the resident and her husband that the facility was not a hotel and threatened they would be removed and banned if they continued to voice grievances, while also making comments about her health and food choices that the resident perceived as demeaning.
Surveyors found that multiple residents receiving oxygen therapy did not have their oxygen managed according to physician orders and facility policy. Several residents on continuous or PRN oxygen via nasal cannula had undated oxygen tubing, one had tubing tangled around a bed rail, and another had an empty humidifier bottle despite an order to check and maintain humidifier water. In one case, a resident was receiving oxygen without any corresponding physician order, while another resident had an oxygen order but no care plan addressing oxygen use. Staff, including an LPN, the DON, and a nursing consultant, acknowledged that oxygen tubing should be dated, humidifier bottles should contain water and be checked routinely, and that oxygen use requires a physician order and inclusion in the care plan.
Surveyors found that a resident had multiple topical medications stored at the bedside, including products brought from home, without corresponding physician orders and contrary to facility policy requiring secure storage. The resident reported that CNAs and a family member applied these medications, while the care plan documented resistance to prescribed treatments but did not address the resident’s wish to keep medications at bedside. In a medication room refrigerator, staff stored several residents’ medications with a broken thermometer, had incomplete temperature logs, and left an expired medication in active stock, despite policies requiring secure, temperature-monitored storage and prompt removal of outdated drugs.
A resident who was alert, oriented, and able to verbalize needs but had limited upper extremity mobility was observed in bed struggling to reach a call light that was tangled between the bed siderail and mattress. The resident reported trying to use the call light to contact nursing staff. An RN acknowledged having given the resident medications earlier and forgetting to ensure the call light was accessible afterward. The DON later confirmed that facility policy requires call lights to be within reach of residents who can use them at all times.
A resident with hemiplegia, hemiparesis, and a history of falls reported repeatedly asking to be transferred from bed to a wheelchair but stated CNAs said they would return and did not, leaving the resident in bed since therapy was discontinued. A CNA acknowledged it had been weeks since assisting the resident to a wheelchair and believed therapy had ended, while an LPN, Rehab Director, and DON all confirmed the resident had no bed restrictions and should be up per resident request or schedule, with existing orders and a care plan for transfer via mechanical lift with 2–3 staff. This resulted in the facility not honoring the resident’s right to self-determination and choice of daily routine as outlined in its resident rights policy.
Staff failed to follow catheter-related physician orders and facility policies for two residents. For one resident with urinary retention, BPH, obstructive uropathy, and functional quadriplegia, surveyors observed dark yellow-orange urine with sediment in the Foley tubing and a drainage bag that produced 1000 ml of urine when emptied, despite the CNA reporting the bag had been empty earlier, and the catheter in place was an 18 Fr with a 5 cc balloon instead of the ordered 18 Fr with a 10 cc balloon, contrary to policy requiring adherence to physician orders and drainage bag emptying at least every 8 hours. For another resident with quadriplegia and neurogenic bladder, surveyors twice observed the indwelling catheter drainage bag attached above the waist on the bed rail, even though the care plan and facility policy required the bag and tubing to be positioned below the bladder level to prevent backflow, and the LPN and DON both acknowledged that the bag should be kept below the waist.
A resident receiving enteral nutrition via G-tube did not receive care in accordance with physician orders and facility policy when an RN administered medication through the tube without verifying placement and used undocumented flush volumes. The feeding container lacked a start time, and the RN could not determine when the feeding had begun. The DON confirmed that staff are expected to verify tube placement before medication administration, ensure the feeding container is properly labeled with name, rate, and start time, and follow ordered and policy-based flush volumes, all of which were not followed in this instance.
Surveyors identified infection control deficiencies involving two residents. One resident with a JP drain to the groin had no EBP order, no EBP signage, and no EBP setup outside the room, despite a facility policy requiring EBP for residents with indwelling medical devices. In a separate incident, an LPN preparing a magnesium dose for another resident cut a 400 mg tablet into quarters, handled the pieces with bare hands, returned the unused portions to the stock bottle, and did not perform hand hygiene, contrary to the DON’s stated standard practice that medications should not be handled with bare hands and unused split tablets should be discarded.
