Alpine Care Of Zion
Inspection history, citations, penalties and survey trends for this long-term care facility in Zion, Illinois.
- Location
- 2534 Elim Avenue, Zion, Illinois 60099
- CMS Provider Number
- 145665
- Inspections on file
- 45
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Alpine Care Of Zion during CMS and state inspections, most recent first.
Two residents who were incontinent and dependent on staff for ADLs and toileting were not changed in a timely manner, resulting in briefs that were completely saturated with foul-smelling urine and, in one case, skin indentations, redness, and a dried ring of urine on the bed linens. CNAs reported they did not know when the residents were last changed and acknowledged that residents are supposed to be checked and changed at least every two hours, while the DON and the facility’s incontinence policy also required two-hourly rounds and perineal care as needed, which were not carried out as planned.
A CNA provided incontinence care to a resident and, after removing a urine-saturated brief and cleansing the perineal area, failed to change gloves or perform hand hygiene before handling clean linens, applying a clean brief and gown, repositioning the resident, adjusting pillows, tidying the overbed table, and removing garbage and soiled linens. The DON later confirmed that facility policy requires changing gloves after contact with soiled briefs and linens and performing hand hygiene, which was not followed in this observed episode of care.
A resident with multiple risk factors for skin breakdown reported pain and a sore on the right buttock, but staff failed to assess, document, and implement ordered treatments for a facility-acquired pressure ulcer. Despite an order for barrier cream, no treatment was provided, and the wound nurse was unaware of the open area until the survey. Required documentation and interventions were not completed according to facility policy.
Multiple residents reported that their bathrooms lacked hand soap for an extended period, despite repeated requests to staff. Staff confirmed that soap had been removed due to a recall and was not replaced in a timely manner, leaving residents without the means to perform proper hand hygiene as required by facility policy.
A resident who was cognitively intact and seeking discharge or transfer closer to family repeatedly requested assistance from social services but did not receive follow-up or referrals. Despite being able to pay for 24-hour care at home and having a suitable home environment, the resident's discharge planning was not initiated as required by facility policy.
Surveyors found that a medication refrigerator on one unit was warm and reading 54–60°F, despite facility requirements that refrigerated medications be stored between 36–46°F. At the time of the observation, the refrigerator contained unopened Humalog insulin pens for two residents, Latanoprost ophthalmic solution for another resident, and a Trulicity auto-injector for a fourth resident. An LPN and the unit supervisor confirmed that these medications should be kept within the 36–46°F range, and maintenance later reported the refrigerator was not cooling properly due to ice buildup, resulting in medications being stored outside the acceptable temperature range.
A resident with dementia, poor trunk control, impulsive behavior, and non-compliance with transfer status was observed in a wheelchair with a lap restraint in place, and records showed the restraint had been in continuous use with routine checks documented. The only documented restraint assessment was from the prior year, despite facility policy requiring at least quarterly assessment and potential reduction. Nursing staff reported that the restraint was used for trunk support and fall risk but acknowledged there were no current restraint or restraint-reduction assessments, and the resident’s MDS inaccurately documented that no physical restraints were used.
A deficiency was cited for failure to provide timely incontinence care and grooming to dependent residents. One nonverbal hospice resident was observed lying for several hours in urine-soaked linens, with strong urine odor present, and records showed no incontinence care documented that day despite a check-and-change schedule. Another resident with MS, morbid obesity, and neuromuscular bladder dysfunction, fully dependent for toileting, reported wearing double pads and sitting on an extra pad because staff did not change her after she got up and often told her they were too busy or lacked help when she requested toileting. A ventilator-dependent resident with severe intellectual disabilities, fully dependent for ADLs and not refusing care, was observed with clearly visible, overgrown facial hair despite being assessed as dependent on staff for shaving.
A resident who reported feeling hungry after meals had an order for double food portions based on his preference, but was observed receiving a regular-sized meal. His meal ticket did not indicate the double-portion order, and the Food Service Manager stated that kitchen staff rely on the meal ticket to know when to serve double portions. The dietitian confirmed that double portions had been ordered as a preference, not as a weight management intervention, yet this preference was not reflected on the meal ticket or in the portion actually served.
A resident on isolation for active COVID-19 had physician orders, a care plan, a door sign, and a facility policy all requiring use of an N-95 mask, gloves, isolation gown, and eye protection for anyone entering the room. A CNA was observed entering the resident’s room with linens and later exiting with soiled linens while not wearing the required eye protection, despite the infection control nurse confirming that eye protection was part of the mandated PPE for COVID-19 isolation.
