Aperion Care Burbank
Inspection history, citations, penalties and survey trends for this long-term care facility in Burbank, Illinois.
- Location
- 5701 West 79th Street, Burbank, Illinois 60459
- CMS Provider Number
- 145913
- Inspections on file
- 24
- Latest survey
- July 8, 2025
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Aperion Care Burbank during CMS and state inspections, most recent first.
Two residents sustained serious injuries due to staff not following established care plans for transfers and supervision. One resident, requiring a two-person assist and mechanical lift, was transferred by a single CNA and suffered a leg laceration. Another resident, needing substantial assistance with bed mobility, was left briefly unattended and fell while reaching for personal items, resulting in an intraparenchymal hematoma. In both cases, staff did not adhere to required safety protocols, leading to these incidents.
A resident with multiple diagnoses, including paraplegia and dementia, fell from bed due to inadequate assistance during repositioning. Despite needing two-person assistance, the care plan ambiguously stated 1-2 staff as needed. The fall prevention program was not effectively implemented, leading to the resident's injuries.
A resident with multiple health conditions reported being pushed out of bed by a CNA during a diaper change, resulting in a head injury. The facility's records inaccurately documented the fall as unwitnessed and due to the resident's confusion. Staff interviews revealed inconsistencies, and external records supported the resident's account.
A resident in an LTC facility fell and sustained a head injury requiring nine sutures due to inadequate assistance during ADL care. The resident, who needed substantial assistance with bed mobility, was being cared for by a single CNA instead of the required two-person assist. The air mattress, set on static mode, contributed to the fall. The care plan did not reflect the need for a two-person assist, highlighting a lapse in safety measures.
A resident with a history of hemiplegia, Parkinson's disease, and neurocognitive disorder developed an unstageable pressure ulcer on the sacrum due to the facility's failure to identify, assess, and implement timely interventions. Despite being at risk for pressure ulcers, the resident's open area was not documented or addressed promptly, leading to the development of the ulcer. The wound care nurse was not present daily, and the facility's protocol for skin assessments and wound care was not adequately followed.
A resident with severe cognitive impairment and a history of falls fell from a wheelchair while being transported by a CNA, resulting in a head injury. The resident, who is dependent on staff for mobility, became agitated and slid out of the wheelchair. Despite being identified as a high fall risk, the facility's interventions were insufficient to prevent the fall, highlighting a deficiency in ensuring safe transportation.
The facility failed to conduct timely background checks for eight residents and seven employees, contrary to its policies. Background checks for residents were delayed by 5 to 29 days post-admission, and there was no documentation of pre-employment screenings for employees. This deficiency potentially affects the safety of all 55 residents.
The facility did not comply with its food safety and sanitation policies, as staff failed to wear hair restraints in the kitchen, and expired food items were not discarded. Personal items were found on food prep tables, violating the facility's HACCP policy. These issues affected all 55 residents.
The facility did not follow its policy for sanitary food prep conditions, as observed by a surveyor who noted gnats and an uncovered garbage bin near the food prep area. This deficiency impacts all 55 residents.
A resident with multiple diagnoses, including dementia and major depressive disorder, was administered Lexapro without proper informed consent. The consent form inaccurately documented the dosage, which was acknowledged as a clerical error by the DON. The facility's policy requires informed consent for psychotropic medications, which was not followed in this instance.
The facility failed to provide routine dental services to three residents, leading to a deficiency in care. A resident with chronic conditions was observed with missing and discolored teeth, with no dental services documented for over a year. Another resident with multiple health issues had heavy tartar buildup and abnormal teeth appearance, with no record of dental care since admission. A third resident with Alzheimer's and other conditions also showed signs of poor dental care. The DON and Social Services Director acknowledged the oversight.
