Alta Rehab At Oak Brook
Inspection history, citations, penalties and survey trends for this long-term care facility in Oak Brook, Illinois.
- Location
- 2013 Midwest Road, Oak Brook, Illinois 60521
- CMS Provider Number
- 145458
- Inspections on file
- 46
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Alta Rehab At Oak Brook during CMS and state inspections, most recent first.
A resident with severely impaired cognition had her pubic hair shaved by CNAs after a family member allegedly requested this care, but the designated Healthcare Power of Attorney (HCPOA) was not informed or asked for consent. The resident later indicated she did not want to be shaved, and the HCPOA reported never authorizing this care and stated she would personally trim hair if needed. One family member denied ever requesting shaving, while staff reported that this family member had requested it on multiple occasions. Facility leadership acknowledged that staff were expected to consult the HCPOA for special care requests outside typical services, but this did not occur, resulting in care being provided without appropriate authorization.
A resident with significant mobility impairments and a history of fractures was transported in a wheelchair with only one footrest, leaving one leg unsupported. During transport, the unsupported leg was caught under the wheelchair, causing an acute fracture. Staff proceeded with transport despite being unable to locate the missing footrest, directly leading to the injury.
A resident with severe cognitive impairment and multiple comorbidities was dropped from a mechanical lift during a transfer when only one staff member assisted and the sling was not properly applied, resulting in a fractured ankle and hospitalization.
A resident's representative was not given accurate information about the process for authorizing an electronic monitoring device in the resident's room. Facility staff, including the DON and RN Supervisor, miscommunicated the facility's policy by stating cameras were not allowed, despite the admission contract permitting them if legal steps were followed. This resulted in miscommunication and lack of informed consent regarding the resident's rights.
A resident with multiple medical conditions and significant skin wounds did not have a grievance regarding poor wound care properly identified, documented, or addressed according to facility policy. The resident's spouse reported concerns about wound management to the Social Service Director, but these concerns were not communicated to administration or recorded in the grievance log, resulting in a lack of investigation or resolution.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as identified by surveyors through observation and record review.
Surveyors found that the facility did not maintain an area free from accident hazards and failed to provide adequate supervision to prevent accidents, resulting in a deficiency.
The facility failed to provide adequate ADL care for residents needing assistance with toileting, repositioning, and bathing. Residents with severe cognitive impairments were left in soiled incontinence briefs and not repositioned as required, leading to potential skin breakdown. Staff interviews and grievances highlighted systemic issues with delayed response times and inadequate assistance, contributing to the deficiency.
A resident with multiple diagnoses was not promptly assessed for injury after an incident with a mechanical lift. Despite complaints of severe pain, the facility failed to document vital signs, range of motion, or pain level, and did not notify the physician or family. The resident was later diagnosed with a deep vein thrombosis after being sent to the emergency department.
The facility failed to provide timely care for two residents with indwelling urinary catheters. One resident experienced a leaking catheter that was not changed promptly, resulting in prolonged exposure to wetness and a pressure ulcer. Another resident's catheter was not changed monthly as ordered by the physician, despite a history of UTIs. The facility's policies on catheter care were not followed, leading to inadequate care.
A resident with severe cognitive impairment and multiple diagnoses was transferred using a mechanical lift by a CNA without the required two-person assistance, leading to the resident sliding out of the lift and sustaining a skin tear. The facility's policy mandates two caregivers for such transfers, but the CNA did not follow this protocol, resulting in the incident.
A resident with hypertension and chronic back pain did not receive prescribed antihypertensive and pain medications at an LTC facility. Despite the medications being delivered, they were not administered, leading to elevated blood pressure and the resident leaving against medical advice. The facility's policy requires documentation of medication administration, which was not followed.
The facility failed to provide adequate feeding assistance to a male resident with cervical spine myelopathy, despite a physician's order for one-to-one feeding. The dietary card did not reflect this requirement, leading to the resident eating without assistance. Additionally, a female resident experienced significant delays in receiving incontinent care, resulting in her being left in a urine-soaked brief. Staff acknowledged the oversight and delay in care.
The facility failed to resolve resident grievances and provide adequate care, as evidenced by three residents experiencing inadequate incontinence care, delayed call light responses, and missed showers. Despite grievances being filed and discussed in Resident Council meetings, the facility did not address these issues within the required timeframe, leading to deficiencies in care.
The facility failed to develop and implement resident-centered care plans for three residents, leading to deficiencies in care. A resident was found in a wet incontinence brief that had not been changed for several hours, and her care plan lacked specific interventions for her needs. Another resident was observed with a soaked incontinence brief and stool caked on her skin, and her care plan did not include necessary interventions for feeding assistance or communication strategies. A third resident was left sitting in the dining room for an extended period without being checked for incontinence, resulting in a pressure ulcer. The facility's failure to provide detailed and individualized care plans resulted in inadequate care and unmet needs.