A resident with chronic respiratory issues was placed on a mechanical ventilator due to low oxygen levels, but the facility failed to notify her family. Despite the resident being alert, the family only learned of the situation upon visiting the next day. The facility's policy requires immediate notification of significant changes, which was not adhered to in this case.
A resident with a history of pleural effusion and shortness of breath experienced hypoxia and difficulty breathing. Despite a physician's order to send the resident to the hospital, staff failed to do so, leading to the resident's deterioration and death. The use of a non-rebreather mask without proper order and inadequate communication of critical test results contributed to the incident.
The facility failed to address and follow up on concerns raised by residents during council meetings, including issues with medications, call light wait times, and television service. Despite residents regularly voicing complaints, there was little or no documented follow-up, and the Activities Director and Administrator acknowledged the importance of the grievance process but did not ensure systematic resolution of these concerns.
The facility failed to follow proper infection control protocols, including the use of PPE for residents on isolation precautions. Staff did not wear gowns or perform hand hygiene during high-contact care activities, and PPE was not removed before leaving isolation rooms. These lapses occurred despite clear policies and care plans indicating the need for enhanced barrier precautions for residents with medical devices and infections.
A facility failed to maintain resident dignity and hygiene in two incidents. A CNA spoke disrespectfully to a resident with multiple diagnoses, pressuring them to eat without regard for their dignity. In another case, staff neglected to change a soiled sheet for a resident with severe cognitive impairment, despite being informed of the issue, compromising the resident's dignity and comfort.
A resident with multiple diabetic wounds on toes, feet, and heels was not provided with necessary off-loading devices to prevent pressure on wounds. Despite staff acknowledging the need for off-loading, the resident's heels were observed resting on the bed without any protective devices. Facility guidelines required off-loading, but documentation showed no record of heel protectors being used.
A resident with severe cognitive impairment and swallowing issues was found unsupervised, drinking non-thickened liquids, contrary to her dietary requirements. Facility staff confirmed the need for nectar thick liquids and supervision to prevent aspiration, but the facility lacked a policy on aspiration precautions.
A resident with moderate cognitive impairment and multiple health conditions was found without a catheter securement device, lying on the catheter tubing, and with the drainage bag positioned above the bladder. The facility's staff failed to clean the catheter tubing after the resident was incontinent of stool, contrary to the care plan and best practices to prevent infection.
The facility failed to ensure accurate weight measurements for two residents, resulting in significant discrepancies. One resident experienced a notable weight loss despite good intake, while another showed a rapid weight gain without verification. The process for obtaining and documenting weights was inconsistent, and required follow-ups were not conducted.
A facility failed to obtain orders and assess a resident's dialysis site, leading to a deficiency in care. The resident, with multiple diagnoses including end-stage renal disease, had no physician's orders for permacath site assessment in July 2024. Despite policy requirements for daily assessment, documentation lacked guidance for staff, resulting in inconsistent site assessments. The DON acknowledged the need for specific orders to ensure proper care.
The facility failed to administer medications timely and correctly for two residents. One resident missed a dose of Hydralazine due to late administration, while another was not instructed to rinse their mouth after using an inhaler, risking thrush. These incidents reflect lapses in following medication pass procedures and manufacturer instructions.
A resident with severe protein-calorie malnutrition and undergoing chemotherapy was not offered dietary substitutions for a pureed diet, despite expressing dissatisfaction with the meal provided. The CNA confirmed no substitutions were available, and the DON acknowledged the resident's dislike for the food and the potential impact on their nutritional intake. This was contrary to the facility's policy requiring equivalent nutritional substitutes.
The facility failed to maintain the third-floor shower room and a resident's air conditioning unit in a safe and sanitary condition. Water was leaking from the ceiling in the shower room, with evidence of mold and water damage, affecting 53 residents. A resident with lung problems had a missing air conditioning cover, exposing insulation and other materials. The maintenance department did not regularly inspect these areas, relying on staff reports, and failed to address the issues promptly.
A facility failed to provide proper tracheostomy care, leading to potential cross-contamination. A resident with a tracheostomy did not receive care as ordered, and a respiratory therapist used soiled gloves to handle clean supplies and placed soiled items on the resident's bed. The facility's guidelines for maintaining cleanliness and documenting care were not followed.