The facility did not maintain an accurate daily nurse staffing posting at the front desk, as the form displayed an outdated date and had not been updated by the responsible receptionist, who reported forgetting to do so due to being busy with holiday activities. The administrator confirmed that the 24-hour nurse staffing information should be updated daily but acknowledged that there was no policy in place for daily nurse staffing posting, and the facility was unable to provide such a policy, potentially affecting all residents receiving care.
A resident with multiple health issues, including high risk for pressure ulcers, experienced both weight loss and the development of a new wound prior to discharge. Staff identified the new wound but did not notify the physician, nurse practitioner, or the resident's family, contrary to facility policy requiring immediate notification of significant changes in condition.
A resident did not receive appropriate care for existing pressure ulcers, and the facility failed to implement effective interventions to prevent new ulcers from developing. Observations and record reviews showed lapses in assessment, monitoring, and treatment, with necessary preventive measures not consistently applied.
The facility failed to maintain a clean and safe environment for residents, with observations of dust, residue, and soiling in resident rooms and care areas. Six residents, including those with dementia and Parkinson's disease, were affected. The DON confirmed the unclean conditions, which violated the facility's housekeeping and infection control policies.
A resident with multiple diagnoses, including a history of falls, experienced two falls while smoking due to inadequate supervision and assistance. The resident, who requires a wheelchair and has impaired cognition, was not provided with necessary support when he dropped his cigar, leading to falls. Facility policies on smoking supervision and fall prevention were not effectively implemented.
A resident with moderate cognitive impairment was physically abused by a CNA, who forcefully pushed and hit the resident. The incident was witnessed by an Activity Aide, but the facility failed to conduct a thorough investigation or document the incident properly. The resident's care plan was not updated, and the facility did not adhere to its abuse policy.
The facility failed to follow their identified offender policy by not performing criminal background checks within 24 hours of new resident admissions and not scheduling fingerprint-based criminal history record inquiries within 72 hours of receiving initial results for four residents. This failure affected the safety and well-being of all 89 residents currently residing in the facility.
Failure to Adequately Supervise High-Risk Blind Resident During Bathroom Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate monitoring and supervision for a newly admitted resident with known high fall risk and impaired safety awareness. The resident, an older male with diagnoses including difficulty in walking, unspecified cataract, history of falling, nontraumatic subdural hemorrhage, cerebral edema, hypertension, ADHD, and other conditions, was blind and required substantial/maximal assistance with toilet transfers per the MDS. The MDS also documented short- and long-term memory problems, yet the resident’s fall risk evaluation scored him as low risk, and there was no documented fall care plan or fall prevention interventions beyond a bed alarm. The family had informed staff upon admission that the resident required constant monitoring due to blindness. On the day of the incident, the resident had been in the facility less than 24 hours and was assigned to a CNA, with clinical students present on the unit. Earlier in the day, the CNA and a clinical student assisted the resident to the bathroom, where he urinated on the floor and was difficult to redirect, insisting he knew what he was doing. They cleaned him, dressed him, returned him to his wheelchair, and left the room. Later, during the lunch meal, the CNA directed the clinical student to assist the resident with feeding. The resident requested to go to the bathroom, and the clinical student took him there. The student then left the resident alone in the bathroom to get help to clean urine on the floor, and when staff returned, the resident was found on the bathroom floor with a puddle of urine present. The resident’s fall was unwitnessed, and he was found sitting on the bathroom floor with his head against the door. Vital signs were obtained, and no visible injuries were initially noted; the resident stated he slipped and fell while coming out of the bathroom. The DON later stated that clinical students cannot provide accurate monitoring and supervision and that proximate supervision requires facility staff to be physically present with students during direct care, but the resident had been left under the student’s care without such proximate staff supervision. The resident was subsequently sent to the hospital, where imaging showed a 7 mm subdural hemorrhage along the parieto-occipital convexity, with the report noting that in the setting of recent trauma, an acute hemorrhage could not be entirely excluded. The facility did not report the fall to authorities, citing uncertainty about whether the hemorrhage was acute and the resident’s prior brain-related history.
