Ambassador Nursing & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 4900 North Bernard, Chicago, Illinois 60625
- CMS Provider Number
- 145343
- Inspections on file
- 47
- Latest survey
- December 9, 2025
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Ambassador Nursing & Rehab Center during CMS and state inspections, most recent first.
A resident with a history of TBI, ataxia, epilepsy, and moderate cognitive impairment sustained a serious head injury after falling in a hallway without 1:1 supervision or a sitter. The resident was non-compliant with wearing a protective helmet, and the falls care plan did not include close monitoring. Staff were unclear about when and why increased supervision was discontinued, and documentation lacked evidence of alternative interventions to address the resident's persistent fall risk.
A resident, who was cognitively intact and had multiple medical conditions, reported being struck in the mouth by a roommate following a verbal exchange. The incident resulted in redness to the resident's lower lip, as documented by staff, but there were no witnesses to the event. The facility did not ensure the resident's right to remain free from abuse, as required by its abuse prevention policy.
A resident with multiple medical conditions alleged that another resident made contact with his arm, leading to an unwitnessed abuse allegation. The MOD completed an incident report and notified the Administrator immediately, but the incident was not reported to IDPH within the required two-hour window, resulting in a delay that did not meet facility policy.
The facility did not provide enough nursing staff to meet resident needs and failed to have a licensed nurse in charge on every shift, as required.
Surveyors found that staff failed to discard expired food, stored food near cleaning chemicals, and distributed uncovered food items to residents, exposing them to potential contaminants. Facility policy requires food to be stored away from chemicals and all expired goods to be discarded, and staff confirmed that food should be covered during distribution for infection control.
Multiple residents did not receive their scheduled medications on time or at all, with some doses administered hours late and others not documented as given. Staff interviews and record reviews confirmed that medication administration and documentation did not follow physician orders or facility policy, often due to short staffing and medication availability issues.
The facility did not ensure that essential equipment, such as wheelchairs and call lights, were safe and accessible for several residents. A resident's wheelchair had worn and unstable armrests secured with tape, and multiple residents were found without call lights within reach or with missing components, despite staff and policy requirements for accessibility and safety. Staff confirmed the importance of these measures, but they were not consistently followed.
Four residents requiring respiratory care did not have their oxygen nasal cannula tubing properly stored in bags when not in use, and one resident's nebulizer tubing and mask were not changed weekly as required. Staff confirmed these lapses, and the facility lacked a written policy on oxygen tubing storage.
Staff did not consistently follow Enhanced Barrier Precautions for two residents with wounds, including failing to post required signage upon admission and not wearing gowns during high-contact care activities, despite facility policy and available PPE. This resulted in lapses in infection prevention and control as required for residents with wounds.
A resident with a chronic cough was evaluated by a nurse practitioner who ordered a chest x-ray, but the order was not promptly entered or completed. Despite attempts by nursing staff to contact the contracted radiology provider and endorse the need for follow-up, the x-ray was never performed, and the resident continued to experience symptoms, eventually seeking hospital evaluation. Facility policy requires prompt provision of diagnostic services, which was not met in this instance.
Two residents, both cognitively intact, were found with Ventolin HFA inhalers at their bedside and reported self-administering the medication without documented physician orders or completed assessments for self-administration. Staff confirmed that facility policy requires such orders and assessments, but these were not present in the clinical records.
Three residents experienced prolonged exposure to unresolved maintenance issues, including a missing ceiling panel with exposed piping and a broken cabinet, which were not addressed despite facility policies requiring daily inspections and prompt repairs. Staff were unaware of these issues until notified by surveyors, and no work orders had been submitted for the repairs.
A resident with multiple mental health diagnoses and recent behavioral changes was not accurately assessed in the PASRR Level I screening, and was not referred for a Level II PASRR evaluation after a significant change in condition. The assessment omitted key diagnoses and medications, and was signed by non-clinical administrative staff due to inconsistent staffing in Admissions and Social Services.
A resident with multiple mental health diagnoses was not referred for a required Level II PASRR evaluation, despite documentation indicating the need for further assessment. Facility staff were unable to provide evidence of the completed assessment, and inconsistent follow-up on PASRR requirements was noted, with the referral only being made during the survey.
A resident with a recent below knee amputation and diabetes did not receive daily wound care as ordered by the physician, with missed dressing changes over a weekend and inaccurate documentation in the TAR. Nursing staff did not verify or follow the wound care orders, resulting in a lapse in care and incomplete records.
A resident with cognitive and functional impairments was found with disposable razors at the bedside, despite facility policy requiring staff supervision and secure storage of such items. Staff interviews confirmed there was no assessment of the resident's ability to use razors safely, and razors were not to be left at the bedside, indicating a failure to prevent accident hazards and ensure adequate supervision.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in a deficiency related to resident safety.
A nurse failed to sign the controlled substances check form during a shift change, resulting in incomplete documentation for several residents receiving medications such as morphine, hydrocodone-acetaminophen, and lorazepam for chronic pain, anxiety, and depression. Facility policy and job descriptions require both incoming and outgoing nurses to count and sign for controlled substances at each shift change, but this was not done as required.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes that affected the resident, resulting in a breakdown of required communication.
A controlled substance was found to be improperly labeled when the instructions on the medication bottle did not match the current physician order, as confirmed by an LPN and the DON. A resident with chronic pain and other diagnoses had a Morphine Sulfate order changed from every 1 hour to every 4 hours as needed, but the medication label was not updated accordingly, resulting in a labeling discrepancy.
A resident with a history of aggressive behavior physically assaulted a roommate, causing facial swelling. The incident occurred after the aggressive resident, who had previously exhibited violence toward staff and others, was placed in a shared room. Staff responded to the altercation and separated the residents, but the injured resident required hospital evaluation. Despite physical evidence and consistent staff reports of aggression, the facility's investigation did not substantiate the abuse allegation due to lack of direct witnesses and uncertainty about intent.
A resident at high risk for falls was found on the floor without injury due to inadequate supervision and failure to implement safety measures such as non-skid socks and proper bed positioning. Despite being cognitively intact, the resident frequently forgets to use the call light and attempts to stand without assistance. Staff interviews revealed that the resident's wheelchair is kept outside the room, contributing to the resident's attempts to move independently. The facility's care plan for the resident was not consistently followed, leading to the fall.