The facility failed to provide timely care and assistance to three residents, including delayed response to call lights, inadequate incontinence care, and lack of feeding assistance. One resident was left in a wet brief for hours, another was found soaked in urine and without feeding help, and a third had a pressure ulcer with no dressing. Documentation showed inconsistencies in providing scheduled showers and hair shampooing.
A resident at high risk for pressure ulcers experienced delayed wound care due to the facility's failure to promptly report and assess a new sacral wound. The wound care nurse discovered the wound had progressed to a stage 4 ulcer with muscle and bone exposure. Despite the CNA reporting the wound in February, the wound care coordinator was only notified on February 27, 2024, with no prior documentation of care initiation. The facility's policy for immediate reporting and assessment was not followed, leading to the wound's deterioration.
The facility failed to maintain food safety and sanitation standards, risking foodborne illnesses. Observations revealed grease-covered vent covers, a dirty meat slicer, and expired food items in refrigerators. The dietary manager admitted to not maintaining sanitizing logs and using the same sanitizer for different purposes without proper documentation. Additionally, the manager did not perform hand hygiene before checking food temperatures, and the facility lacked a policy for kitchen staff hygiene.
The facility failed to ensure call lights were within reach for two residents, one with right-sided hemiplegia and another who was cognitively intact but required assistance. Despite care plans and facility policy, staff left call lights out of reach, confirmed by interviews with staff and the DON.
The facility failed to reassess a resident with a hand wound for an appropriate-fitting device and did not implement skin prevention interventions for a resident with a scratching behavior. Additionally, an LPN did not follow proper procedures for checking blood glucose levels, using the first drop of blood instead of the second. These deficiencies affected two residents with complex medical histories, including dementia and diabetes.
A resident with multiple health conditions experienced a decline in range of motion due to the facility's failure to provide appropriate restorative care. The resident's care plan lacked a hand splint, and assessments were not properly documented or followed. Restorative services were inconsistently provided, contributing to the resident's contracted hand and inability to extend fingers.
The facility failed to act on pharmacy MRRs and provide documentation for two residents, leading to delayed or missing physician responses to medication recommendations. One resident, with multiple diagnoses including dementia and a history of falls, had several pharmacy recommendations for medication adjustments that were not timely addressed. Another resident, with depression and bipolar disorder, also experienced delays in addressing pharmacy recommendations for antipsychotic use. The facility's inability to provide complete MRR documentation indicates a systemic issue in medication management.
A resident with type 2 diabetes was administered 25 units of Humalog insulin by an LPN without priming the insulin pen, contrary to the facility's procedure. The LPN, another LPN, and the DON all acknowledged the requirement to prime the pen with two units of insulin to ensure proper function. The resident had a physician's order for daily insulin administration.
A resident requiring new dentures did not receive necessary dental services due to a lack of follow-up by the facility. Despite requests from the resident's family and notes from a dental hygienist, no dentist evaluated the resident. The facility's dental program, which should have provided free services to Medicaid recipients, was not effectively communicated or utilized, leading to the resident remaining on a mechanical soft diet due to ill-fitting dentures.
A facility failed to obtain an appropriate arbitration agreement from a resident with dementia, who was severely cognitively impaired. Despite the facility's policy requiring agreements to be obtained from a representative in such cases, the resident signed the agreement. Staff interviews confirmed the resident's inability to make decisions, highlighting a lapse in following the facility's policy on resident rights.
The facility failed to ensure that residents' rooms were located at or above ground level, affecting 25 residents who were observed residing on a lower-level floor below ground. The Regional Administrator acknowledged the noncompliance and admitted that the facility had not obtained a building waiver for these rooms.
The facility failed to implement pressure injury prevention strategies for a resident with advanced dementia, who was observed without the prescribed off-loading boots while in bed, despite a physician's order. This contributed to a deficiency in pressure injury prevention and treatment.