Failure to Provide Timely Incontinence and ADL Care
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and assistance with activities of daily living (ADLs) for residents who were unable to care for themselves. One resident, lying in bed on a low air loss mattress, reported being incontinent and currently wet and was unsure of the last time he had been changed, estimating it may have been around 7:00 AM. When a CNA began changing him at 9:39 AM, his incontinence brief was completely saturated with foul-smelling urine, and the CNA did not know when he was last changed, stating that if the night shift CNA had last changed him, it was probably around 6:00 AM. Deep grooves and indentations from the brief were observed in his thighs and groin area, with redness and inflammation noted on the left thigh, and a dried ring of urine was seen on the fitted sheet, prompting a full linen change. This resident’s assessment and care plan documented that he was dependent on staff for personal hygiene, bed mobility, toileting, and transfers, and required assistance with ADLs as needed. Another resident, also on a low air loss mattress, was observed at 10:15 AM when a CNA came in to change him and stated she did not know the last time he had been changed and had not changed him yet that day, explaining she had to get residents ready for breakfast and feed this resident. When the CNA removed the incontinence brief, the front and back were saturated with foul-smelling urine, and the resident did not assist with turning. The care plan for this resident showed bowel and bladder incontinence, frequent bladder incontinence, impaired mobility related to limited ROM, and required total staff assistance for toilet use, with instructions for staff to check and change him, including full perineal care, every two hours and as needed. Both CNAs and the DON stated that residents are supposed to be checked and changed at least every two hours and as needed, and the facility’s Incontinent and Perineal Care Policy required rounds at least every two hours to check for incontinence during each shift, which was not followed in these instances.
Failure to Change Gloves and Perform Hand Hygiene During Incontinence Care
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to incontinence care for one resident. During an observation, a CNA provided incontinence care to a resident wearing a urine-saturated brief. While wearing a single pair of gloves, the CNA pulled down the saturated brief, used peri wash and disposable wipes to cleanse the resident’s front perineal area, retracted the foreskin and cleaned the glans, and wiped the groin. The CNA then turned the resident, removed the soiled brief and linens, and, without changing gloves or performing hand hygiene, arranged and rolled a clean fitted sheet, pad, and brief under the resident. The CNA positioned the resident on his back and fastened the clean brief, still using the same gloves. The CNA then continued additional resident care and environmental tasks without changing gloves or performing hand hygiene. With the same gloves, the CNA obtained assistance to boost the resident up in bed, put a clean gown on the resident, covered him with a clean top sheet and personal blanket, adjusted the resident’s pillows, tidied items on the overbed table, and removed the garbage. The CNA left the room carrying a bag of soiled linens while still wearing the same gloves used throughout the entire procedure. The DON later stated that during incontinence care, gloves should be changed after removing dirty briefs and linens and after wiping soiled areas, and that hands should be sanitized, which was also reflected in the facility’s Incontinent and Perineal Care Policy requiring glove changes and handwashing at specified points in the procedure.
Failure to Identify and Treat Facility-Acquired Pressure Ulcer
Penalty
Summary
A deficiency occurred when the facility failed to identify, assess, and implement treatment orders for a resident who developed a facility-acquired pressure ulcer. The resident, who had risk factors such as impaired mobility, bowel incontinence, and peripheral vascular disease, reported pain and a sore on his right buttock to staff approximately two weeks prior to the survey. Despite the resident's report and a previous order for barrier cream, no dressing or cream was being applied, and the resident stated that nothing had been done after he informed staff. During observation, an open area was found on the resident's right buttock with no treatment in place, and the wound nurse was unaware of the open area until the day of the survey. Further review revealed that the barrier cream ordered for the resident was not present in his room, and there was no documentation in the electronic health record regarding the skin alteration. The wound nurse was unable to locate wound notes for the previously identified skin issue, and the care plan, while noting the potential for pressure ulcer development and interventions, was not being followed as treatments were not administered as ordered. The facility's policy requires prompt identification, documentation, and treatment of skin breakdown, but these steps were not carried out for this resident.
Failure to Provide Hand Soap in Resident Bathrooms for Infection Control
Penalty
Summary
The facility failed to ensure that residents' bathrooms were stocked with antiseptic hand soap for four out of eight residents reviewed for infection control. Observations revealed that multiple residents' bathrooms lacked hand soap, and residents reported that this had been an ongoing issue. Residents stated that they had repeatedly requested hand soap from staff but were ignored, and some mentioned that the soap had been removed due to a recall and was not replaced for an extended period. Residents affected were assessed as having no cognitive impairment and were able to articulate their concerns clearly. Staff interviews confirmed the absence of hand soap in the bathrooms, and it was acknowledged by both the Director of Nursing and the Maintenance Director that a soap recall had occurred months prior, but soap had not been replenished in a timely manner. The facility's own hand hygiene policy, which aligns with CDC guidelines, requires handwashing with soap and water, especially before eating and after using the toilet. The lack of hand soap in resident bathrooms directly contravened this policy and compromised infection control practices.