A resident reported an alleged abuse incident involving another resident, which was recorded and shared with staff. However, the facility failed to report the incident to the IDPH within the required timeframe due to miscommunication and delayed action by staff members.
A facility failed to prevent an altercation between two residents on the smoking patio, resulting in one resident sustaining a hip fracture. Despite staff supervision, a verbal altercation escalated when one resident reportedly pulled the other's wrist, causing a fall. The incident was investigated, but the abuse allegation could not be substantiated. Medical evaluation confirmed fractures, and the incident was reported to the police.
A cognitively intact 85-year-old resident with a history of mobility issues had her cane removed by the Social Service Director without prior intervention or family notification, despite using it safely for short distances. The removal was due to concerns about the resident using the cane to propel her wheelchair, although no incidents had occurred. This action contradicted the facility's policy on maintaining residents' health and required care planning.
A staff member, V11, was found to be physically and verbally abusive towards multiple residents in an LTC facility. Incidents included yanking a gown off a resident's head, twisting a resident's leg, knocking a resident down, and making inappropriate comments. These actions resulted in emotional trauma and fear among the residents.
The facility failed to store, label, and protect food items according to professional standards, with issues such as expired and improperly stored food, uncovered items, and a fly in the kitchen. These deficiencies could impact 135 residents who consume food from the kitchen.
Surveyors observed that the facility failed to properly contain waste in its dumpsters. The recycling dumpster had an open lid, and the garbage dumpster was missing a lid for half of it, leading to overfilled trash bags with disposable chucks and briefs. The Maintenance Director acknowledged the missing lid and had not contacted the dumpster company for a replacement. Facility policy requires dumpsters to be closed at all times and to contact garbage service if full.
A CNA in an LTC facility was allowed to continue working despite multiple allegations of inappropriate behavior, including rough handling and verbal abuse, reported by several residents. The facility's administration initially categorized these actions as poor customer service rather than abuse, allowing the CNA to work until a recent suspension. This oversight potentially affected all residents.
The facility failed to follow infection control policies in laundry handling, Legionella prevention, and medication administration. A dusty fan was used near clean linens, and soiled linen was improperly sorted, risking contamination. The maintenance director could not provide recent Legionella testing records or risk assessments. A nurse administered medication without hand hygiene, increasing infection risk.
The facility failed to dispose of expired Ibuprofen for a resident and improperly stored insulin for three residents. Expired medication was found in the cart, risking administration errors, while insulin requiring refrigeration was left unrefrigerated without proper labeling, potentially affecting its effectiveness.
The facility failed to maintain correct food temperatures, as observed during a survey. Three residents reported that their food was often cold, and a test tray revealed a hamburger temperature of 120°F, below the facility's standard of 150°F. The facility's policy requires hot foods to be served at a palatable temperature, generally not less than 125°F. A cook acknowledged that cold food could make residents sick, indicating a failure to adhere to the facility's policy.
A resident with schizophrenia and impaired cognition did not have an advance directive care plan in place until the day of the survey. The Social Service Director admitted there was no documentation of discussions about advance directives, and the resident's State Guardian was only contacted the day before the survey. Hospital records indicated the resident lacked decisional capacity, and the facility's policy on advance directives was not followed.
A resident's privacy was compromised when an RN left a computer screen open, displaying the resident's medical information, while attending to another task. This allowed other residents and staff to view the confidential data, violating HIPAA regulations. The DON confirmed the requirement for nurses to lock screens to protect resident information.
A resident's bathroom had a one-foot hole in the ceiling for about a month, which was not repaired despite requests. The Maintenance Director stated the hole was left to dry out after a leak, but no work order was received. The facility's protocol for urgent maintenance requests was not followed, leading to a deficiency in maintaining a homelike environment.
A cognitively intact resident with mobility issues was not placed on a bowel and bladder toileting program, despite being able to feel the need to urinate and have bowel movements. The resident was frequently left to wait for assistance and was changed in bed after episodes of incontinence. The restorative nurse admitted to overlooking the resident's suitability for a training program, and the CNA confirmed the resident was not taken to the toilet, contrary to facility policy.
A resident was improperly positioned during enteral feeding administration, with her head dangling off the bed, which was not corrected until pointed out. The facility's policy and physician's orders require the head of the bed to be elevated 30 to 45 degrees to prevent aspiration.
The facility failed to provide adequate education on the benefits and risks of influenza and pneumococcal vaccinations to two residents. One resident, with intact cognition, did not receive direct education, while another, with cognitive impairment, only received partial information and no follow-up was conducted. The facility's guidelines require that residents or their representatives be informed about the benefits and risks of immunizations.
The facility failed to maintain a safe and functional bathroom for two residents, with a broken sink and non-working toilet observed. The issues persisted for about a month, forcing one resident to use facilities in another room. Staff interviews revealed a lack of communication and reporting of maintenance issues, and incomplete maintenance records indicated a lapse in oversight.
Failure to Implement Effective Fall Prevention Interventions
Penalty
Summary
The facility failed to develop and implement effective interventions to prevent a serious fall-related injury for a resident with multiple risk factors, including a history of traumatic brain injury, ataxia, epilepsy, schizophrenia, and moderate cognitive impairment (BIMS score of 10). The resident was known to be non-compliant with wearing a protective helmet and had a documented behavior of repeatedly getting out of bed despite education. At the time of the incident, the resident was not under 1:1 supervision or assigned a sitter, and was housed in a room far from the nurse's station, making monitoring difficult. The resident was found on the floor in the hallway with an open area to the back of the head and was subsequently diagnosed with a subarachnoid hemorrhage and required staples to the head. Staff interviews revealed uncertainty regarding when and why 1:1 supervision or sitter services were discontinued, and the falls care plan did not include close monitoring as an intervention. The resident's helmet was often not worn correctly or at all, and staff acknowledged that re-education was likely ineffective due to the resident's cognitive status. Documentation did not clarify the rationale for changes in supervision, and there was no evidence of alternative or additional interventions being implemented to address the resident's ongoing fall risk and non-compliance with safety measures.