Failure to Obtain HCPOA Consent for Atypical Personal Care
Penalty
Summary
The deficiency involves the facility’s failure to inform and obtain consent from a resident’s Healthcare Power of Attorney (HCPOA) before providing atypical personal care. The resident’s MDS documented severely impaired cognition, and the HCPOA (V4) later filed a grievance stating that the resident’s pubic hair had been shaved by a CNA without permission. During an examination with the DON (V2) and restorative staff (V17), the resident’s pubic area appeared recently shaved with approximately 1/4 inch hair regrowth. When asked, the resident indicated awareness that her pubic area had been shaved and indicated she did not want to have been shaved. Staff interviews revealed that a CNA (V5) reported a family member (V7) requested that the resident’s pubic hair be shaved so the resident would be “nice and clean,” and another CNA (V11) confirmed it was clear to them that V7 made this request. V5 stated she obtained razors and shaved the resident’s pubic area while V7 was out of the room. An LPN (V12) also stated that V7 had previously asked her to shave the resident’s pubic hair. V7, however, denied ever asking staff to shave the resident’s pubic hair and stated she knew only the HCPOA (V4) could make such care decisions. V4 stated she had never given permission for staff to shave the resident’s pubic hair and that, if trimming were needed, she would do it herself. Facility leadership (V2 and V14) stated staff were expected to check with the HCPOA before providing any special care requests outside typical services, consistent with the facility’s Resident Rights policy, but this did not occur in this case.
Failure to Provide Proper Foot Support During Wheelchair Transport Resulting in Fracture
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including multiple sclerosis, spastic hemiplegia, paraplegia, prior femur fractures, diabetes, and dementia, was transported in a wheelchair without proper foot support. The resident required extensive assistance with activities of daily living and was dependent on staff for lower body mobility and transfers. During transport from the therapy room to the resident's room, only one footrest was attached to the wheelchair, leaving the resident's left leg unsupported. As a result of the missing footrest, the resident's left leg was abruptly placed on the floor and became caught under the wheelchair, leading to an acute nondisplaced fracture of the proximal left tibia. Staff reported that they were unable to locate the second footrest but proceeded with the transport regardless, which directly resulted in the injury. The incident was confirmed through staff interviews, medical record review, and diagnostic imaging.
Resident Injury Due to Improper Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dementia, atrial fibrillation, congestive heart failure, and pain, who was admitted to hospice care, was transferred using a mechanical lift by only one staff member. The resident's care plan required two staff members to assist with mechanical lift transfers, and the facility's policy also mandated two caregivers for such transfers. During the transfer, the staff member did not properly apply the sling, resulting in the resident being dropped from the lift. As a result of this improper transfer, the resident sustained a displaced fracture to the distal tibia and fibula and required hospital evaluation and treatment. Documentation in the electronic medical record, progress notes, and incident report confirmed that the transfer was performed by a single staff member and that the sling was not adequately secured, directly leading to the resident's fall and injury.
Failure to Provide Accurate Information on Electronic Monitoring Rights
Penalty
Summary
The facility failed to provide accurate information to a resident's representative regarding the authorization and process for installing an electronic monitoring device in the resident's room, resulting in miscommunication and lack of informed consent related to resident rights. The resident in question was admitted with multiple diagnoses, including muscle wasting, COPD, acute bronchitis, and COVID-19, and was noted to be alert and oriented to person and place, but with moderate impairment in decision-making and episodes of confusion. The resident's daughter, who held Power of Attorney, requested to install a video surveillance camera in the resident's room and was initially told by the RN Supervisor, based on information from the DON, that cameras were not allowed in resident rooms according to facility policy. The admission contract, however, stated that video cameras are prohibited in resident rooms unless the resident or representative follows steps outlined under Illinois law, which includes notifying the facility and obtaining necessary consents. The admission assistant discussed this policy with the resident and the daughter, and the contract was signed, with the daughter acknowledging that cameras could be allowed if procedures were followed. Despite this, the RN Supervisor continued to inform the family that cameras were not permitted, based on the DON's interpretation of the policy, which overlooked the exception allowing cameras if legal steps were followed. The DON later admitted that she had focused only on the prohibition statement in the contract and did not notice the clause allowing cameras under certain conditions. There was no direct communication between the DON and the resident's representative regarding the request, and the family was not provided with accurate or complete information about the process for authorizing electronic monitoring, leading to confusion and a lack of informed consent regarding the resident's rights.
