Aperion Care Dekalb
Inspection history, citations, penalties and survey trends for this long-term care facility in Dekalb, Illinois.
- Location
- 1212 South Second Street, Dekalb, Illinois 60115
- CMS Provider Number
- 145261
- Inspections on file
- 47
- Latest survey
- December 24, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Aperion Care Dekalb during CMS and state inspections, most recent first.
Two residents did not receive or have documented wound care as ordered, with multiple missed entries on the TAR and no explanations in progress notes. One resident reported that staff were sometimes too busy to perform wound treatments, and the facility could not provide a wound care policy when requested.
Two residents did not receive their prescribed medications due to pharmacy rejections and lack of communication among staff. In one case, a nurse borrowed medications from other residents and administered the wrong formulation and dose, while in another, a resident missed multiple doses of a bladder medication without being notified. Facility policy prohibiting such practices was not followed, and the DON was not informed of the medication issues.
Dietary staff, including aides and a cook, were observed preparing and handling food without having completed the required food handler training within thirty days of hire. Two aides had been employed for three months without certification, and there was no facility policy in place to ensure compliance with this requirement. The administrator was aware of the lapse, and documentation confirmed the missing certificates, affecting all residents receiving meals from these staff.
A resident with a surgical wound did not receive wound care as ordered, with daily iodoform packing omitted and care provided only three times a week. This deviation from prescribed treatment led to worsening of the wound, increased drainage, infection, and ultimately required hospitalization for surgical intervention and intravenous antibiotics.
A CNA verbally abused a resident with communication difficulties by mocking her crying and raising her voice after an accidental incident involving the resident's communication device. Multiple staff members confirmed hearing the mocking and raised voice, and the DON acknowledged that such behavior constitutes verbal abuse under facility policy.
A resident with a history of stroke and requiring substantial assistance for bed mobility fell out of bed and sustained a humeral fracture due to inadequate supervision. The CNA attempted to reposition the resident alone, contrary to the care plan that required two-person assistance. The resident's weak side was unsupported, leading to the fall. The incident revealed a critical oversight in staff awareness and adherence to care protocols.
The facility failed to identify and treat pressure ulcers in two residents, leading to increased risk of infection and delayed healing. One resident returned from a hospital stay with an unstageable coccyx ulcer that was not previously identified by staff, while another resident had a heel wound without treatment orders. The facility did not conduct required weekly skin assessments or document skin issues, compromising resident care.
A facility failed to notify a resident's family about an advanced stage coccyx pressure ulcer, which was discovered during a hospital admission. The resident, with severe cognitive impairment, required total staff assistance. The resident's daughter, who visited frequently, was informed of the wound by the hospital, not the facility. The facility's policy mandates notifying family of significant changes, which was not followed.
A resident at moderate risk for pressure injuries developed two stage 3 ulcers on the ears due to inadequate preventative measures and skin assessments. Despite being dependent on staff for care, the facility failed to anticipate the risk from oxygen mask straps and did not conduct timely risk assessments, leading to advanced-stage injuries.
A resident experienced a change in condition marked by weakness, but the facility failed to notify the physician in a timely manner. Although a Nurse Practitioner was informed, no actions were taken, and there was no documentation of communication with the primary care physician. Staff interviews revealed that nurses assumed others had notified the physician, contrary to the facility's policy requiring timely communication of significant changes.
A resident with multiple health conditions experienced a change in condition marked by weakness, which was not properly documented or communicated by the facility staff. Despite the resident's symptoms persisting and worsening, there was a lack of timely assessment and physician notification. The resident was eventually transferred to the hospital with dehydration and a UTI. The facility's policy on change in condition was not effectively implemented, leading to a deficiency in care.
A resident with a history of joint replacement surgery and major depressive disorder was mistakenly given Hydrocodone instead of the newly prescribed Oxycodone due to a nurse's failure to verify updated medication orders. The nurse administered the discontinued medication based on the resident's statement without checking the MAR, leading to a breach in medication administration protocols.
A facility failed to follow its abuse policy by not immediately removing a CNA from resident care during an abuse investigation. A resident alleged that the CNA pushed him, but the CNA continued working for over an hour before being sent home. The facility's policy requires immediate removal of staff accused of abuse, which was not adhered to in this case.
The facility failed to supervise a resident at risk for aspiration during meals and did not ensure safe transfer practices for two residents, as staff did not use gait belts as required. Additionally, medical equipment for three residents was improperly connected to power strips instead of wall outlets, compromising safety.
The facility did not follow food service safety standards when a cook placed a fallen oven mitt back on a clean prep table without washing hands, affecting residents on pureed diets. The Food Service Director confirmed the need for proper hand hygiene and separation of clean and dirty areas.