Failure to Maintain Resident Dignity During Care, Medication Pass, and Care Plan Meeting
Penalty
Summary
The deficiency involves the facility’s failure to ensure a cognitively intact resident was treated with dignity and respect during care interactions and a care plan meeting. The resident, an adult with Meniere's Disease, PTSD, and Acute Metabolic Acidosis, reported that on 01/09/2026 an LPN responded to her call light after a delay of about 10 minutes, during which she had requested assistance to the bedside commode and medication for stomach, gas, and chest pain. The resident stated that the CNA who assisted her was a tall Black male who did not speak, did not provide instructions or guidance during the transfer, did not use a gait belt, and left the room despite her request that he stay nearby. She reported that when the LPN arrived, the nurse appeared very angry, slammed the medication cup onto the bedside table, and used profanity, telling her to “shut the f*** up” and referring to her as a “f***ing problem” and “that bitch” while speaking with the CNA outside the room. The resident demonstrated to surveyors how the pills were slammed down and described feeling afraid she would fall during the transfer. During a care plan meeting held in the resident’s room with the Administrator, DON, therapy staff, and nursing staff, the resident reported that the Administrator told her and her husband that “this is not a hotel” and threatened that she and her husband would be thrown out and banned from the facility if they continued to voice grievances or if her husband kept “screaming” at staff. The resident denied screaming at staff and expressed frustration about not receiving daily baths as requested and documented on a sign in her room, and about therapy being discontinued after she refused one session due to claustrophobia related to using the elevator. The Administrator acknowledged to surveyors that he may have commented that the facility was not a hotel and discussed the resident’s food choices in relation to his personal experience with diabetes, while denying that he threatened eviction or made derogatory remarks about her appearance. The CNA confirmed witnessing the LPN being rude and lacking professionalism toward the resident, though he could not recall exact words, while the LPN denied using profanity and attributed the resident’s behavior to anxiety and PTSD.
Failure to Manage Oxygen Therapy per Orders and Facility Policy
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate respiratory care by not obtaining required physician orders for oxygen, not dating oxygen tubing when changed, and not maintaining humidifier water bottles as specified in facility policy. During observation, one resident was found in bed on continuous oxygen at 3 LPM via nasal cannula with undated tubing that was tangled around the bedside rail; the LPN stated tubing should be free of tangles and dated weekly. This resident’s record showed diagnoses including COPD, pleural effusion, and palliative care, with an active order for continuous oxygen at 2–3 LPM and instructions to check the humidifier water level every shift. Another resident with a diagnosis including cerebral infarction was observed in bed on 3 LPM oxygen via nasal cannula with undated tubing; the LPN confirmed tubing should be dated. The active physician order for this resident specified oxygen at 3 LPM via nasal cannula for SpO2 below 90% every shift for shortness of breath, but there was no care plan formulated for oxygen use. A third resident with diagnoses including hemiplegia, hemiparesis, and muscle wasting was observed in bed on 3 LPM oxygen via nasal cannula with an empty humidifier bottle and undated tubing; the LPN stated tubing should be dated and humidifier water checked and replaced when empty. The physician order indicated continuous oxygen at 2 LPM via nasal cannula, and the comprehensive care plan documented oxygen therapy related to ineffective gas exchange and interstitial pulmonary disease with an intervention to give oxygen as ordered. A fourth resident with diagnoses including hemiplegia, hemiparesis, and paroxysmal atrial fibrillation was observed in bed on 2.5 LPM oxygen via nasal cannula with undated tubing, and review of the active physician order sheet showed no order for oxygen use, although the comprehensive care plan included a plan for oxygen usage. The DON and a nursing consultant later confirmed that oxygen tubing should be dated when changed, humidifier bottles should be checked and refilled as needed, and that residents using oxygen should have a physician order and be care planned, consistent with facility policies on oxygen therapy and physician orders.