Failure to Protect Resident from Physical Abuse by Roommate
Penalty
Summary
The facility failed to ensure that a resident remained free from abuse, as required by policy, for one of four residents reviewed for abuse. The incident involved a resident who alleged that his roommate struck him in the mouth after a verbal exchange regarding slamming the door. The affected resident was found to have redness on the lower lip, which was documented in both the incident report and nursing progress notes. Staff statements confirmed that the resident reported being struck, although there were no witnesses to the event, and the resident denied experiencing pain or discomfort. The medical records indicate that the resident who reported the abuse was cognitively intact, with a BIMS score of 15, and had multiple diagnoses, including specified disorders of the brain and seizures. The roommate involved in the alleged incident had a history of chronic medical conditions and was no longer in the facility at the time of the investigation. The facility's abuse prevention policy prohibits and aims to prevent all forms of abuse, including physical abuse, but the incident was not substantiated due to lack of witnesses. Nevertheless, the documentation shows that the facility did not ensure the resident's right to remain free from abuse, as required.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse within the required two-hour timeframe after notification. A resident with multiple diagnoses, including spinal stenosis, morbid obesity, and heart failure, alleged that another resident made contact with his arm while he was in bed. The incident was unwitnessed and reported by the resident to the Manager on Duty (MOD) shortly after 7:00 am. The MOD completed an incident report and notified the Administrator immediately by telephone. An in-house X-ray was performed due to the resident's complaint of arm pain, but no injuries or redness were found. Despite the facility's policy requiring that all abuse allegations be reported to the appropriate authorities within two hours, the incident involving the resident was reported to the Illinois Department of Public Health (IDPH) at 10:22 am, which was more than two hours after the initial allegation was made. Interviews with facility staff, including the DON, MOD, and Administrator, confirmed the timeline and the facility's reporting requirements. The deficiency was identified through interviews and record review, showing a delay in reporting the alleged abuse as required by policy.
Insufficient Nursing Staff and Lack of Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through observations and review of staffing patterns, which showed that staffing levels were insufficient to meet resident care needs and that there were shifts without a licensed nurse in charge. These findings indicate that the facility did not comply with requirements to maintain adequate nursing staff coverage and proper supervision by licensed personnel on all shifts.
Deficient Food Storage and Unsanitary Meal Distribution
Penalty
Summary
Surveyors identified several deficiencies related to food storage, preparation, and distribution within the facility. During a kitchen tour, an opened box of powdered non-dairy creamer packets was found with a 'best use by' date that had already passed, and the Dietary Manager was unsure if the product was still safe to use. Additionally, a large box of bananas was stored on a bottom shelf next to a sanitation bucket containing cleaning solution, contrary to the facility's policy that prohibits storing food near chemicals. The facility's own policy also requires that all out-dated goods be discarded the day after expiration, which was not followed in this instance. Further observations revealed that staff distributed lunch trays to residents' rooms with uncovered food items, such as mandarin oranges in dessert bowls and juice in plastic cups, leaving them exposed to potential contaminants. Both the Dietary Manager and the Regional Director of Operations confirmed that food items should be covered during distribution to prevent contamination, and the Director of Nursing stated that staff are expected to distribute meal trays in a sanitary manner with all food items covered. These actions and inactions resulted in food being stored, prepared, and served in a manner not consistent with professional standards and facility policy.
Failure to Administer Medications as Ordered and Document Timely Administration
Penalty
Summary
Surveyors identified that the facility failed to administer medications to residents according to physician orders and facility policy, resulting in multiple instances of late or missed medication administration. Several residents, all cognitively intact, reported receiving their scheduled medications hours late or not at all, particularly on a specific date when staffing was insufficient. Observations and interviews confirmed that medications intended for administration at 9am were instead given between 11:29am and 12:40pm, exceeding the facility's policy of a 60-minute window before or after the scheduled time. In some cases, medications were not available, and staff had to order them from the pharmacy, further delaying administration. Documentation review revealed that medication administration records (MARs) were not consistently signed, indicating that medications were either not given or not properly documented as administered. For example, one resident's MAR showed that fourteen medications were not signed or administered during a specific shift, while another resident's MAR showed fifteen medications not signed or administered during another shift. Staff interviews confirmed that if the MAR is not signed, the medication is considered not given, which could affect resident well-being. Residents also reported that the timeliness of medication administration depended on which nurse was working and that short staffing contributed to delays. The facility's policies and job descriptions require that medications be administered as ordered by the physician and within the specified time frame, and that the MAR be signed after each medication is given. The Director of Nursing and other staff acknowledged these expectations during interviews. However, the survey findings demonstrated that these procedures were not consistently followed, leading to late or missed medication doses for multiple residents. Resident council meeting minutes and grievance forms further corroborated ongoing concerns about medication administration timeliness.
Failure to Maintain Safe and Accessible Equipment for Residents
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of several residents by not ensuring that essential equipment, such as wheelchairs and call lights, were in safe and functional condition. One resident, who was cognitively intact and dependent on a wheelchair for mobility, reported that both armrests of his wheelchair were worn out, wobbly, and secured with blue tape. Despite informing staff about the issue, the problem persisted, and the maintenance director acknowledged that taped or broken equipment is unsafe and should be addressed immediately. The restorative nurse and director of nursing both confirmed that wheelchairs used by residents should be in proper working order for safety. Additionally, the facility failed to ensure that call lights were within reach and in good working order for multiple residents. One resident, who had been in the facility for six months, stated he had no call light and could not call for help when needed. Observations confirmed that his call light was not visible or within reach, and staff had to retrieve it from the floor and attach it to his bed sheet. Other residents were also found without accessible call lights, with some missing the necessary string to activate the system. Staff interviews confirmed that call lights should always be within reach and attached to the bed or resident's clothing, as outlined in facility policy. The care plans for residents at risk for falls specifically included interventions to keep call lights within reach and encourage their use for assistance. However, observations revealed that call lights were often found on the floor, missing strings, or otherwise inaccessible, directly contradicting both care plans and facility policy. Staff acknowledged the importance of accessible call lights for resident safety and the need to replace missing components promptly, but these measures were not consistently implemented.