Failure to Follow Care Plans for Transfers and Supervision Results in Resident Injuries
Penalty
Summary
The facility failed to implement safety measures as indicated in the care plans for two residents, resulting in significant injuries. One resident, with diagnoses including chronic obstructive pulmonary disease, lumbar radiculopathy, and a need for assistance with personal care, was care planned for dependent transfers requiring two staff members and the use of a mechanical lift. Despite this, the resident was transferred from wheelchair to bed by a single CNA using a stand-pivot method, during which the resident's left leg struck the lever of the bed's halo, causing a laceration that required hospital treatment and sutures. Documentation and staff interviews confirmed that the resident's care plan and transfer requirements were not followed at the time of the incident. Another resident, with a history of moderate intellectual disabilities, lack of coordination, and a history of falls, required substantial assistance with bed mobility and was care planned for assistance by one to two staff as needed. After being transferred into bed by a CNA, the resident was left momentarily unattended while the CNA turned away after providing incontinence care. During this brief period, the resident attempted to reach for personal comfort items and slid out of bed, resulting in a fall and subsequent diagnosis of an intraparenchymal hematoma. The care plan specified that essential and personal items should be kept within reach, but the resident's attempt to access these items led to the fall. In both cases, staff interviews and record reviews indicated that the established care plans and facility protocols for safe transfers and fall prevention were not consistently followed. The incidents were attributed to staff not adhering to the required level of assistance during transfers and not maintaining appropriate supervision during care activities, directly leading to the residents' injuries.
Failure to Provide Adequate Assistance Leads to Resident Fall
Penalty
Summary
The facility failed to provide the required two-person assistance while turning a dependent resident, resulting in the resident falling from the bed and sustaining injuries. The resident, who has multiple diagnoses including paraplegia, dementia, and immobility syndrome, was documented as needing two-person assistance for bed mobility. Despite this, the care plan ambiguously stated assistance of 1-2 staff as needed, which may have contributed to the incident. On the night of the incident, the resident was found on the floor by a CNA during rounds, with a frontal hematoma and laceration on the forehead. The resident was confused and had a history of not using the call light. The fall was unwitnessed, and the resident reported that she was being turned by a staff member when she fell. The facility's documentation and staff interviews revealed inconsistencies in the account of the incident, with some staff unaware of the resident's needs and others confirming the requirement for two-person assistance. The facility's fall prevention program was not effectively implemented, as evidenced by the lack of clear direction in the resident's care plan and the failure to adhere to the two-person assistance requirement. The resident's fall risk assessment indicated a high risk, yet the necessary precautions were not taken. The incident highlights a breakdown in communication and adherence to care protocols, leading to the resident's fall and subsequent injuries.
Inaccurate Documentation of Resident Fall Incident
Penalty
Summary
The facility failed to maintain accurate medical records for a resident's fall incident, affecting one of three residents reviewed for record accuracy. The incident involved a resident with multiple diagnoses, including paraplegia, dementia, and immobility syndrome, who was found on the floor with a head injury. The resident reported being pushed out of bed by a CNA during a diaper change, which was corroborated by the fire department and hospital records. However, the facility's records inaccurately documented the fall as unwitnessed and attributed it to the resident's confusion and incontinence. Interviews with staff revealed inconsistencies in the accounts of the fall. A CNA involved in the incident did not recall the resident or the fall, while another CNA reported being informed of the fall by a nurse. The resident, who was alert and oriented to place and self, described the incident as being pushed out of bed, which was not reflected in the facility's investigation records. The Director of Nursing and Regional Nurse Consultant acknowledged the need for further investigation into the discrepancies between the resident's account and the facility's documentation.
Failure to Provide Adequate Assistance Leads to Resident Fall
Penalty
Summary
The facility failed to prevent a fall by not providing the required two-person assist with bed mobility during ADL care for a resident. This deficiency resulted in the resident rolling off the bed and sustaining a head injury that required nine sutures. The incident occurred when a CNA was providing a bed bath, and the resident, who was lying on his left side, turned further and fell out of bed. The air mattress, which was on static mode, contributed to the resident being pushed out of bed. The resident involved in the incident had a history of requiring substantial to maximal assistance with bed mobility, as noted in the MDS. The resident was known to have gait imbalance and weakness on the left side, which were predisposing physiological factors. Despite these needs, the care plan did not address the use of a two-person assist with bed mobility or turning and repositioning while using an air mattress. Interviews with staff revealed that the CNA was aware of the need for a two-person assist but was alone during the incident. The Director of Nursing confirmed that the facility's plan was to use two people for turning and repositioning residents using an air mattress. However, this plan was not reflected in the resident's care plan, indicating a lapse in communication and implementation of safety measures.