The facility failed to provide necessary treatment for a resident with a fractured arm, as the resident was observed without a required splint, and staff were unaware of its whereabouts. Additionally, the facility did not obtain daily weights for a resident with congestive heart failure, despite physician orders, with the resident reporting inconsistent weighing practices and a broken scale as reasons for missed measurements.
The facility failed to provide prescribed medications to two residents, leading to deficiencies in pharmaceutical services. One resident did not receive Farxiga and Memantine due to unavailability, while another self-administered undocumented eye drops. The DON was aware of these issues but did not ensure proper medication administration and documentation.
The facility failed to ensure proper evaluation and monitoring of residents on PRN antipsychotic medications. A resident had an active PRN order for Seroquel without a stop date, contrary to guidelines limiting such orders to 14 days. The attending physician did not evaluate the resident after 14 days. Additionally, another resident was not monitored for antipsychotic side effects using the AIMS assessment every 6 months as required, with assessments conducted 13 months apart.
The facility failed to administer medications as prescribed, resulting in a 10.34% error rate. A resident did not receive Farxiga and Memantine due to unavailability in the dispensing system, and another resident received an incorrect dosage of Aspirin. The facility's policy requires adherence to physician orders, which was not followed.
A resident was not adequately informed about a binding arbitration agreement upon admission. The resident, who was cognitively intact, did not recall signing the agreement and stated it was not explained to her. The facility's administrator confirmed that the agreement is completed upon admission but is not mandatory for admission, and residents have 30 days to rescind it.
The facility failed to ensure staff wore PPE for residents on Contact Isolation and Enhanced Barrier Precautions. A CNA and an LPN entered a resident's room without PPE, despite the resident being on contact isolation for a urinary tract infection. Another CNA provided care to a resident with a urinary catheter on Enhanced Barrier Precautions without wearing a gown, contrary to facility policy.
A facility failed to provide timely incontinence care for a resident dependent on staff for ADLs. The resident, who is cognitively intact, was found in bed with a faint odor of urine and reported not being changed since early morning, despite being incontinent and taking a water pill. A CNA confirmed the delay in care, which should occur every 2 hours per facility policy.
Failure to Provide and Document Ordered Wound Care
Penalty
Summary
The facility failed to provide and document ordered wound care for two residents with multiple wounds, as evidenced by missing documentation on the Treatment Administration Records (TAR) and lack of progress notes for several dates when wound care was scheduled. One resident, with diagnoses including dementia, diabetes type 2, heart failure, and an antibiotic-resistant infection, had orders for daily wound treatments to both legs. The TAR and progress notes showed that wound care was not documented as completed on multiple occasions, and there was no explanation for the missing treatments. The Director of Nursing confirmed that wound care should be documented when performed and that documentation is necessary to verify completion. Another resident with skin tears to the left foot and knee had orders for wound care three times a week. The TAR indicated that wound care was not documented as completed on specific dates for both wounds. The resident reported that staff were sometimes too busy to perform wound treatments. Additionally, when requested, the facility was unable to provide a policy for wound care treatment.
Failure to Provide and Administer Correct Medications
Penalty
Summary
The facility failed to provide ordered medications and administer the correct medication to two residents. One resident with a history of stroke, heart failure, and atrial fibrillation did not receive her prescribed doses of diltiazem (an extended-release cardiac medication) and duloxetine for depression because the pharmacy rejected the refills. The nurse on duty borrowed duloxetine from another resident and substituted regular diltiazem from a different resident, administering multiple tablets to approximate the prescribed dose. The nurse was inconsistent in reporting the number of tablets given and acknowledged that the medications were not the correct formulation. Facility policy prohibits administering medications prescribed for one resident to another and requires staff to notify the Director of Nursing if medications are unavailable or rejected by the pharmacy. Another resident with diagnoses including dysuria, urinary tract infections, and kidney cancer did not receive her prescribed mirabegron for incontinence on multiple occasions, as documented in the Medication Administration Record. The nurse confirmed the medication was not available and had not checked the emergency supply. The resident was not notified about the missing medication and was unsure if she was still receiving it, though she continued to experience symptoms of overactive bladder. The Director of Nursing stated she was not informed of the pharmacy rejection and could not determine the last day the resident received the medication. The facility's failure to ensure the availability and correct administration of medications, as well as the lack of communication and adherence to policy regarding medication shortages and pharmacy rejections, resulted in residents missing essential doses and receiving medications not prescribed to them. These actions directly violated facility policy and the standard of care for medication administration.