Failure to Identify and Address Grievance Regarding Wound Care
Penalty
Summary
The facility failed to identify, document, and address a grievance in accordance with its policy for a resident who was admitted following a fall and had multiple complex medical conditions, including dementia, repeated falls, ataxia, diabetes, COPD, cirrhosis, malnutrition, and depression. Upon admission, the resident had several skin impairments, including a left elbow skin tear, a deep tissue injury to the sacrum, and a bruise to the left hip, as well as multiple bruises and scabbing on various parts of the body. Facility-acquired skin tears were later documented on the shoulders, right forearm, and head. On one occasion, the Wound Care Nurse observed significant bloody drainage from a right forearm wound but did not notify the physician or Nurse Practitioner despite the change in wound status. The resident's spouse voiced concerns to the Social Service Director about poor wound care, specifically mentioning dried blood leaking through the resident's shirt and subsequently requested a transfer to another facility. The Social Service Director acknowledged not reporting this grievance to the Administrator or Assistant DON. There was no documentation in the facility's grievance records that the spouse's concerns were reported, investigated, or resolved. Both the Administrator and Assistant DON confirmed they had not received any report of a grievance related to the resident's wound care. The facility's grievance policy requires prompt resolution of all grievances related to care and treatment, but this process was not followed in this case.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of records, which showed that care provided did not align with the documented orders or the expressed wishes and objectives of the resident. Specific details regarding the actions or omissions that led to this deficiency, as well as information about the resident’s medical history or condition at the time, were not provided in the report.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. This deficiency was identified based on observations and findings by surveyors, indicating that the environment posed risks for accidents and that supervision measures in place were insufficient to prevent such incidents. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Adequate ADL Care
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for residents requiring assistance with toileting, repositioning, and bathing. This deficiency was observed in all 16 residents reviewed for ADL care. Residents with severe cognitive impairments and physical limitations were left without necessary assistance, leading to prolonged periods in soiled incontinence briefs and lack of repositioning, which are critical for preventing skin breakdown and maintaining dignity. One resident, diagnosed with Alzheimer's disease and other cognitive impairments, was observed sitting in a wheelchair for over three hours without having her incontinence brief checked or changed, despite being incontinent of bowel and bladder. Another resident, dependent on staff for transfers and toileting, was left in a wheelchair for over two hours without repositioning or incontinence care. Similar neglect was noted for other residents, including one with a pressure injury related to immobility, who was not toileted or repositioned for extended periods. The facility's incontinence care policy mandates checking and changing incontinence briefs every two hours, yet staff interviews revealed that this protocol was not consistently followed. Multiple grievances from residents and their families highlighted ongoing issues with delayed response times to call lights, inadequate assistance with toileting, and missed showers. These grievances, along with resident council meeting minutes, underscored systemic problems in staffing and resource availability, such as the need for additional mechanical lifts, contributing to the deficiency in care.
Failure to Assess Resident After Mechanical Lift Incident
Penalty
Summary
The facility failed to promptly assess a resident for injury following an incident during a transfer with a mechanical lift. The resident, who had multiple diagnoses including drug-induced polyneuropathy, sepsis, and atrial fibrillation, was cognitively intact and dependent on staff for all activities of daily living, including transfers. During a transfer using a sit-to-stand lift, the resident let go of the machine handles, resulting in an abrasion and redness on the left arm. Despite the resident's complaints of severe pain, the facility did not document a comprehensive assessment, including vital signs, range of motion, or pain level, nor did they notify the resident's physician or family. The incident report and subsequent documentation by facility staff, including a CNA, LPN, and WCN, lacked detailed assessments of the resident's condition following the incident. The LPN and WCN did not assess or document the resident's pain level or range of motion, and the incident report did not include vital signs or a detailed description of the injury. The facility's Director of Nursing acknowledged the lack of documentation and assessment, stating that the resident should have been assessed for pain and other vital signs following the incident. The resident was later seen by a Nurse Practitioner who noted swelling, erythema, and severe pain in the left arm, leading to orders for a Doppler ultrasound and X-ray. The resident's spouse requested a quicker evaluation, resulting in the resident being sent to the emergency department. Hospital records confirmed a diagnosis of left upper extremity deep vein thrombosis. The facility's policy on accidents and incidents requires prompt investigation and documentation, which was not adhered to in this case.
Deficiencies in Catheter Management for Two Residents
Penalty
Summary
The facility failed to ensure timely care for residents with indwelling urinary catheters, leading to deficiencies in catheter management for two residents. One resident, R2, experienced a leaking catheter that was not addressed promptly. Despite reporting the issue to multiple staff members, the catheter was not changed until several days later, resulting in the resident lying in a wet bed with a significant pressure ulcer. The facility documentation shows that the catheter was noted to be leaking on January 31, 2025, but it was not replaced until February 2, 2025. This delay in care was acknowledged by the Director of Nursing, who had instructed staff to change the catheter, but the instructions were not followed in a timely manner. Another resident, R4, had an indwelling urinary catheter that was not changed monthly as per the physician's documented orders. The resident had a history of multiple urinary tract infections (UTIs) and was hospitalized due to a UTI and altered mental status. The physician had repeatedly documented the need for monthly catheter changes, but the facility failed to provide documentation that these changes were carried out as ordered. The physician expressed that it was his expectation for the catheter to be changed monthly, which was communicated to the nursing staff. The facility's policies on equipment replacement and urinary catheter care were not adhered to, contributing to the deficiencies observed. The policies outlined conditions under which catheters should be changed, including physician orders, but these were not followed in the cases of R2 and R4. The lack of timely catheter changes and adherence to physician orders resulted in inadequate care for the residents, as evidenced by the documented events and interviews with staff and family members.