Failure to Initiate Discharge Planning Upon Resident Request
Penalty
Summary
The facility failed to initiate and follow through with discharge planning upon a resident's request, resulting in a deficiency. The resident, who was cognitively intact with a BIMS score of 15 and was at the facility for therapy, expressed a desire to either return home or transfer to another facility closer to family. Despite multiple requests made to different social workers, the resident did not receive any updates or assistance regarding his discharge or transfer options. The resident was capable of private pay for 24-hour nursing care at home and had a home environment suitable for his needs, but no progress was made toward facilitating his discharge or transfer. Documentation shows that a social worker met with the resident and acknowledged his request, but only provided supportive listening and did not take further action or make referrals to other facilities. The social worker documented the conversation but did not follow up or initiate the discharge process. The Social Service Director confirmed that no referrals had been made for the resident, and discharge planning had not started as required by facility policy, which mandates that discharge planning begin at admission and be reevaluated regularly. This lack of action resulted in the resident's needs and preferences for discharge not being addressed.
Improper Refrigeration of Medications Outside Required Temperature Range
Penalty
Summary
Surveyors identified a failure to maintain a medication refrigerator within the facility’s required temperature range for medications stored for four residents. During an observation of the 3rd floor medication refrigerator, the unit felt warm and the internal thermometer read 54°F. After the refrigerator door was closed and approximately 25 minutes passed, a recheck showed the internal temperature had increased to 60°F. The facility’s temperature log, provided by the DON, specified that the medication refrigerator temperature must be maintained between 36°F and 46°F, and staff interviewed acknowledged that medications such as unopened insulin pens, eye drops, and Trulicity should be stored within that 36–46°F range. At the time of the observation, the refrigerator contained an unopened Humalog Lispro insulin pen for one resident, an unopened Humalog insulin pen for another resident, Latanoprost 0.005% ophthalmic solution eye drops for a third resident, and a Dulaglutide (Trulicity) 1.5 mg/0.5 mL auto-injector for a fourth resident. The LPN present and the 3rd floor supervisor both confirmed that the refrigerator temperature was outside the acceptable range needed to maintain the effectiveness of these medications. Maintenance staff later stated that the refrigerator was not cooling due to excessive ice buildup, which resulted in the unit not functioning properly, but at the time of the surveyor’s observation, these medications remained stored in a refrigerator that was operating above the facility’s specified temperature parameters.
Failure to Perform Ongoing Assessment for Physical Restraint Use
Penalty
Summary
Surveyors identified a deficiency related to the use and assessment of a physical restraint for one resident. The resident was observed seated in a wheelchair in the hallway by the nurse’s station wearing a waist (lap) restraint attached to the wheelchair. Documentation showed a Physical Restraints Informed Consent dated 08/22/2024 indicating the lap restraint was used due to dementia, non-compliance with transfer status, impulsive behavior, and poor trunk control. A restraint assessment from the same date documented that the device prevented the resident from standing, transferring, or walking, met the definition of a restraint, and that the resident was unable to remove it independently, with staff responsible for removing it during ADLs. The Medication Administration Record for 08/2025 showed ongoing use of the waist restraint with instructions to check every two hours for skin integrity and circulation, marked as completed on all shifts from August 1 through August 11, 2025. Despite the ongoing use of the restraint, staff interviews and records revealed a lack of ongoing restraint assessments. The Restorative Nurse stated that restraint assessments should be completed annually and quarterly and that if the restraint is used for trunk support, the restorative nurse performs the assessment; however, the only restraint assessment available for this resident was dated 08/22/2024. The Falls/Psychotropic Nurse reported that the resident was a fall risk and that the restraint was used due to poor trunk support, but acknowledged having no restraint assessment or restraint reduction assessment for the resident. Additionally, the resident’s MDS dated 07/2025 indicated that physical restraints were not used, which conflicted with the observed and documented use of the lap restraint. The facility’s restraint policy, revised 07/03/25, stated that the use of the restraining device may be assessed and reduced at least quarterly, but there was no evidence of such ongoing assessments for this resident.