Failure to Ensure Timely Food Handler Certification for Dietary Staff
Penalty
Summary
The facility failed to ensure that dietary support staff completed a food handler's training course within thirty days of hire, as required by Illinois Department of Public Health (IDPH) regulations. During observations in the main dining room and kitchen, several dietary aides and a cook were seen preparing and handling resident food. Interviews revealed that two dietary aides had been employed for three months but had not obtained their food handler's certificates. One aide was unaware of the requirement, and neither could provide a start date for the course. The cook confirmed the absence of a dietary manager for about a month, with the administrator currently overseeing dietary staff. The administrator acknowledged that two of the three dietary aides working did not have their food handler's certificates and confirmed the lack of a facility policy to ensure completion of this training. Review of documentation showed no certificates for the two aides in question. This deficiency affected all 80 residents currently residing in the facility, as all resident meals were prepared by the dietary staff who had not met the required training standards.
Failure to Follow Wound Care Orders Resulting in Wound Deterioration and Hospitalization
Penalty
Summary
The facility failed to follow wound treatment orders for a resident with a surgical wound on the left lower leg, which ultimately led to the deterioration of the wound and required hospitalization and surgical intervention. The resident had a history of surgery on the knee, followed by infection and subsequent treatments, including oral antibiotics and wound care. Despite the wound nurse practitioner's order for daily iodoform packing to manage tunneling and drainage, the wound care was only performed on Mondays, Wednesdays, and Fridays, contrary to the prescribed daily regimen. Interviews with facility staff revealed a lack of awareness and adherence to the wound care orders. The wound nurse practitioner emphasized that daily packing is necessary to prevent infection and promote healing, especially in residents colonized with MRSA. However, the wound care was not performed as ordered, and the wound nurse practitioner was not informed of this deviation. Documentation showed inconsistencies in the transcription of physician orders, with some orders omitting the required packing and others specifying a reduced frequency of dressing changes. As a result of the failure to follow the prescribed wound care regimen, the resident's wound developed increased drainage, tunneling, and signs of infection. The wound deteriorated, leading to the need for hospital transfer, where an abscess and possible osteomyelitis were identified. The resident underwent an incision and drainage procedure, received intravenous antibiotics, and returned to the facility with a wound vacuum in place. The facility's policy required adherence to physician orders for wound care, but this was not followed in the resident's case.
Verbal Abuse of Resident by CNA
Penalty
Summary
A certified nursing assistant (CNA) was observed and reported to have verbally abused a resident who uses a communication device. On the evening in question, the CNA appeared frustrated while assisting the resident, and the communication device accidentally fell onto the resident's leg, causing the resident to cry. Multiple staff interviews confirmed that the CNA responded by mocking the resident's crying and imitating her speech, and also raised her voice, telling the resident to be quiet. Other staff members in the vicinity heard the incident, with one registered nurse (RN) and another CNA corroborating that the resident was being mocked and told to be quiet. The Director of Nursing (DON) stated that such actions, including yelling or mocking a resident, are considered verbal abuse and are not acceptable, especially given the resident's communication difficulties. The resident involved has a care plan indicating the use of a communication device to express needs. The facility's abuse prevention policy affirms residents' rights to be free from abuse, neglect, and mistreatment by staff. The incident was substantiated through interviews and record review, showing that the staff member's actions violated the resident's right to be free from verbal abuse and did not align with facility policy or the resident's care plan.
Failure to Provide Adequate Supervision During Bed Repositioning
Penalty
Summary
The facility failed to safely reposition a resident in bed, resulting in the resident rolling out of bed and sustaining a humeral fracture. The resident, who had a history of stroke and was dependent on staff for bed mobility, was being cared for by a CNA who attempted to reposition her alone. The resident's care plan indicated that she required substantial assistance from two staff members for bed mobility due to her condition, which included hemiplegia and an inability to use her left arm and leg. During the incident, the CNA rolled the resident onto her right side, away from the CNA, causing her legs to slide off the bed. The resident's weak side was up, and she was unable to grab the side rail due to her impaired left arm. This resulted in the resident falling to the floor, where she was found kneeling with an abrasion on her left knee and complaining of left arm pain. An X-ray confirmed a fracture in the surgical neck of the humerus. The Director of Nursing acknowledged that the resident was on a low air loss mattress and should have been assisted by two staff members. The CNA involved was not aware of the requirement for two-person assistance, which was a critical oversight. The resident's pain management was adjusted following the fall, and the incident highlighted a failure in ensuring adequate supervision and adherence to the care plan for residents requiring extensive assistance.