Improper Medication Storage and Use of Unordered Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications and biologicals were stored securely and used only in accordance with physician orders and facility policy. During wound care for R7, surveyors observed multiple topical medications kept at the bedside, including ketoconazole 2% cream, zinc oxide 4%, triamcinolone 0.1% ointment, and mupirocin 2% ointment. The Wound Care Nurse stated that treatment medications should not be kept at the bedside without a physician order but acknowledged that R7 requested to keep them there and that R7’s son had brought some medications from home. R7 reported that CNAs applied these medications to his buttocks after incontinence episodes and that his son also applied them during visits. Record review for R7 showed active physician orders for mupirocin 2% cream and triamcinolone 0.1% cream for specific wound care sites and frequencies, but no orders for ketoconazole 2% cream or zinc oxide 4%. The DON confirmed that the ketoconazole and zinc oxide had been brought in by a family member and that residents could not keep treatment medications at the bedside without physician orders. R7’s comprehensive care plan documented that he resists care, refuses to follow physician orders and guidance, and believes his own treatment approaches are more beneficial than those recommended by health care professionals. He was identified as high risk for pressure sore development, with contributing conditions including arthropathic psoriasis and seborrheic dermatitis, but the care plan did not address his desire to keep medications at the bedside. Surveyors also identified medication storage issues in the third-floor medication room refrigerator, where medications for several residents were stored with a broken thermometer and an incomplete temperature monitoring log for two months. An expired medication, Konvomep (omeprazole) 2-84 mg/ml, labeled as opened on 8/28/2025 and expired on 9/27/2025, remained in the refrigerator for one resident. The RN on duty stated he was unaware the thermometer was broken and that the night shift nurse completed the refrigerator log. Facility policies required medications to be secured in locked storage, to be administered only with written physician orders, to be stored at appropriate refrigerated temperatures with daily temperature logs, and for outdated or deteriorated medications to be immediately removed and disposed of, but these procedures were not followed in the observed instances.
Call Light Not Kept Within Reach for Resident With Limited Mobility
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was kept within reach as required by policy. During observation on 12/2/25 at 10:46 AM, a resident who was alert and oriented x3, able to verbalize needs, and had limited upper extremity mobility was found lying in bed attempting, but struggling, to reach a call light that was tangled between the bed siderail and mattress. The resident stated he was trying to reach the call light to call for his nurse or CNA. When the surveyor notified the assigned RN at 10:50 AM and showed her the situation, the RN acknowledged she had administered the resident’s medications that morning and had forgotten to ensure the call light was accessible. The RN then had to lift the mattress to remove the tangled call light. Later that day, the DON confirmed that residents’ call lights should be within reach and accessible at all times, consistent with the facility’s call light policy revised on 6/30/25, which states that call lights must be placed within reach of residents who are able to use them at all times. This sequence of events demonstrates that the resident’s needs and preferences for accessible communication with staff were not reasonably accommodated when staff failed to position the call light within the resident’s reach after providing care, resulting in the resident being unable to independently summon assistance.