Failure to Provide Timely Incontinence Care and Grooming for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and grooming assistance to dependent residents. One resident who was nonverbal, on hospice, and required check-and-change incontinence care every two hours was observed lying in bed in urine-soaked linens for an extended period. Surveyors first observed a wet, yellow circle under the resident’s buttocks and feet at 9:48 AM, with a strong urine odor noted later, and the resident remained in the same wet position through at least 12:14 PM while being fed lunch in bed. The resident was not changed until 12:32 PM, at which time staff found the disposable brief, bed pad, and bottom sheet saturated with urine. The CNA assigned to the resident stated the resident was difficult to care for because she “be fighting,” although the resident did not resist care during the observed change. Documentation showed no urinary continence task entries for that day and indicated the last recorded change occurred the previous evening, despite the resident’s care needs and hospice status. Another resident with multiple sclerosis, morbid obesity, impaired mobility, neuromuscular bladder dysfunction, and no cognitive impairment reported being dependent on staff for toileting and always incontinent of bowel and bladder. This resident stated she wore two incontinence pads and sat on an additional pad in her chair because staff did not change her after she got up in the morning and that staff often told her they were busy or lacked help when she requested toileting. She reported remaining up for many hours without being changed and expressed a desire to be changed at least once after getting up. A third resident, a ventilator-dependent individual with severe intellectual disabilities and dependent on staff for ADLs, was observed with visible facial hair on the upper lip and chin, approximately 1/8 to 1/4 inch long, noticeable from halfway across the room. The resident’s guardian confirmed the resident was nonverbal, dependent on staff, and needed shaving, and facility records showed she was dependent on staff for shaving and did not reject care, with no documentation of care refusal in behavior tasks.
Failure to Provide Ordered Double Meal Portions Based on Resident Preference
Penalty
Summary
The facility failed to provide a resident with meals in accordance with his documented food portion preference for double portions. On 08/11/2025 at 10:26 AM, the resident reported he was always hungry after meals and stated he was supposed to receive double portions of food but was not getting them. The resident’s Order Summary Report dated 08/11/2025 showed an order for double portions of food. At 12:02 PM the same day, observation of the resident eating in his room showed his meal appeared to be the same size as a regular meal, and the meal ticket on his tray did not indicate that he was to receive double portions. At 12:30 PM, the Food Service Manager stated that if a resident was to receive double portions, this would be listed on the meal ticket, which is how the kitchen staff would know to serve double portions. On 08/12/2025 at 10:33 AM, the Dietitian confirmed the resident was to receive double portions based on his preference after he reported being hungry after meals, and clarified that the double portions were ordered as a preference and not as a weight management intervention.
Failure to Ensure Complete PPE Use for Resident on COVID-19 Isolation
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) protocols for a resident on COVID-19 isolation. On 08/11/2025 at 10:30 AM, a sign on the resident’s door indicated the resident was on isolation and required anyone entering the room to wear an N-95 mask, gloves, isolation gown, and eye protection. At 10:35 AM, a certified nursing assistant entered the resident’s room with linens wearing PPE but without any eye protection, and later exited the room with a clear bag of what appeared to be dirty linens. On 08/12/2025 at 10:58 AM, the infection control nurse confirmed the resident was on isolation for COVID-19 and stated that staff should wear an N-95 mask, gloves, isolation gown, and eye protection when entering the room. The resident’s Order Summary Report dated 08/12/2025 showed an order to maintain strict contact and droplet isolation at all times due to active COVID-19 infection, and the resident’s care plan initiated on 08/05/2025 included an intervention to use appropriate PPE. The facility’s policy on preventing and controlling acute respiratory illness outbreaks, revised 07/16/2025, also specified that required PPE for COVID-19 isolation included eye protection. This deficiency was based on observation, interview, and record review showing that staff did not fully comply with the posted isolation requirements, the resident’s physician orders and care plan, and the facility’s written infection control policy regarding PPE use for COVID-19 isolation.
Failure to Notify Family of Resident's Ventilator Use
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in condition, specifically when the resident was placed on a mechanical ventilator. The resident, a female with multiple diagnoses including chronic respiratory failure and congestive heart failure, was observed to have low oxygen levels. Despite being alert and oriented, the resident's family was not informed of the change in her condition until they visited the next day and saw her on the ventilator. The Registered Nurse (RN) involved did not notify the emergency contact, believing it was unnecessary due to the resident's cognitive status. The Respiratory Therapist (RT) noted that the resident was lethargic with oxygen levels in the 70s, requiring respiratory treatment and eventually placement on a mechanical ventilator. The facility's policy mandates immediate notification of the resident's legal representative or family member in such significant changes, but this was not followed. The Director of Nursing (DON) acknowledged the family's concerns about the lack of notification, indicating that the decision to inform the emergency contact was left to the resident, who was agreeable to the ventilator placement.