Failure to Maintain Proper Respiratory Equipment Storage and Maintenance
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for four residents by not maintaining proper storage of oxygen nasal cannula tubing and not ensuring timely changes of nebulizer tubing and masks. Specifically, three residents with diagnoses including chronic obstructive pulmonary disease (COPD), heart failure, and respiratory failure were observed with their oxygen nasal cannula tubing hanging on wheelchairs or concentrator tanks when not in use, rather than being stored in a bag as required by facility practice. Staff interviews confirmed that the tubing should be stored in a bag to prevent contamination, but this was not consistently done. Additionally, one resident with a history of asthma and cardiac issues received nebulizer treatments with tubing and a mask that had not been changed for over two weeks, despite the facility's policy requiring weekly changes. Staff acknowledged the lapse, and the Director of Nursing confirmed expectations for weekly changes and proper storage. The facility was unable to provide a written policy regarding the storage of oxygen nasal cannula tubing when not in use.
Failure to Implement Enhanced Barrier Precautions and PPE Use for Residents with Wounds
Penalty
Summary
Staff failed to consistently implement appropriate infection prevention and control measures related to Enhanced Barrier Precautions (EBP) for residents with wounds. One resident with a new left below-knee amputation and additional wounds was admitted to the facility, but EBP signage was not posted on the resident's door upon admission, despite an order for EBP being present. The signage was only put up the day after admission, resulting in staff not being alerted to the need for EBP and potentially not wearing required personal protective equipment (PPE) such as gowns and gloves during direct care activities. In another instance, a certified nursing assistant was observed providing incontinence care to a resident on EBP while wearing only a mask and gloves, but not a gown, despite adequate PPE supplies and EBP signage being present outside the resident's door. The CNA stated she sometimes wore a gown but did not consistently do so unless she saw an isolation sign. Interviews with nursing and infection control staff confirmed that gowns and gloves are required for high-contact care activities for residents on EBP, and that signage is essential to alert staff and visitors to the necessary precautions. Documentation and interviews further revealed that both residents had wounds requiring EBP, and that the facility's policy mandates the use of gowns and gloves during high-contact care activities for such residents. The lack of timely signage and inconsistent use of PPE by staff during direct care activities led to a failure in adhering to established infection control protocols for residents on EBP.
Failure to Provide Timely Radiology Services Following Provider Order
Penalty
Summary
The facility failed to provide timely radiology services as ordered for one resident who experienced chronic coughing. After the resident reported coughing spells, a nurse practitioner evaluated the resident and ordered a chest x-ray as part of the treatment plan. The order was not immediately entered into the electronic medical record; instead, it was entered two days later by a nurse after a verbal order was relayed. Despite the order being in the system, the chest x-ray was not completed, and there were no results available for the resident. The nurse responsible attempted to contact the contracted radiology company twice during their shift and endorsed the need for follow-up to the oncoming shift, but the x-ray was still not performed. Facility staff interviews revealed that nurses are expected to acknowledge and confirm new orders in the electronic medical record, and if an order is not seen, they are to verify with the provider or consult with nursing leadership. Documentation showed that the resident continued to complain of cough and was still due for the chest x-ray several days after the order. Ultimately, the resident called emergency services for hospital evaluation. The facility's own policy requires that radiology and diagnostic services be provided promptly to meet residents' needs, but this was not followed in this case.
Failure to Obtain Physician Orders and Assessments for Self-Administration of Medication
Penalty
Summary
The facility failed to obtain physician orders and conduct appropriate assessments for residents to self-administer medications at their bedside. Specifically, two residents, both assessed as cognitively intact according to their Minimum Data Set (MDS) and Brief Interview Scores, were observed with Ventolin HFA inhalers at their bedside tables. Both residents reported having the inhalers at their bedside for over a month and confirmed recent use. However, a review of their clinical records revealed no documentation of a physician order permitting self-administration or to keep the medication at bedside, nor was there evidence of a completed assessment to determine their ability to safely self-administer the medication. Staff interviews confirmed that facility policy requires a physician order and an interdisciplinary team assessment before allowing residents to self-administer medications or keep them at bedside. Both an LPN and the Director of Nursing stated that these steps are necessary to prevent misuse, overuse, or access by other residents. Despite this, the required documentation and orders were not present in the records for either resident, and the medications remained accessible at their bedside.
Failure to Maintain Safe and Homelike Resident Environment Due to Unresolved Maintenance Issues
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for three residents, as evidenced by unresolved maintenance issues in their shared room. One resident reported that a ceiling panel by the window had been missing for weeks following a leak, with exposed piping and multiple towels and linens placed on the floor beneath the opening. Both residents occupying the room confirmed that the ceiling panel had not been replaced for an extended period, and that the facility had not addressed the issue. Additionally, a cabinet in the room was missing a side panel and door, which had fallen off days prior and remained unrepaired. One resident stated the cabinet was already broken upon moving into the room. Interviews with housekeeping and maintenance staff revealed that the broken cabinet had been reported previously, but there was no record of a work order for either the ceiling panel or the cabinet in the facility's maintenance system. The Maintenance Director and Assistant were unaware of the missing ceiling panel until informed by the surveyor, despite facility policies requiring daily inspections and prompt attention to repairs. The facility's own policies mandate the provision of a safe, clean, and comfortable environment, as well as daily inspection and immediate response to maintenance issues, which were not followed in these instances.
Failure to Complete Accurate PASRR Assessment and Referral After Significant Change
Penalty
Summary
The facility failed to submit an accurate Level I PASRR (Pre-admission Screening and Resident Review) assessment for one resident and did not refer the resident for a Level II PASRR evaluation after a significant change in condition. The resident exhibited symptoms such as being withdrawn, having a flat affect, and requiring more assistance with activities of daily living. Despite these changes and a documented history of schizoaffective disorder, bipolar disorder, PTSD, anxiety disorder, homicidal ideations, auditory hallucinations, and mild intellectual disabilities, the Level I PASRR assessment did not include these mental health diagnoses, behaviors, symptoms, or related medications. The resident was also prescribed multiple psychotropic medications, including antipsychotics and medications for anxiety and behavior disturbances. The office manager, who was not a clinical professional, signed and submitted the PASRR assessment without conducting or reviewing the clinical information, as required by policy. There was a lack of consistent staff in the Admissions and Social Services departments, leading to administrative staff handling clinical documentation. The facility's own policy requires compliance with federal and state PASRR standards, but the process was not followed, resulting in the resident not being properly assessed or referred for necessary services after a significant change in their condition.