Failure to Honor Resident Choice to Get Out of Bed After Therapy Discharge
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to self-determination and choice regarding daily routines, specifically the resident’s request to get out of bed and into a wheelchair. On 12/2/2025 at 11:15 a.m., Resident 18 reported that she asked every day to be placed in her wheelchair, but CNAs told her they would return and did not come back until later, and that she had not been out of bed since her therapy was discontinued a couple of weeks prior. A CNA stated at 11:20 a.m. that she had assisted the resident out of bed when the resident was in therapy, but it had been weeks since she last assisted the resident to her wheelchair and she believed the resident was no longer in therapy. An LPN stated at 11:25 a.m. that the resident should be out of bed as requested by the resident or according to a schedule for being up in a chair. On 12/3/2025 at 1:00 p.m., the Rehab Director confirmed that the resident had no bed restrictions and could be out of bed as requested by the resident or per a schedule, and that the resident received PROM (passive range of motion) to all extremities. Earlier that day at 10:30 a.m., the DON stated that all residents should be out of bed per a schedule, therapy, or resident request, and that no one should remain in bed solely because therapy was completed. Record review showed that the resident had diagnoses of hemiplegia and hemiparesis and a history of falling, with orders dated 4/22/2025 for nursing rehab transfer to a manual wheelchair via full body lift with 2–3 staff for safety, and a care plan dated 1/25/2025 specifying transfer via mechanical aid, lift sling, and 2 staff for transfers. An occupational therapy discharge summary indicated the highest practical level had been achieved. Despite these orders and the facility’s written policy on resident rights and self-determination, the resident’s expressed choice to get out of bed and into a wheelchair was not being consistently honored after therapy was discontinued.
Failure to Follow Catheter Orders and Positioning Requirements
Penalty
Summary
Surveyors identified that staff did not follow physician orders and facility policies for indwelling urinary catheter management for two residents. For one resident with diagnoses including urinary retention, functional quadriplegia, benign prostatic hypertrophy, obstructive and reflux uropathy, and kidney calculi, observation during wound care showed catheter tubing with sediment draining dark yellow-orange urine and a drainage bag that yielded 1000 ml of urine when emptied, despite the CNA stating the bag had been empty at the start of the morning shift. Review of the medical record showed an active physician order for an 18 Fr Foley catheter with a 10 cc balloon and catheter care every shift, but the resident was found to have an 18 Fr catheter with a 5 cc balloon in place. Facility policies required adherence to physician orders and emptying catheter drainage bags at least every 8 hours, with accurate recording of urinary output, but the drainage bag had not been emptied by the end of the night shift as required. For another resident with quadriplegia, neurogenic bladder, functional quadriplegia, and chronic multiple wounds, surveyors twice observed the indwelling urinary catheter drainage bag attached to the upper bed railing above the resident’s waist. The LPN present acknowledged that the drainage bag should be placed below the waist to prevent backflow and then repositioned the bag. The DON later confirmed that all indwelling catheter drainage bags should be placed below the waist. The resident’s admission record and care plan included an order for an indwelling catheter size 16 Fr with a 10 ml balloon for neurogenic bladder and an intervention to position the catheter bag and tubing below the level of the bladder. The facility’s indwelling catheter policy stated that the catheter bag will always be positioned below the bladder region to prevent backflow when the Foley bag has no anti-backflow valve, but this was not followed for this resident.
Failure to Follow Enteral Feeding and G-Tube Medication Administration Protocols
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies and physician orders for enteral (tube) feeding management and medication administration for one resident with a G-tube. During an observation, an RN administered a medication via the resident’s enteral tube without checking tube placement beforehand. The nurse acknowledged that she did not verify placement, despite stating that tube feeding placement should be checked prior to medication administration using a pH strip or by aspiration. The tube feeding site was covered with a clean, dry dressing, but no other placement confirmation was identified. The tube feeding bottle was infusing at 50 mL/hr, but the container did not have a visible start time, and the nurse stated she could not determine when the feeding had been started, noting that there should be a start time of infusion. The RN also flushed the tube with 60 mL of tap water before administering the medication and 90 mL of water afterward, explaining that she gives extra flushing because the resident does not drink water. The DON later stated that nurses should check tube placement before medication administration, that the tube feeding container should include the resident’s name, rate, and start time, and that tube feedings should be flushed according to the physician’s order and facility policy. The physician’s order specified Jevity 1.2 at 50 mL/hr starting at 3 p.m. for 21 hours or until 1050 mL is reached per day, with a 150 mL flush every 6 hours. Facility policies required that feeding bags be labeled with the date and time feeding was started, that G-tube placement be checked by tube marker location and gastric content aspiration with pH confirmation, and that the G-tube be flushed with 15–30 mL of water before and after medications. These requirements were not followed during the observed medication pass.