Failure to Prevent and Address Pressure Ulcer Development
Penalty
Summary
The facility failed to identify, assess, and implement interventions to prevent the development of a pressure ulcer for a resident, resulting in the resident developing an unstageable pressure ulcer on the sacral area. The resident, a female with a history of hemiplegia, hemiparesis, Parkinson's disease, and neurocognitive disorder, was at risk for pressure ulcers as indicated by her MDS and Braden score. Despite this, the facility did not document any skin issues until an open area was noted on the sacrum during a shower on August 6, 2024, but there was no corresponding documentation in the progress or wound notes. The wound was later assessed on August 9, 2024, as an unstageable pressure ulcer, and treatment orders were given. The wound care nurse, who was not present daily, was informed of the wound upon her return and notified the wound nurse practitioner. The facility's protocol required CNAs to assess skin during daily care and report issues to nurses, who would then assess and notify the physician. However, there was a lack of documentation and timely intervention following the initial identification of the open area on the sacrum. Interviews with staff revealed that the wound care nurse was not always present, and the responsibility for skin assessments and wound care fell to floor nurses and CNAs. The Director of Nursing was informed of the wound over the phone but was not present at the time of the incident. The facility's policy on pressure ulcer prevention emphasized regular skin inspections, but the lack of documentation and timely response contributed to the deficiency in care for the resident.
Resident Falls from Wheelchair Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure the safe transportation of a dependent resident, identified as R21, in a wheelchair, which resulted in the resident falling forward and sustaining a head injury. R21, who has severe cognitive impairment and is dependent on staff for mobility, was being wheeled back to his room by a CNA when he became agitated and slid out of the wheelchair, hitting his head on the floor. This incident led to a contusion on R21's forehead, requiring emergent care at a local hospital. R21 has a history of falls and is considered at high risk for falls, as documented in multiple fall risk assessments. The care plan for R21 acknowledges the risk of falls and includes interventions such as placing essential items within reach, assisting with ADLs, and providing supervision. However, during the incident, the CNA was unable to prevent the fall due to the resident's sudden agitated behavior, and it is unclear if leg rests were used during transportation. Interviews with staff, including the DON and CNAs, revealed that R21 is known to be a high fall risk and sometimes exhibits restless or aggressive behavior. Despite this knowledge, the facility's interventions at the time of the incident were insufficient to prevent the fall. The facility's fall prevention program outlines the need for safety interventions for residents at risk, but the incident indicates a lapse in ensuring these measures were effectively implemented during R21's transport.
Failure to Conduct Timely Background Checks
Penalty
Summary
The facility failed to adhere to its policies regarding background checks for both residents and employees, leading to a deficiency in ensuring the safety and security of its residents. Specifically, the facility did not conduct timely background checks for eight residents, with delays ranging from 5 to 29 days post-admission. These residents had various medical conditions, including Systemic Lupus Erythematosus, heart failure, dementia, hemiplegia, and metabolic encephalopathy. The facility's policy mandates that criminal history and sex offender registry checks be conducted prior to or immediately upon admission, which was not followed. Additionally, the facility did not perform pre-employment screenings for seven employees, including CNAs and housekeeping staff. There was no documentation of checks on the state health agency registry, sex offender websites, or the Department of Corrections prior to their employment. The facility's policy requires these checks to be completed on the day of the interview, which was not done, as confirmed by interviews with the Admissions Director, Administrator, and Receptionist. The facility's policies, including the 'Admission of Identified Offender' and 'Abuse Prevention and Reporting,' clearly outline the procedures for conducting background checks to prevent abuse, neglect, and exploitation. However, the facility failed to implement these procedures effectively, as evidenced by the lack of documentation and delayed checks. This deficiency has the potential to affect all 55 residents currently residing in the facility, compromising their safety and well-being.