Failure to Refer Resident for Required Level II PASRR Evaluation
Penalty
Summary
The facility failed to follow up and refer a resident with multiple mental health diagnoses, including schizoaffective disorder, bipolar disorder, insomnia, and depression, for a required Level II PASRR (Pre-admission Screening and Resident Review) evaluation. The resident's admission records and clinical physician orders documented these diagnoses and included prescriptions for medications such as Ziprasidone Hydrochloride, Trazadone, and Amitriptyline Hydrochloride. The initial PASRR Level I screen indicated the need for a Level II onsite assessment, but there was no evidence that this assessment was completed. Throughout the survey, multiple facility staff, including the Administrator, DON, Social Service Coordinator, Nurse Consultant, and Social Service Director, were unable to provide documentation of a completed Level II PASRR for the resident. The Social Service Director confirmed that the staff responsible for admissions had not consistently followed up on PASRR requirements, and that the current admissions staff was new and still learning the process. The facility's own policy requires compliance with PASRR procedures and timely follow-up, but the necessary referral to the state-designated authority for the Level II assessment was not made until the time of the survey.
Failure to Follow Physician Orders and Perform Wound Care
Penalty
Summary
The facility failed to follow physician orders and provide daily wound care for one resident with a recent left below knee amputation (BKA) and diabetes. The resident was admitted for wound care and other skilled services, with physician orders specifying daily dressing changes to the amputation site. Despite these orders, the resident reported that wound care was not performed over the weekend following admission, and the first dressing change occurred only on the following Monday. The Treatment Administration Record (TAR) inaccurately indicated that wound care was completed on Saturday, but the nurse responsible confirmed that the dressing change was not performed as documented. Further review revealed that the wound care coordinator placed the necessary orders after being contacted by staff, but the assigned wound care nurse did not carry out the dressing change as required. Additionally, there was no documentation of wound care being performed on Sunday, and the wound care coordinator was unsure why the scheduled nurse did not complete the task. Facility policies require adherence to physician orders and timely wound care, but these were not followed in this instance, resulting in a lapse in care and inaccurate recordkeeping.
Failure to Secure Hazardous Items and Provide Supervision During Resident Grooming
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including dementia, mood disorder, and dependence on a wheelchair, was found to have two disposable razors stored in plastic cups on their overbed table. The resident's medical records indicated significant cognitive and functional impairments, with documentation showing a self-care deficit and dependence on staff for personal hygiene tasks. Despite this, the resident reported shaving independently and keeping razors at the bedside, which was not in accordance with facility policy or the care plan that required staff assistance and supervision for grooming activities. Interviews with facility staff, including the Regional Nurse Consultant, DON, and Restorative Nurse, revealed that there was no documented assessment for the resident's ability to safely use razors. Staff confirmed that razors should be stored securely and only provided to residents under supervision, with immediate disposal after use. The lack of a shaving assessment and the presence of razors at the bedside represented a failure to ensure hazardous items were stored securely and that adequate supervision was provided to prevent accidents, as required by facility policy and resident care plans.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. 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 Maintain Safe Environment and 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. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Document Controlled Substance Count at Shift Change
Penalty
Summary
The facility failed to ensure that the outgoing nurse signed the Controlled Substances Check Form for the First Floor Team II medication cart, specifically missing a signature for the 3-11 shift on 7/11/2025. This omission was identified during a medication storage and labeling review with an LPN, who confirmed that nurses are required to sign the form to document that controlled medications have been counted and accounted for at each shift change. The Director of Nursing also stated that both incoming and outgoing nurses are expected to count and sign for controlled substances during shift changes to ensure none are missing. This deficiency affected four residents who were prescribed controlled medications, including morphine sulfate, hydrocodone-acetaminophen, and lorazepam, for conditions such as chronic pain syndrome, anxiety disorder, and depression. Facility policy and the registered nurse job description both require accurate narcotic records and dual signatures for controlled substance counts at each shift change, but this procedure was not followed as documented by the missing signature.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping residents and their representatives informed about significant events impacting the resident's well-being.
Controlled Substance Labeling Discrepancy
Penalty
Summary
A deficiency occurred when a controlled substance, Morphine Sulfate, was not properly labeled in accordance with the resident's current physician order. During an observation, a surveyor found that the medication label on the resident's Morphine Sulfate bottle instructed administration every 1 hour as needed, while the active physician order specified administration every 4 hours as needed. The LPN confirmed that the label and the active order did not match, and the expectation was for the label to reflect the current order to ensure accuracy in medication administration. The resident involved was cognitively intact and had diagnoses including abdominal pain, restless leg syndrome, and chronic pain syndrome. The medication order had been changed from every 1 hour to every 4 hours as needed, but the label on the medication bottle had not been updated to reflect this change. Facility policy required that medication labels, physician orders, and the MAR be consistent and uniform, and that improperly labeled medications be rejected or returned. However, the outdated label remained on the medication, creating a discrepancy between the label and the current physician order.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse, resulting in one resident sustaining swelling to the left side of the face near the eyebrow. The incident involved a resident with multiple complex medical diagnoses, including moderate cognitive impairment, who was physically assaulted by a roommate with a documented history of aggressive and violent behaviors. The aggressive resident had previously exhibited both verbal and physical aggression toward staff and other residents, including being sent to the hospital for psychiatric evaluation due to these behaviors. On the day of the incident, the aggressive resident was observed by staff charging toward the other resident, who was in bed eating lunch. The assaulted resident reported that the aggressor was slamming drawers, taking belongings, and then struck him on the left side of the face, causing swelling. Staff responded to the commotion, separated the residents, and called a Code Gray. The assaulted resident was sent to the hospital for evaluation, where swelling to the left eyebrow was noted. Multiple staff interviews confirmed the aggressive behaviors of the perpetrator, including previous incidents of violence toward staff and other residents, and the need for 1:1 monitoring upon return from the hospital. Despite the physical evidence of injury and consistent reports of aggressive behavior, the facility's internal investigation concluded the allegation was unsubstantiated, citing lack of direct witnesses and uncertainty about the intent due to the aggressor's cognitive status. However, staff statements and resident interviews consistently described a pattern of aggression and the specific incident leading to injury. The facility's policies require the prevention of abuse, but the actions taken prior to the incident were insufficient to prevent the assault and resulting injury.