Failure to Implement Enhanced Barrier Precautions and Safe Medication Handling
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control practices related to both enhanced barrier precautions (EBP) and medication handling. One resident, R96, was observed lying in bed with family at the bedside with no EBP signage posted and no EBP setup outside the room, despite having a Jackson-Pratt (JP) drain to the right groin for a right groin hematoma and an order to empty and monitor the drain every shift. On two separate observations, there was no EBP order, no signage, and no setup in place, even though the facility’s EBP policy requires use of gowns and gloves and posting of EBP signs for residents with indwelling medical devices, regardless of colonization status. The Infection Preventionist acknowledged that R96 should have had an EBP order due to the surgical drainage. A second deficiency was identified during a medication pass observation involving R89. An LPN prepared a 100 mg dose of magnesium oxide when only a 400 mg house stock tablet was available. The LPN cut the 400 mg tablet into four parts, handled the medication pieces with bare hands, and returned the remaining three-quarters of the tablet to the original stock bottle without performing hand hygiene at any point. The DON later stated that medications should not be touched with bare hands and that once a tablet is split, any unused portion should be discarded rather than returned to the original container for infection control purposes. The facility did not have a specific written policy on handling medications, but the stated standard practice was that medications should not be handled with bare hands for infection control reasons.
Failure to Maintain and Update Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information form posted at the front desk was updated each day, potentially affecting 92 residents receiving care. On 12/2/25 at 9:24 AM, surveyors observed that the posted daily nurse staffing form still showed the date 11/24/25. The receptionist stated she was responsible for updating the daily nursing posting when she arrived at work at 8:00 AM but reported that she became busy due to the holiday and forgot to update it. When informed of this observation at 1:28 PM the same day, the administrator acknowledged that the 24-hour nurse staffing form should be updated and posted on a daily basis and also stated that the facility did not have a policy on daily nurse staffing posting. The facility was unable to provide a policy related to this requirement. No additional resident-specific clinical information or medical histories were provided in the report beyond the statement that 92 residents were receiving care in the facility at the time.
Failure to Notify Responsible Party and Physician of Change in Condition
Penalty
Summary
The facility failed to follow its policy regarding notification of a resident's responsible party and physician when there was a significant change in condition, specifically related to weight loss and the identification of a new wound. Interviews and record reviews revealed that a resident with multiple diagnoses, including Parkinsonism, impaired mobility, and a high risk for pressure ulcers, developed a new wound prior to discharge. The wound was identified by a registered nurse, who covered it with a dressing but did not notify the physician or nurse practitioner. The wound care nurse was informed about the new wound only shortly before the resident was discharged, and by the time the nurse attempted to assess the wound, the resident had already left the facility. Additionally, the facility did not notify the resident's family or responsible party about the new wound or the resident's weight loss, despite facility policy requiring immediate notification of significant changes in a resident's condition. The director of nursing confirmed that the family was not informed of these changes prior to discharge. The facility's policies on change of condition and weight monitoring require prompt communication with the physician and family when significant changes occur, but these procedures were not followed in this instance.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews that indicated lapses in the assessment, monitoring, and treatment of pressure ulcers for residents at risk. The report notes that necessary interventions to prevent skin breakdown were not consistently applied, and existing pressure ulcers were not managed according to established protocols.
Facility Fails to Maintain Clean and Safe Environment for Residents
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for its residents, as evidenced by multiple observations of unclean and damaged conditions in resident rooms and care areas. Six residents were directly affected by these deficiencies, including residents with complex medical histories such as dementia, Parkinson's disease, and heart failure. The surveyor observed significant dust, residue, and soiling on personal protective equipment bins, medical equipment, and various surfaces within resident rooms. Specific instances included a bladder scan machine left uncovered and soiled in a hallway, a resident's room with a missing drawer and broken handles on furniture, and another resident's oxygen machine covered in dust. Additionally, several rooms had unclean conditions such as stained pillowcases, dusty blinds, and soiled bed rails. The facility's Director of Nursing confirmed these observations and acknowledged that the rooms and equipment should have been maintained in a clean condition. The facility's policies on housekeeping and infection control were not adhered to, as evidenced by the persistent unclean conditions despite daily cleaning protocols. The Director of Nursing stated that housekeeping and maintenance staff are responsible for cleaning and maintaining resident rooms, yet the observed conditions indicated a failure to meet these standards. The facility's failure to ensure a clean and safe environment for residents was a clear deficiency in their care practices.