Failure to Follow Transfer Protocols with Mechanical Lift
Penalty
Summary
The facility failed to ensure that a resident was transferred with the assistance of two people while using a mechanical lift, as required by the facility's policy. This deficiency was observed during the transfer of a resident who has severe cognitive impairment and multiple diagnoses, including dementia and agitation. The resident requires substantial assistance for various activities, including transfers, and is dependent on staff for these tasks. The care plan for the resident clearly states that transfers should be conducted with a total body mechanical lift and two-person assistance. On a specific occasion, a CNA attempted to transfer the resident alone, resulting in the resident sliding out of the mechanical lift and sustaining a skin tear on the left lower extremity. The incident occurred because the CNA did not request assistance from another staff member, contrary to the facility's guidelines. The Director of Nursing confirmed that the CNA was aware of the protocol but failed to adhere to it, leading to the resident's fall and injury.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility failed to administer prescribed antihypertensive and pain medications to a resident with multiple diagnoses, including hypertension and chronic back pain, following a recent back surgery. The resident was admitted to the facility and had physician orders for Gabapentin and Losartan Potassium-HCTZ, which were not administered as scheduled. The medications were delivered to the facility, but the nursing staff did not administer them, leading to the resident's elevated blood pressure and subsequent distress. On the morning of the resident's discharge, the resident expressed frustration over not receiving her medications, which was documented by an LPN. The resident's blood pressure was recorded as high, and the attending physician was notified. The physician ordered alternate medications to be administered immediately, but there is no documentation in the EMAR that these alternate medications were given. The resident eventually left the facility against medical advice. The Director of Nursing confirmed that the medications were delivered but not administered, and the facility's policy requires that the MAR be used during medication administration. The attending physician emphasized the significance of the medications, noting that their omission could lead to significant results. The failure to administer the medications as prescribed and document their administration constitutes a significant medication error.
Failure to Provide Adequate ADL Assistance and Timely Incontinent Care
Penalty
Summary
The facility failed to provide adequate feeding assistance to a male resident with cervical spine myelopathy, who was admitted with a physician's order for one-to-one feeding due to his arm weakness. Despite the order being in place since mid-October, the dietary card did not reflect this requirement, leading to the resident having to eat without assistance, which he described as akin to eating like a dog. The oversight was confirmed by multiple staff members, including CNAs and the Dietary Manager, who acknowledged the absence of the one-to-one feeding instruction on the dietary card. The Director of Nursing also confirmed that the staff should have adhered to the physician's order for feeding assistance. Additionally, the facility failed to provide timely incontinent care to a female resident who was dependent on assistance for toileting hygiene and repositioning in bed. The resident reported significant delays in receiving care, including a delay from 3:00 AM to 4:45 AM for a brief change. Observations confirmed that the resident was left in a urine-soaked brief with stained linens. The staff, including the Wound Care Nurse and the assigned CNA, acknowledged the delay in providing care. The Director of Nursing stated that incontinent care should have been offered without delay when requested by the resident.
Failure to Resolve Resident Grievances and Provide Adequate Care
Penalty
Summary
The facility failed to honor residents' rights to voice grievances without discrimination or reprisal and did not establish a grievance policy to resolve grievances promptly. This deficiency was observed in the care of three residents who required assistance with Activities of Daily Living (ADLs). The facility did not provide adequate incontinence care, timely response to call lights, or scheduled showers as per their policy. For instance, one resident was found in a wet incontinence brief and bed sheets, with no record of receiving scheduled showers or hair washing. Another resident, who was dependent on staff for all ADLs, was found with a soaked incontinence brief and stool caked on her skin, despite a grievance being filed by her family weeks earlier. The facility lacked documentation of providing the resident with scheduled showers. Additionally, a third resident was left in a wheelchair without incontinence checks, resulting in a pressure ulcer on her sacrum. A grievance had been filed by the resident's family regarding similar issues, but no resolution was documented. The Resident Council meeting minutes revealed ongoing concerns about call light response times, incontinence care, and the behavior of Certified Nursing Assistants (CNAs), particularly agency CNAs. Despite these grievances being discussed in meetings, the facility did not resolve the issues within the timeframe outlined in their grievance policy. The facility's failure to address these grievances in a timely manner contributed to the deficiency in care provided to the residents.