Failure to Prevent Fall for High-Risk Resident
Penalty
Summary
The facility failed to provide appropriate supervision and reduce the risk of falls for a resident identified as R5, who is at high risk for falls. On the morning of January 8, 2025, R5 was found on the floor by a night shift nurse, with his bottom on the floor next to his bed. Observations revealed that R5 was not wearing non-skid socks, and his bed was not in the lowest position, which are both measures that could have potentially prevented the fall. R5, who has a history of repeated falls and requires assistance with personal care, was noted to have a cognitive status that is mostly intact, with a BIMS score of 13/15. Despite this, R5 frequently forgets to use the call light for assistance and does not like to remain in bed or a wheelchair for extended periods. Interviews with staff, including a CNA and an RN, indicated that R5 often attempts to stand without assistance and forgets to use available aids such as the urinal and bed commode. The RN mentioned that R5's wheelchair is kept outside the room due to space constraints, which may contribute to the resident's attempts to move independently. The facility's documentation and care plan for R5 highlight the need for a safe environment, including appropriate footwear and bed positioning, but these measures were not consistently implemented. The Director of Nursing acknowledged the oversight regarding the non-skid socks, and the facility's incident documentation suggests that the care plan should address measurable goals with appropriate interventions, which were not adequately in place at the time of the incident.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the Illinois Department of Public Health (IDPH) within the required two-hour timeframe and did not submit a final report within five days as mandated. The incident involved a resident who was allegedly pushed by a staff member, as reported by another resident who overheard the incident and recorded it. The recording was shared with various staff members, including the Assistant Director of Nursing (ADON) and the Minimum Data Set Coordinator, but the report was delayed due to miscommunication and lack of immediate action by the staff. The incident was first reported by a resident to the ADON on the morning of the alleged abuse, but the Director of Nursing (DON) and the Administrator were not informed until several days later. The facility's Abuse Prevention Program requires immediate reporting of such incidents, but the staff failed to adhere to these procedures. The delay in reporting was further compounded by the Administrator's absence from the facility, leading to a lack of timely investigation and notification to the IDPH.
Failure to Prevent Resident-to-Resident Altercation
Penalty
Summary
The facility failed to adhere to its abuse prevention policy, resulting in an incident involving two residents, R1 and R3, on the smoking patio. R1 reported that R3 pulled R1's wrist, causing R1 to fall and sustain a right hip fracture. However, R3, who primarily speaks Polish, denied the accusation and claimed that R1 pulled R3's wheelchair. The incident was witnessed by staff, who reported a verbal altercation between the two residents, with R1 bumping R1's rollator into R3's wheelchair. Despite the presence of a smoking monitor, the altercation escalated, leading to R1's fall. The incident was investigated by the facility's abuse coordinator, who could not substantiate the abuse allegation. Medical evaluation revealed fractures in R1's right superior and inferior pubic rami, potentially related to the fall. The facility's abuse policy mandates the prevention of resident abuse, and the smoking policy requires supervision during smoking activities. Despite these policies, the altercation occurred, and staff members acknowledged that bumping is considered a form of resident-to-resident physical abuse. The incident was reported to the police, and a battery report was filed.
Failure to Accommodate Resident's Mobility Needs
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident, identified as R1, who is an 85-year-old with a medical history including transient cerebral ischemic attack, vitamin D deficiency, atherosclerotic heart disease, chronic obstructive pulmonary disease, weakness, and urinary retention. R1, who is cognitively intact, expressed that she experienced back pain and required the use of her cane for short distances and a walker for longer distances. Despite this, her cane was taken away by the Social Service Director without explanation or prior intervention, leading to distress and difficulty in maintaining her independence and mobility. The Social Service Director removed R1's cane because R1 was using it to propel her wheelchair, raising concerns about potential safety risks, although R1 had not hit anyone or fallen. The Director of Therapy and the Restorative Nurse confirmed that R1 was safe to use her cane and had not had any incidents with it. The facility's administration did not implement any interventions or notify R1's family before taking the cane, and the behavior was not care planned until after the issue was raised. This action was contrary to the facility's policy on residents' rights, which emphasizes maintaining residents' physical and mental health at the highest practical level and requires documentation of any negotiated risk agreements in the care plan.
Staff Member Abusive Towards Residents
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by multiple incidents involving a staff member, V11, who was physically and verbally abusive towards several residents. The incidents involved four residents experiencing physical abuse and one resident experiencing verbal abuse. The abuse led to emotional trauma, fear, and anxiety among the residents. The facility's policy to ensure residents are free from abuse was not followed, resulting in these deficiencies. One incident involved a resident, R119, who experienced physical abuse when V11 yanked a gown off the resident's head, causing distress and fear. The resident's husband, R120, witnessed the incident and expressed feeling vulnerable and scared of V11. Another resident, R104, reported that V11 was rough during care, twisting the resident's leg aggressively. Although R104 did not initially report the incident, it was mentioned in a casual conversation with another CNA. Additional incidents included R64, who reported being knocked down on the bed by V11, resulting in a head injury. R50 experienced verbal abuse when V11 made inappropriate comments about the resident's age and worth, causing sadness and isolation. R32 also reported physical contact by V11, which was addressed through education on customer service expectations. Despite these incidents, some staff members did not report any issues with V11, indicating a possible lack of awareness or communication regarding the abuse.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. The kitchen was found to have several deficiencies, including improperly labeled and stored food items. Peeled eggs were found in the walk-in cooler without a use-by date, and a whipped cream bottle was past its use-by date. Additionally, opened and uncovered meat was left unattended on the counter, and approximately forty uncovered chocolate puddings were observed on a tray cart. A fly was also seen in the kitchen, indicating potential contamination risks. Further inspection of the dry storage room revealed expired food items, including cans of evaporated milk and a box of raisins past their expiration dates. The facility's food service policy and storage guidelines were not followed, as evidenced by the presence of expired and improperly stored food items. These deficiencies have the potential to affect the 135 residents who consume food from the kitchen, as the facility's census documented a total of 138 residents, with three on an NPO diet.