Non-compliance with Food Safety and Sanitation Policies
Penalty
Summary
The facility failed to adhere to its policies and procedures for maintaining sanitary conditions in food preparation and storage areas. Observations revealed that staff entering the kitchen did not consistently wear hair restraints, as required by the facility's Hair Restraint Policy. Specifically, a receptionist was seen walking through the kitchen without a hair net on two occasions. Additionally, personal items such as a phone and car keys were found on the food prep table, which is against the facility's HACCP and Foodborne Illness Policy that aims to prevent physical hazards like hair and dirt from contaminating food. Further inspection of the kitchen's food storage practices showed that the facility did not discard food items past their use-by and best-by dates, contrary to their Food Storage Policy. Grilled cheese sandwiches and a milk carton with expired dates were found in the refrigerator, and multiple milk cartons with expired use-by dates were stored in the freezer. These lapses in following established food safety protocols potentially compromised the safety and quality of food served to all 55 residents in the facility.
Failure to Maintain Sanitary Conditions in Food Prep Area
Penalty
Summary
The facility failed to adhere to its policy and procedures for maintaining sanitary conditions in food preparation areas, specifically regarding garbage and waste disposal. During an observation on August 12, 2024, at 9:25 AM, a surveyor noted the presence of gnats in the kitchen and observed a large garbage bin next to the food prep area that was open without a lid when not in use. A subsequent observation at 11:02 AM on the same day confirmed the same issue with the garbage bin being uncovered. The facility's Garbage and Rubbish Disposal Policy, reviewed on August 14, 2024, mandates that all garbage and rubbish containing food waste must be covered when not in immediate use to prevent access by vermin. This deficiency affects all 55 residents in the facility.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent prior to administering a psychotropic medication to a resident, identified as R17, who was part of a sample of thirty-seven residents reviewed for unnecessary medications. R17, an elderly resident with diagnoses including dementia, major depressive disorder, schizophrenia, and Alzheimer's disease, was prescribed Lexapro for major depressive disorder. The medication order, dated 05/27/2023, specified a dosage of 0.5 tablet of a 20 mg Lexapro tablet, equating to 10 mg. However, the consent form, dated 05/28/2023, incorrectly documented the dosage as 0.5 mg, which was acknowledged as a clerical error by the Director of Nursing (DON). The DON admitted that the consent form was incorrect and confusing for the nursing staff, as it did not match the actual medication order. Despite recognizing the error, the DON confirmed that no other consents were available for R17 regarding Lexapro. The facility's policy on psychotropic medication and gradual dosage reduction, dated 11/28/12, mandates that informed consent must be obtained before administering such medications. This policy was not adhered to in R17's case, leading to the deficiency noted in the report.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental services to meet the needs of three residents, leading to a deficiency in dental care. Resident R41, a male with chronic respiratory failure, congestive heart failure, severe protein malnutrition, and chronic kidney disease, was observed with missing and discolored teeth. Despite having a care plan initiated in September 2023 that included coordinating dental care, there was no documentation of dental services from June 2023 to August 2024. A dental consult in June 2024 noted that R41 was not seen by the dentist due to hospitalization. Resident R51, a female with dysphasia, type 2 diabetes, Parkinson's disease, and systemic lupus erythematosus, was observed with heavy tartar buildup and abnormal teeth appearance. Her care plan, initiated upon admission in April 2024, included coordinating dental care, yet there was no record of her being seen by a dental hygienist from April to August 2024. Similarly, R30, a female with chronic respiratory failure, vitamin D deficiency, cerebral ischemia, and early-onset Alzheimer's disease, was observed with missing, discolored teeth and tartar buildup. Her care plan from October 2023 also indicated a need for dental care, but there was no documentation of dental services from June 2023 to August 2024. The Director of Nursing and Social Services Director acknowledged the oversight, noting that residents should be seen by the dental hygienist every three months.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