Deficiencies in Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement resident-centered care plans for three residents, leading to deficiencies in care. Resident 1 (R1) was found in a wet incontinence brief that had not been changed since 2:00 AM, despite being dependent on staff for toilet hygiene and other activities of daily living (ADLs). The care plan for R1 lacked specific interventions for her needs, such as the requirement for bed baths due to the absence of a suitable shower chair. Additionally, the care plan did not specify the amount of assistance needed for ADLs, and the green care card in R1's room did not detail her specific care needs. Resident 2 (R2) was observed with a soaked incontinence brief and stool caked on her skin, indicating a lack of timely incontinence care. R2's care plan did not include necessary interventions for her one-to-one feeding assistance, specific transfer methods, or communication strategies for her unclear speech. The care plan also failed to address R2's dietary needs and the assistance required for eating, despite her dependence on staff for all ADLs and her moderate cognitive impairment. Resident 3 (R3) was left sitting in the dining room for an extended period without being checked for incontinence, resulting in a pressure ulcer. R3's care plan did not specify the type of assistive mobility device needed, nor did it address her incontinence issues or communication needs due to her lack of speech. The facility's failure to provide detailed and individualized care plans for these residents resulted in inadequate care and unmet needs, as confirmed by staff interviews and record reviews.
Deficiencies in Resident Care and Assistance
Penalty
Summary
The facility failed to promptly respond to call lights and provide timely incontinence care, feeding assistance, and showers/bed baths as per their policy for three residents. Resident 1, who was admitted with multiple diagnoses including lymphedema, hypertension, and morbid obesity, was found in a wet incontinence brief that had not been changed since 2:00 AM. The resident's call light was illuminated for over 26 minutes before staff responded. The facility lacked appropriate equipment to provide showers for Resident 1 due to her obesity, and documentation showed inconsistencies in providing scheduled showers and hair shampooing. Resident 2, with diagnoses including metabolic encephalopathy and hemiplegia, was found in a wheelchair with soaked pants and a strong urine odor. The CNA assigned to her care admitted to not checking her incontinence brief since 9:30 AM. Additionally, Resident 2 was observed attempting to feed herself without assistance, despite having an active order for 1:1 feeding assistance. Documentation also showed a lack of hair shampooing during the 30-day review period. Resident 3, who has multiple diagnoses including metabolic encephalopathy and UTI, was observed sitting in the dining room for over two hours without being checked for incontinence. When finally attended to, stool was found in her incontinence brief, and a pressure ulcer was visible on her sacrum without a dressing. The facility's policies on call light response, bathing, and incontinence care were not adhered to, as evidenced by the ongoing issues discussed in Resident Council meetings and concern forms submitted by family members.
Delayed Reporting and Treatment of Pressure Ulcer
Penalty
Summary
The facility failed to report, assess, and obtain treatment orders for a resident identified with a new wound before it became unstageable. This resulted in delayed wound care and deterioration of the wound for the resident, who was at high risk for pressure ulcers due to multiple health conditions including encephalopathy, malnutrition, and dementia. The resident required substantial to maximal staff assistance with personal hygiene and bed mobility, and had a history of skin alterations. The wound care nurse discovered the resident's sacral wound had muscle and bone exposed, with significant slough tissue, indicating a stage 4 pressure ulcer. The certified nurse assistant reported noticing a small open area on the resident's sacrum in February, which was reported to the nurse on duty. However, the wound care coordinator was only notified of the wound on February 27, 2024, and found no documentation of the wound's identification or initiation of care prior to this date. The wound physician managing the resident's care noted the resident was at risk for pressure ulcers due to immobility, incontinence, poor nutrition, and dependency on staff for repositioning. The facility's policy required immediate reporting and assessment of new skin alterations, but this was not followed, leading to the wound's deterioration. The resident's care plan included interventions for skin integrity, but the lack of prompt reporting and treatment initiation contributed to the wound becoming unstageable.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to maintain proper food safety and sanitation standards, which could lead to foodborne illnesses. During a kitchen tour, it was observed that the vent covers over the stove were covered with grease and lint/dust, and the meat slicer had smears of grease and crust on its base. The dietary manager admitted that testing logs for sanitizing buckets were not maintained, and the same sanitizer used for the three-compartment sink was also used for disinfecting buckets without proper documentation of its concentration or contact time. The facility's policy did not specify the frequency of testing or documentation for the dishwasher, three-compartment sink, or sanitization buckets, nor did it document the disinfecting product used. Additionally, expired food items were found in various refrigerators, including expired orange juice concentrate, milk, applesauce, and sour cream. Some items were not labeled or dated, contrary to the facility's signage that stated items should be discarded after three days or if they lacked information. The dietary manager acknowledged that expired food might be overlooked and served to residents. Furthermore, the dietary manager was observed not performing hand hygiene before conducting food holding temperatures, and the facility did not provide a policy for kitchen staff hand hygiene and head coverings.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to ensure that residents' call lights were placed within reach, affecting two residents assessed for accommodation of needs. One resident, who had right-sided hemiplegia and other medical conditions, was found with her call light out of reach on multiple occasions. Despite having a care plan that specified the call light should be accessible on her left side, staff repeatedly left the call light behind her bed or chair, making it inaccessible. Interviews with staff confirmed that the call light should be placed within reach of the resident's functional side, yet this was not consistently done. Another resident, who was cognitively intact but required assistance for various activities, also had her call light placed out of reach. The call light was left behind her on the bed while she was in a wheelchair, preventing her from reaching it. The facility's policy stated that call lights should be accessible to residents at all times, but this was not adhered to, as confirmed by the Director of Nursing and other staff members.