Failure to Follow Physician's Orders Leads to Resident's Death
Penalty
Summary
The facility failed to follow a physician's order to send a resident, who was experiencing hypoxia and difficulty breathing, to the hospital. This oversight led to the resident's condition deteriorating towards the end of the evening shift, eventually requiring cardiopulmonary resuscitation (CPR) and resulting in the resident's death in their room. The incident involved a registered nurse who provided the resident with a 100% non-rebreather mask due to low blood oxygen levels but did not follow the physician's order to send the resident to the hospital. The resident had a history of pleural effusion and episodes of shortness of breath with activity and changes in position. Despite the physician's order to send the resident to the hospital if they experienced difficulty breathing, the staff did not act on this directive. The resident's condition was further complicated by the use of a non-rebreather mask without a proper order, and the oxygen flow rate was not maintained at the necessary level to ensure adequate oxygenation. The physician was not informed of the results of a stat chest x-ray, which showed significant findings that could have warranted further action. The lack of communication and failure to follow the physician's orders contributed to the resident's decline and eventual death. The facility's policies on physician orders and oxygen therapy were not adhered to, resulting in a critical lapse in care for the resident.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to address and follow up on resident concerns brought forward in resident council meetings. During a resident council meeting held as part of the facility's Annual Certification Survey, several residents, including the resident council president and vice president, reported that they regularly voiced complaints at these meetings. However, they noted that there was little or no follow-up on their concerns, such as issues with late and missing medications, long wait times for call lights, and downgraded television service. The minutes from previous meetings did not document these concerns, and residents expressed frustration over the lack of communication regarding the resolution of their issues. The Activities Director, who attended the meetings and took minutes, acknowledged the importance of the grievance process but admitted not keeping track of follow-ups on grievances from the meetings. The Administrator also recognized the importance of the grievance process for both understanding resident issues and ensuring residents feel heard. Despite this acknowledgment, there was no evidence of a systematic approach to addressing and resolving the concerns raised during resident council meetings, as reflected in the absence of documented follow-up in the meeting minutes.
Infection Control Deficiencies in PPE Use and Isolation Precautions
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, particularly in the use of personal protective equipment (PPE) for residents under isolation precautions. In the case of a resident with severe cognitive impairment and multiple medical conditions, including a tracheostomy and g-tube, staff did not wear gowns while providing incontinence care, despite the resident being on enhanced barrier precautions. Additionally, staff failed to perform hand hygiene between glove changes, which is crucial to prevent cross-contamination. The resident's care plan and facility policy clearly indicated the need for gowns and gloves during high-contact activities, yet these protocols were not followed. Another incident involved a housekeeper who exited a resident's room wearing PPE, including gloves, gown, and mask, and walked down the hallway before removing the PPE. This action contradicts the facility's policy, which requires PPE to be removed before leaving an isolation room to prevent the spread of infections. The housekeeper acknowledged the mistake, attributing it to feeling unwell and disoriented at the time. Further deficiencies were observed with other residents who required enhanced barrier precautions due to medical devices like catheters and wounds. In one instance, a resident's room lacked appropriate signage and PPE containers, leading to staff providing care without gowns. Another resident, on contact isolation, was attended to by a nurse who failed to don a gown before entering the room. These lapses in protocol highlight a systemic issue in the facility's infection control practices, as staff did not consistently follow established guidelines for PPE use and hand hygiene.
Failure to Maintain Resident Dignity and Hygiene
Penalty
Summary
The facility failed to treat residents in a dignified manner, as evidenced by two separate incidents involving residents R147 and R457. For resident R147, who was admitted with multiple diagnoses including malignant neoplasms and severe protein calorie malnutrition, the deficiency was observed when a CNA, V19, was overheard speaking to R147 in a disrespectful manner. The CNA expressed impatience and a lack of empathy by stating that they had other residents to feed and pressured R147 to eat without considering the resident's dignity and need for privacy during meals. In the case of resident R457, who has severe cognitive impairment and is dependent on staff for all ADLs, the deficiency was noted when CNAs V11 and V12 failed to change the resident's soiled fitted sheet after an episode of vomiting. Despite being informed of the soiled linens, the staff left the room without addressing the issue, compromising the resident's dignity and comfort. This inaction was further compounded when a wound care nurse and CNA also neglected to change the soiled sheet, despite being notified by the surveyor. The Director of Nursing later acknowledged that sheets should be changed immediately when soiled, highlighting the facility's failure to uphold resident dignity and proper infection control practices.