Improper Waste Containment in Facility Dumpsters
Penalty
Summary
The facility failed to properly contain waste in its dumpsters, as observed by surveyors. During the inspection, the Maintenance Director showed the surveyor the location of the facility's two dumpsters. It was noted that the recycling dumpster had an open lid, while the garbage dumpster was missing a lid for half of the dumpster. The garbage dumpster was overfilled with clear trash bags containing disposable chucks and briefs. The Maintenance Director acknowledged the missing lid and mentioned that it might have been thrown away, and he had not yet contacted the dumpster company to order a new lid. A facility document from April 2022, titled 'Garbage Disposal,' states that dumpsters should be kept closed at all times and that the garbage service should be contacted for removal if the dumpster becomes full. This indicates a failure to adhere to the facility's own waste management policy.
Failure to Address Multiple Abuse Allegations Against CNA
Penalty
Summary
The facility failed to manage staff effectively, allowing a Certified Nursing Assistant (CNA), identified as V11, to continue working despite multiple allegations of inappropriate behavior towards residents. These allegations include incidents of rough handling and verbal abuse, which were reported by several residents. The facility's records indicate that V11 was involved in multiple incidents where residents felt threatened or were physically mishandled, yet V11 was allowed to continue working until a recent suspension pending investigation. One resident, R119, reported feeling distressed and vulnerable when V11 yanked a gown off their head, causing their glasses to become skewed. Another resident, R104, described an incident where V11 aggressively twisted their leg during care, causing pain. R64, a resident with severe cognitive impairment, reported feeling threatened by V11 after being knocked down on their bed, resulting in a head injury. Additionally, R50 reported inappropriate verbal interactions with V11, which led to re-education on customer service expectations. Despite these allegations, the facility's administration, including the Director of Nursing and a Nurse Consultant, initially deemed V11's actions as poor customer service rather than abuse. The facility's abuse prevention policy clearly prohibits any form of abuse or mistreatment, yet V11 was allowed to work from January to March 2024, and again in July 2024, before being suspended. This oversight in staff management and failure to act on multiple allegations of abuse potentially affected all residents in the facility.
Infection Control and Policy Failures in Laundry, Legionella Prevention, and Medication Administration
Penalty
Summary
The facility failed to adhere to its laundry policy, resulting in potential contamination of clean linens. During an observation, a laundry aide was seen folding clean linens near a dusty fan, which was circulating air in the laundry room. The aide acknowledged the fan's dirtiness and the potential for contamination but continued to use it due to the heat. Additionally, the soiled linen area was found to be overflowing, with bags of soiled linen on the floor, indicating a failure to sort and handle soiled linen properly. The laundry supervisor confirmed the issue, noting that staff had not sorted the soiled laundry into designated containers, which were found to be empty. The facility also failed to follow its Legionella prevention policy. The maintenance director was unable to present the current policy or provide recent records of water testing for Legionella. The last documented test was over three years ago, and the director was unaware of any recent testing or specific areas at risk within the facility. The facility's water management program outlined procedures for identifying and monitoring potential Legionella risks, but the necessary documentation and worksheets were not available, indicating a lapse in preventive measures. Furthermore, the facility did not comply with its medication administration policy regarding hand hygiene. A registered nurse was observed administering medication to a resident without washing hands or using gloves. The nurse handled the medication and inhaler device without performing hand hygiene, even after the resident used the inhaler. The nurse admitted to neglecting hand hygiene due to being busy, acknowledging the risk of spreading germs. The director of nursing confirmed that hand hygiene should be performed before and after medication administration to prevent infections.
Improper Medication Disposal and Insulin Storage
Penalty
Summary
The facility failed to adhere to its policy on disposing of expired medications and properly storing insulin, leading to deficiencies in pharmaceutical services. Specifically, the facility did not dispose of expired Ibuprofen for one resident, R127, whose medication was found in the medication cart despite being discontinued and expired. The Registered Nurse, V5, acknowledged that expired medications should not be in the cart as they could be mistakenly administered, and they should be sent to the pharmacy for destruction. The Director of Nursing, V2, confirmed that expired medications should be removed immediately to maintain their potency and effectiveness. Additionally, the facility did not properly store insulin for three residents, R4, R7, and R90. During an observation, unopened insulin pens/vials labeled for refrigeration were found in the medication cart without a received-on date. The Licensed Practical Nurse, V15, and Nurse Consultant, V28, both stated that insulin should be refrigerated to maintain potency and effectiveness. If left unrefrigerated, the insulin should be labeled with a received-on date to ensure it is discarded after 28 days. The lack of proper labeling and storage could affect the medication's effectiveness, as noted by V28.
Failure to Maintain Correct Food Temperatures
Penalty
Summary
The facility failed to maintain correct food temperatures when delivering meals to residents, as observed during a survey. Three residents expressed dissatisfaction with the temperature of their food, stating that it was often cold. One resident mentioned that the food was bad and cold, while another stated that the food was 90% always cold. A third resident suggested that the food was cold because it was handed out late. These observations were made during interviews and record reviews, indicating a pattern of inadequate food temperature management. During the survey, a test tray was used to measure the temperature of a hamburger, which was found to be 120 degrees Fahrenheit, below the facility's standard of at least 150 degrees Fahrenheit. The facility's policy, dated April 2017, requires hot foods to be served at a temperature palatable and acceptable to residents, generally not less than 125 degrees Fahrenheit. A cook at the facility acknowledged that cold food could potentially make residents sick, as not all stomachs can tolerate cold food. This deficiency highlights the facility's failure to adhere to its own policy regarding food temperature, potentially impacting resident satisfaction and health.