Deficiencies in Wound Care and Blood Glucose Monitoring
Penalty
Summary
The facility failed to reassess a resident, R61, for an appropriate-fitting device despite having a hand wound. R61, who had multiple diagnoses including encephalopathy, dementia, and anxiety, was dependent on staff for activities of daily living. Observations revealed that R61 had a contracted left hand with a wound between the first and second fingers, and was using a palm protector device with a finger separator strap, which was not reassessed despite the presence of the wound. The wound care nurse and restorative nurse were unaware of the wound and the inappropriate use of the device, indicating a lack of communication and reassessment. Additionally, R61's care plan included interventions for skin impairment and behaviors such as scratching, but these were not effectively implemented, as evidenced by untrimmed fingernails and the absence of protective gloves. The facility also failed to ensure proper skin prevention interventions for R61, who had a known behavior of scratching. The wound care coordinator noted that R61's plan of care included keeping nails trimmed, applying gloves, and monitoring for scratching, but these measures were not consistently followed. R61 was observed with untrimmed nails and without gloves, contributing to self-inflicted injuries. The facility's policies on pressure injury and skin condition assessment, as well as restorative services, were not adequately followed, leading to the oversight in reassessing the appropriateness of the contracture device and implementing preventive measures. Additionally, the facility failed to adhere to proper procedures for checking blood glucose levels for another resident, R58. An LPN was observed testing R58's blood glucose using the first drop of blood, contrary to the procedure of wiping the first drop and testing the second to avoid alcohol contamination. This was confirmed by the LPN and the Director of Nursing, who stated the expectation to follow the correct procedure. R58 had a history of type 2 diabetes mellitus and was on a physician-ordered regimen for blood glucose monitoring and insulin administration, highlighting the importance of accurate testing procedures.
Failure to Prevent Decrease in Range of Motion for Resident
Penalty
Summary
The facility failed to prevent a decrease in range of motion for a resident, identified as R36, who was admitted with multiple diagnoses including acute kidney failure, dementia, and poly-osteoarthritis. Upon observation, R36 was found with a contracted left hand and was unable to extend her fingers. The resident reported not having a splint for her hand, and the Certified Nursing Assistant confirmed that a hand splint was not included in her care plan. The Restorative Nurse acknowledged that R36 should have undergone an Occupational Therapy (OT) and Physical Therapy (PT) assessment upon admission to guide her care, but there was no documentation of contractures at that time. The Restorative Aide, responsible for documenting changes, stated that R36 was supposed to receive restorative services three times a week, but these sessions were sometimes missed due to staffing issues. The Director of Rehab Services was unable to access R36's OT and PT assessments, and the Occupational Therapist evaluated R36 during the survey, noting tightness and decreased ability to extend her fingers. The resident's care plan indicated a need for restorative nursing and active range of motion exercises, but there was no completed and signed restorative nurse assessment since February. The facility's policies required services to be provided according to assessment results and care plans, but these were not adequately followed, leading to the resident's decline in range of motion.
Failure to Act on Pharmacy Medication Regimen Reviews
Penalty
Summary
The facility failed to act on the pharmacy Medication Regimen Review (MRR) and provide documentation of monthly MRRs for two residents, R44 and R52, out of a sample of 23. For R44, the pharmacist made several recommendations regarding the resident's medication regimen, including requests for gradual dose reductions (GDR) and stop dates for certain medications. However, these recommendations were not consistently addressed by the physician or prescriber, with some responses delayed by months or not provided at all. Additionally, the facility was unable to provide documentation of MRRs for several months, indicating a lack of consistent review and action on pharmacy recommendations. R44, who has multiple diagnoses including dementia, psychosis, and a history of falls, was on psychotropic therapy with medications such as Mirtazapine, Quetiapine, and Lorazepam. The pharmacist highlighted potential risks associated with these medications, such as increased fall risk, and recommended reevaluation and dose adjustments. Despite these recommendations, there was a lack of timely physician response, and the facility did not document MRRs for several months, failing to ensure appropriate medication management for R44. Similarly, for R52, the facility did not provide complete documentation of MRRs, and there were delays in addressing pharmacy recommendations. R52, with diagnoses including depression, bipolar disorder, and a history of falls, was prescribed multiple antipsychotics. The pharmacist recommended reviewing the use of these medications due to potential side effects, but the physician's response was delayed. The facility's failure to provide complete MRR documentation and timely responses to pharmacy recommendations indicates a systemic issue in managing medication regimens for residents.