Failure to Off-load Heels for Resident with Diabetic Wounds
Penalty
Summary
The facility failed to ensure that a resident's heels were off-loaded, as required for wound care management. On multiple occasions, a resident identified as R204 was observed lying in bed with his heels resting directly on the bed surface, without any off-loading devices such as boots or pillows in place. Despite the presence of gauze dressings on his feet and heels, the necessary off-loading to prevent pressure on his wounds was not implemented. Certified Nursing Assistants (CNAs) and a Registered Nurse (RN) acknowledged the need for off-loading but did not take action to elevate the resident's heels during care. The resident, R204, had multiple full-thickness diabetic wounds on his toes, feet, and heels, as documented by a Wound Care Physician's Note. The facility's Wound Care Guidelines required the use of supportive devices to off-load pressure from bony prominences, including the heels. However, the Point of Care Task documentation showed no record of heel protectors being applied or removed, indicating a lack of adherence to the prescribed wound care protocol. This oversight in care was observed over consecutive days, highlighting a deficiency in following the established wound care guidelines.
Failure to Provide Nectar Thick Liquids and Supervision
Penalty
Summary
The facility failed to ensure that a resident, identified as R4, received nectar thick liquids as required for her safety. R4, who has severe cognitive impairment and requires staff supervision for eating, was observed alone in her room drinking a liquid nutritional supplement from a straw and had a half-empty cup of water on her bedside table. Both drinks were not nectar thickened, contrary to her dietary requirements. Certified Nurse Aides (V5 and V10) confirmed that R4 needs thickened liquids to prevent aspiration due to her swallowing issues and should not be drinking regular consistency liquids without supervision. Further interviews with facility staff, including a Registered Nurse (V9) and the Director of Nurses (V2), revealed that R4 is confused, has behaviors, and is resistive to care. She requires mechanical soft foods and nectar thickened liquids to prevent swallowing problems. V2 emphasized that residents with aspiration precautions should be supervised with foods and liquids to prevent choking and aspiration. However, it was noted that the facility lacked a policy related to aspiration precautions or swallowing problems, contributing to the oversight in R4's care.
Deficiency in Catheter Care for a Resident
Penalty
Summary
The facility failed to ensure proper catheter care for a resident, leading to a deficiency. The resident was observed lying in bed on top of the indwelling urinary catheter tubing without a securement device in place. The catheter drainage bag was positioned above the level of the bladder, contrary to best practices that prevent backflow and potential infection. The resident's incontinence brief was open, and the catheter tubing was not cleaned during care, despite the resident being incontinent of a large bowel movement. Staff confirmed the absence of a securement device and acknowledged that the catheter tubing should be free of kinks to prevent backflow and infection. The resident, who has moderate cognitive impairment and is dependent on toileting hygiene, has a care plan indicating the need for catheter care every shift and positioning of the catheter bag below the bladder. The facility's policy requires the catheter bag to be positioned below the bladder to prevent backflow, but it does not explicitly mention keeping the tubing free of kinks. The resident's medical history includes conditions such as peripheral vascular disease, diabetes, and chronic kidney disease, which may increase the risk of complications from improper catheter care.
Failure to Ensure Accurate Weight Measurements
Penalty
Summary
The facility failed to ensure accurate weight measurements for two residents, leading to significant discrepancies in their recorded weights. One resident, who had multiple diagnoses including Parkinson's disease and major depressive disorder, experienced a significant weight loss over a few months. Despite receiving a regular diet with supplements and having good oral intake, the resident's weight dropped from 196 lbs to 169 lbs over three months. The dietitian noted the weight loss and intended to follow up, but a re-weigh was not conducted, and the process for obtaining and entering weights was inconsistent. Another resident, diagnosed with conditions such as schizophrenia and dementia, showed a significant weight gain of 20 lbs within five days. The resident had lymphedema, which could affect weight, but no re-weigh was conducted to verify the accuracy of the recorded weight. The facility's policy required monthly weights and assessment of significant weight changes by the interdisciplinary team, but this was not adhered to in these cases. Interviews with the dietitian and the Director of Nursing revealed issues with the process of obtaining and documenting weights. The dietitian typically communicated recommendations via email, but there was a lack of follow-up and oversight. The Director of Nursing indicated that weights should be rechecked if there is a significant change, but this protocol was not followed, leading to the deficiencies noted in the report.