Failure to Provide Advance Directive Planning for a Resident
Penalty
Summary
The facility failed to uphold the resident's right to formulate an advance directive and engage in advance care planning for a resident with schizophrenia and impaired cognition. The resident, who was admitted with a medical diagnosis of schizophrenia and a BIMS score indicating impaired cognition, had a documented code status of full code. However, there was no care plan for advance directives in place until the day of the survey, and the Social Service Director admitted that there was no documentation of discussions about advance directives in the progress notes. The Social Service Director stated that although there was no documentation, a discussion about advance directives had occurred with the resident. However, the resident's appointed State Guardian was only contacted the day before the survey to clarify the resident's intentions regarding code status. The hospital records indicated that the resident lacked decisional capacity to make some or all decisions, demonstrating poor insight, understanding, and reasoning. The facility's policy requires that upon admission, it should be determined if a resident has an advance directive and if not, the resident should be provided with information and education about advance directives, which was not adequately done in this case.
Privacy Breach of Resident's Medical Records
Penalty
Summary
The facility failed to protect the privacy and confidentiality of a resident's personal and medical records. During an observation, a registered nurse (RN) was seen administering medication to a resident on the first floor. The RN left the computer screen open, displaying the resident's personal and medical information, while attending to another matter at the nursing station. This lapse allowed other residents and staff passing by to view the confidential information, which included the resident's medications and medical diagnoses such as schizophrenia, major depressive disorder, and bipolar disorder. The RN acknowledged forgetting to lock the computer screen, recognizing it as a violation of the Health Insurance Portability and Accountability Act (HIPAA). The Director of Nursing (DON) confirmed that nurses are required to lock their computer screens when stepping away to prevent unauthorized access to residents' protected health information. The facility's policy on resident rights emphasizes the right to privacy over personal and clinical records, which was not upheld in this instance.
Failure to Maintain Homelike Environment Due to Unattended Maintenance Issue
Penalty
Summary
The facility failed to maintain a homelike environment for a resident, identified as R80, due to a significant maintenance issue in the resident's bathroom. On two separate occasions, a surveyor observed a one-foot hole in the ceiling tile above the toilet, which had been present for about a month. The resident reported that she had requested the repair, but no action had been taken to address the issue. This deficiency was noted during a review of the facility's maintenance practices and procedures. The Maintenance Director, identified as V16, acknowledged the presence of the hole, explaining that it was left open to allow the area to dry out following a water leakage from the room above, to prevent mold growth. However, V16 stated that he had not received any work order regarding this issue, despite the facility's protocol for entering maintenance requests into the TELS system. The facility's maintenance request log indicated that urgent issues should be addressed promptly, but no work order for R80's bathroom was found, highlighting a lapse in communication and follow-up on maintenance requests.
Failure to Provide Appropriate Bowel and Bladder Care
Penalty
Summary
The facility failed to provide appropriate services to restore continence for a resident who was incontinent of bowel and bladder. The resident, a cognitively intact male with end-stage renal disease and mobility issues, required substantial assistance for toilet transfers. Despite being able to feel the need to urinate and have bowel movements, the resident was not placed on a bowel and bladder toileting program. Instead, the resident was frequently left to wait for assistance and was changed in bed after episodes of incontinence. The restorative nurse admitted to overlooking the resident's suitability for a bowel and bladder training program, stating that the resident could have been placed on such a program if he could verbalize the need to use the restroom. The certified nursing assistant confirmed that the resident was not taken to the toilet and was instead changed in bed, despite the resident's previous use of a bedpan and urinal. The facility's policy requires maintaining and improving residents' abilities in activities of daily living, but this was not adhered to in the resident's case.
Improper Positioning During Enteral Feeding Administration
Penalty
Summary
The facility failed to ensure proper positioning of a resident during the administration and flushing of enteral feeding, which could potentially lead to aspiration. On July 9, 2024, a registered nurse was observed flushing a resident's feeding tube while the resident was lying on her side with her head dangling off the bed at the level of her knees. This positioning was not corrected until it was pointed out by an observer, at which point the nurse repositioned the resident to an upright position. The nurse acknowledged that the head should be maintained at least 30 degrees to avoid aspiration. The Director of Nursing confirmed that the facility's policy requires the head of the bed to be elevated 30 to 45 degrees during and after enteral feeding to prevent aspiration. The resident in question had recently had an enteral tube placed following a hospital visit. The physician's order also specified that the head of the bed should be elevated 30 to 45 degrees at all times, except during activities of daily living care. The facility's guidelines and national recommendations emphasize the importance of maintaining the head of the bed at the correct angle to reduce the risk of aspiration.
Failure to Provide Adequate Vaccination Education
Penalty
Summary
The facility failed to provide adequate education on the benefits and risks of influenza and pneumococcal vaccinations to two residents, R147 and R29, as per their policy. R147, who has an intact cognitive status with a BIMS score of 13, did not receive direct education about the vaccinations. Instead, the education was provided to R147's granddaughter, which was not in accordance with the facility's guidelines that require education to be given directly to the resident if they are cognitively intact. This oversight potentially affected R147's understanding of the vaccinations. For R29, who has a BIMS score of 7 indicating cognitive impairment, the education on vaccinations was incomplete, as R29 only heard part of the information. Despite R29's documented lack of decisional capacity, no education was provided to R29's representative, and there was no follow-up education after R29 initially refused the vaccinations. The facility's guidelines require that residents or their representatives be informed about the benefits and risks of immunizations, which was not fulfilled in this case.
Facility Fails to Maintain Safe and Functional Bathroom Facilities
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for residents, specifically in the case of two residents, R4 and R6. The surveyor observed that the shared bathroom for these residents had a broken sink faucet with no water coming out and a non-working toilet that was not flushing properly, with water surrounding the area on the floor. The administrator, V1, was unaware of these issues until the surveyor pointed them out. R4 reported that the bathroom sink had been broken for about a month, and the toilet kept leaking, forcing her to use facilities in another room. R6, who is bedridden, confirmed that staff had to fetch water from another room to provide care. Staff interviews revealed a lack of communication and reporting regarding the maintenance issues. V9, an LPN, stated that maintenance issues are either verbalized or submitted through a work order system, but was unaware of the plumbing issues in the room. V17, a CNA, mentioned that before going on vacation, the sink and toilet were functioning, but upon return, they were not. V19, a housekeeper, noticed the broken faucet handles but did not report it. The housekeeping director, V20, stated that housekeepers should report such issues immediately. The facility's preventative maintenance program policy requires regular inspection and repair of faucets and toilets, but records for recent months were incomplete, indicating a lapse in maintenance oversight.
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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