Failure to Prime Insulin Pen Before Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the improper administration of insulin to a resident. On July 17, 2024, an LPN was observed administering 25 units of Humalog insulin to a resident without priming the insulin pen, which is a necessary step to remove air bubbles and ensure the needle is functioning properly. The LPN acknowledged the need to prime the pen before administration, as did another LPN and the Director of Nursing, who confirmed that the procedure requires priming with two units of insulin. The resident involved had a medical history including type 2 diabetes mellitus, generalized osteoarthritis, hypertension, asthma, pain, low back pain, tremors, and repeated falls, and had a physician's order for Humulin KwikPen to be administered daily. The facility's insulin pen procedure, reviewed in August 2020, clearly stated the requirement to prime the pen before each injection.
Failure to Provide Necessary Dental Services
Penalty
Summary
The facility failed to provide necessary dental services to a resident who required new dentures. The resident, who had a history of hemiplegia, dysphagia, and dementia, was on a mechanical soft diet due to ill-fitting dentures. Despite the resident's family requesting a dental evaluation and the dental hygienist noting the need for better-fitting dentures, no dentist visited the resident. The dental hygienist's notes indicated that the family requested a dentist to evaluate and possibly make new dentures, but the facility did not follow up on this request. The facility's dental program, which was supposed to provide free dental services to eligible Medicaid recipients, was not effectively communicated or utilized. The Director of Nursing and other staff members were unclear about the enrollment process and responsibilities for scheduling dental appointments. The Medical Records Director confirmed that the dentist had not visited the resident, and the Social Services Director was unaware of the resident's denture needs. The lack of coordination and communication among facility staff led to the resident not receiving the necessary dental care.
Failure to Obtain Proper Arbitration Agreement for Cognitively Impaired Resident
Penalty
Summary
The facility failed to properly explain and obtain an appropriate arbitration agreement from a resident with impaired decision-making abilities. The resident, identified as R67, was admitted with multiple diagnoses, including dementia, and was documented as severely cognitively impaired. During an interview, R67 was found to be confused and unable to engage, with a registered nurse confirming the resident's inability to make decisions. Despite this, the facility had R67 sign an arbitration agreement, which was not in compliance with their policy requiring the agreement to be obtained from the resident's representative in cases of cognitive impairment. The admissions assistant, responsible for obtaining arbitration agreements, stated that she contacts the next of kin or the resident's decisional maker if a resident has a cognitive deficit. However, in this case, the arbitration agreement was signed by R67, who was not capable of making such decisions. The admissions director confirmed that the facility's policy mandates obtaining the agreement from a representative when a resident is cognitively impaired. The facility's policy on resident rights emphasizes promoting the exercise of rights for residents facing barriers such as cognitive limitations, which was not adhered to in this instance.
Residents Housed Below Ground Level Without Waiver
Penalty
Summary
The facility failed to ensure that residents' rooms were located at or above ground level, affecting 25 residents. During an initial tour, it was observed that these residents were residing on a lower-level floor in rooms below ground level. The facility's Resident Roster confirmed that these residents were indeed housed in rooms on the lower floor. The Regional Administrator acknowledged the noncompliance and admitted that the facility had not obtained a building waiver for these rooms located below ground level.
Failure to Implement Pressure Injury Prevention Strategies
Penalty
Summary
The facility failed to implement strategies and equipment to prevent pressure injuries for a resident (R2) with advanced dementia who requires moderate assistance with bed mobility and substantial assistance with all transfers. R2 was admitted to the facility on January 9, 2024, and had a pressure injury to the left heel, diagnosed as unstageable. Despite a physician's order dated February 12, 2024, to apply off-loading boots while in bed every shift, R2 was observed without heel floating boots during an intermittent observation period on April 17, 2024, from 1:00 pm to 3:05 pm. During this time, no staff entered R2's room with the boots, and the boots could not be located when checked by the RN at 3:00 pm. The wound assessment performed by the Wound Doctor on April 10, 2024, showed the wound as worsening, but an assessment on April 17, 2024, indicated improvement. However, the lack of adherence to the physician's order for off-loading boots was confirmed by both the RN and the Wound Care Nurse, who stated that the boots should be on the resident while in bed to prevent the wound from worsening. This failure to follow the prescribed care plan contributed to the deficiency in pressure injury prevention and treatment for R2.
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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