Inadequate Supervision During Smoking Leads to Resident Falls
Penalty
Summary
The facility failed to provide effective fall interventions and adequate supervision for a resident while smoking, leading to a deficiency. The resident, a male with multiple diagnoses including dysarthria, lack of coordination, abnormalities of gait and mobility, and a history of falling, was involved in two incidents where he fell while smoking. On one occasion, the resident fell out of his wheelchair while attempting to pick up a dropped cigar, resulting in his face landing on the concrete. The staff member present at the time, who was not trained to transfer residents or evaluate them after a fall, had to call for nursing personnel to assist the resident. The facility's policy requires that residents assessed as unsafe smokers receive supervision during smoking. However, the staff did not provide adequate supervision or assistance to the resident, who was known to have impaired cognition and required a wheelchair for mobility. The resident's smoking assessment indicated that he was not a safe smoker and required management and supervision. Despite this, the resident was not provided with the necessary assistance when he dropped his cigar, leading to falls. The facility's policy on fall occurrences also mandates that interventions be put in place and reevaluated as necessary, which was not effectively done in this case.
Failure to Protect Resident from Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) who was physically abusive towards a resident. The resident, who has moderate cognitive impairment and requires assistance with daily activities, reported being forcefully pushed and hit by the CNA while attempting to get up from a wheelchair. This incident was corroborated by an Activity Aide who witnessed the CNA pushing the resident roughly onto a toilet, causing the resident to scream and cry. The facility's response to the incident was inadequate. The Director of Nursing (DON) and other staff members failed to conduct a thorough investigation or document the incident properly. Despite being informed of the abuse allegation, the DON did not utilize available Spanish-speaking staff to communicate effectively with the resident, who primarily speaks Spanish. Additionally, the Social Services Director did not complete any assessments or provide documented emotional support to the resident following the incident. The facility's abuse policy mandates a timely and thorough investigation of abuse allegations, which was not adhered to in this case. The lack of documentation and follow-up assessments highlights a significant deficiency in the facility's handling of the situation. The resident's care plan was not updated to reflect the incident, and there was no evidence of measures taken to prevent further occurrences of abuse.
Failure to Conduct Timely Background Checks for Identified Offenders
Penalty
Summary
The facility failed to follow their identified offender policy by not complying with state regulations in performing criminal background checks within 24 hours of the admission of new residents and failed to schedule a fingerprint-based criminal history record inquiry within 72 hours of receiving the initial criminal background results for four residents. This failure has the potential to affect the safety and well-being of all 89 residents currently residing in the facility. The facility's census indicated a total of 89 residents, with five identified offenders currently residing there. Interviews with the Social Services Director and Social Services Designee revealed that identified offender reviews for new residents upon admission were delayed due to the lack of an admissions director. An audit was performed towards the end of the year to initiate these reviews. The criminal history information response process should be done within 24 hours of admission, and fingerprinting should be completed within 30 days if applicable. However, the facility did not adhere to these timelines for four of the five identified offenders reviewed. The admission records and criminal history inquiries for the four residents showed significant delays and incomplete processes. For instance, one resident's initial criminal background results were expired, necessitating a new search. Another resident had no fingerprint documentation, and their sex offender check was incomplete. Additionally, two residents had sex offender checks attempted with no results due to system issues, and no further attempts were made. The facility's failure to conduct timely and complete background checks and fingerprinting for identified offenders compromised the safety protocols intended to protect all residents.
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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