Failure to Assess Dialysis Site for Resident
Penalty
Summary
The facility failed to obtain orders and assess a resident's dialysis site for a resident who requires dialysis services. The resident, identified as R56, has multiple diagnoses including end-stage renal disease and dependence on renal dialysis. Despite having a permacath on the right chest for hemodialysis, there were no physician's orders for the assessment of the permacath site in July 2024. This lack of orders resulted in the absence of consistent site assessments, as confirmed by the registered nurse and licensed practical nurse involved in the resident's care. The facility's policy requires that the condition of the hemodialysis site be assessed and recorded daily. However, the monitoring documentation for R56 showed no area for staff to document or be aware of the need to assess the permacath site. The Director of Nursing acknowledged that nurses should ensure the dressing is in place and the site is covered when the resident returns from dialysis, but there was no specific order in the resident's chart to guide this practice. This oversight led to a deficiency in providing safe and appropriate dialysis care for the resident.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to administer medications in a timely manner for two residents, leading to a missed dose and improper medication administration. For one resident, who had diagnoses including nontraumatic intracerebral hemorrhage and hypertension, the facility did not administer the first dose of Hydralazine at the scheduled time. The nurse manager was informed late, and the nurse practitioner was contacted to decide on the course of action, resulting in the decision to skip the second dose. The facility's policy requires adherence to medication pass procedures, which was not followed in this instance. In another case, a resident was administered an inhaler medication without being instructed to rinse their mouth afterward, as per the manufacturer's instructions. This step is crucial to prevent thrush, a fungal infection, especially when using inhaled steroids. The failure to follow these instructions was observed during medication administration, highlighting a lapse in the facility's adherence to proper medication administration protocols.
Failure to Provide Dietary Substitutions for Resident on Pureed Diet
Penalty
Summary
The facility failed to offer a dietary substitution to a resident, identified as R147, who was on a pureed diet due to multiple medical conditions including malignant neoplasm of the esophagus, dysphagia, and severe protein-calorie malnutrition. During an observation, R147 expressed dissatisfaction with the meal provided, stating it was cold and unappetizing, and mentioned a preference for previous meals like gravy and potatoes. The CNA, V19, confirmed that no substitutions were available for R147's pureed diet, indicating that the resident was limited to the menu items provided. The Director of Nursing, V2, acknowledged the resident's dislike for the pureed food and the potential impact of not offering substitutes, especially given R147's ongoing chemotherapy and associated nausea. The facility's policy, revised on 6/6/24, mandates offering food substitutes equivalent in nutritional value to the main meal, but this was not adhered to in R147's case. The failure to provide dietary alternatives as per the facility's policy and federal regulations resulted in a deficiency in meeting the nutritional needs and preferences of the resident.
Deficiencies in Shower Room and Resident Room Maintenance
Penalty
Summary
The facility failed to maintain the third-floor shower room in a safe, comfortable, and sanitary condition, affecting 53 residents who use this area. During an inspection, it was observed that water was steadily dripping from the ceiling grates in the shower room, and there was evidence of water damage and mold. The Maintenance Director, V4, was unaware of the source of the water and had not taken steps to address the issue, despite it being reported in the maintenance log eight days prior. The shower room was still in use, and no drying fans were present to mitigate the water damage. Additionally, there was a lack of documentation on the steps taken to address the leaks, and the maintenance department did not regularly inspect the shower rooms. A resident, R1, was found to have a missing air conditioning cover in their room, exposing pink insulation and other materials. R1, who has lung problems and uses humidified oxygen for a tracheostomy, expressed concern about the potential health risks of breathing in materials from the exposed wall. The Maintenance Director acknowledged the issue but stated that the maintenance department relies on staff to report such concerns and does not conduct regular inspections of the air conditioning units. The facility's maintenance policy requires that all equipment and the building environment be maintained by the maintenance department, with issues reported by staff to be addressed as soon as possible. However, the facility failed to adhere to this policy, as evidenced by the ongoing water leaks and the unresolved issue with R1's air conditioning unit. A request for the facility's Mold and/or Water Mitigation Policy was made but not received, indicating a potential gap in the facility's procedures for handling such issues.
Failure in Tracheostomy Care and Cross-Contamination Prevention
Penalty
Summary
The facility failed to provide tracheostomy care in a manner that prevents cross-contamination and did not complete the care as ordered for a resident. During an observation, a respiratory therapist (RT) donned protective gear to enter a resident's room, who had a tracheostomy attached to humidified oxygen. The RT removed the resident's inner cannula and placed it on the bed, then used the same soiled gloves to handle a new inner cannula and continued the procedure without changing gloves. The RT placed soiled supplies directly on the resident's bed and did not use a drape from the trach care kit, increasing the risk of cross-contamination. The RT acknowledged that gloves should be changed when dirty and that trach treatments should be documented in the Respiratory Record. The resident had multiple diagnoses, including chronic respiratory failure and chronic obstructive respiratory disease, and was cognitively intact. The facility's guidelines required tracheostomy care every shift and as needed, with specific procedures for maintaining cleanliness and documenting care. However, the care was not completed as ordered on several days, and the RT did not follow the facility's guidelines for disposing of soiled supplies and maintaining a clean environment during the procedure. Another RT confirmed that the observed procedure was not conducted properly and emphasized the importance of moving from clean to dirty tasks to reduce infection risk.
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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