Failure to Identify and Treat Pressure Ulcers in Residents
Penalty
Summary
The facility failed to identify and treat pressure ulcers in two residents, leading to significant deficiencies in care. Resident 1, who had multiple diagnoses including encephalopathy, diabetes, and Alzheimer's disease, was at moderate risk for pressure ulcer development. Despite this, the facility did not conduct weekly skin assessments or document any skin issues until after the resident returned from a hospital stay, during which an unstageable coccyx pressure ulcer was discovered. The facility's staff, including CNAs and nurses, failed to identify the wound in a timely manner, resulting in an increased risk of infection and delayed wound healing. Resident 2 was found to have a deep tissue injury (DTI) on the right heel, but there were no treatment orders in place for this wound. The facility's records showed that the treatment order for the heel wound was discontinued in February, and no new orders were established until the day of the survey. This lack of treatment orders meant that the wound was not being properly cared for, increasing the risk of infection and delayed healing. The facility's staff, including the Wound Care Nurse and Director of Nurses, acknowledged the oversight and the need for immediate clarification and continuation of treatment. The facility's policy required weekly skin assessments by licensed nurses and daily observations by CNAs, but these were not consistently performed or documented. The failure to adhere to these protocols resulted in the late identification and treatment of pressure ulcers, compromising the residents' health and safety. The facility's leadership, including the VP of Clinical Operations and the Director of Nurses, recognized the deficiencies and the importance of early detection and treatment of skin issues to prevent further complications.
Failure to Notify Family of Resident's Advanced Stage Wound
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in the resident's condition, specifically the development of an advanced stage wound. The resident, who had severe cognitive impairment and required total staff assistance, was admitted to the hospital where a wound consult revealed an unstageable coccyx pressure ulcer. This wound was present upon the resident's admission to the hospital, indicating it had developed while the resident was under the facility's care. The resident's daughter, who visits almost daily, was not informed by the facility about the wound. Instead, she was notified by the hospital staff. The facility's Wound Care Nurse acknowledged that any new or worsening wound should be reported to the physician and family promptly. The Director of Nurses confirmed that the family was not notified by the facility, which is a violation of the facility's policy requiring notification of significant changes in a resident's condition.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to adequately identify and manage the risk of pressure injuries for a resident who was at moderate risk for developing such injuries. The resident, who had a history of sepsis, acute respiratory failure, and other conditions, was dependent on staff for personal care and mobility. Upon admission, the resident was assessed as being at moderate risk for pressure injuries, but the facility did not implement sufficient preventative measures or conduct adequate skin assessments, leading to the development of two stage 3 pressure injuries on the resident's ears. The resident's care plan initially included interventions such as using ear protectors with the oxygen cannula and documenting weekly treatment of skin breakdowns. However, these measures were not effectively implemented or monitored. The resident developed a stage 3 pressure ulcer on the left ear, which was identified during a wound assessment, and later a similar ulcer on the right ear. Despite the presence of ear protectors, the facility did not recognize the potential for pressure injuries from the oxygen mask straps until after the injuries occurred. Interviews with the Director of Nursing and the Wound Care Nurse revealed that the facility did not anticipate the risk of pressure injuries from the mask straps and failed to conduct a repeat pressure ulcer risk assessment after the second injury was identified. The facility's policy required daily skin assessments and prompt notification of skin breakdowns, but these procedures were not adequately followed, resulting in the resident's pressure injuries being identified at an advanced stage.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician of an ongoing change in condition for a resident in a timely manner. The resident experienced a change in condition characterized by weakness starting on December 18, 2024. Although a Nurse Practitioner was notified of the change, no actions were taken, and there was no documentation in the resident's chart indicating that the primary care physician or Nurse Practitioner was informed of the condition from December 18th to December 22nd, 2024. Interviews with staff revealed that the Registered Nurse who worked with the resident on December 18th and 21st reported the initial change to the Nurse Practitioner but did not update the physician when the resident's condition remained unchanged. Another Registered Nurse who worked with the resident on December 19th and 20th also failed to notify the physician, assuming that a colleague had done so. The facility's policy requires timely communication of significant changes in a resident's condition to the physician and family, which was not adhered to in this case.
Failure to Assess and Communicate Change in Resident's Condition
Penalty
Summary
The facility failed to identify and assess a resident for an ongoing change in condition, which was observed in one of the three residents reviewed for quality of care. The resident, who had a history of cerebral infarction, diabetes mellitus II, cerebral aneurysm, hemiplegia, adjustment disorder with anxiety, and dementia, experienced a change in condition characterized by weakness on December 18, 2024. Despite this, there was no documentation in the resident's electronic medical record regarding the change in condition until two days later, on December 21, 2024. During this period, the resident's symptoms remained unchanged, and there was no evidence of physician notification or intervention. The resident's condition continued to deteriorate, with decreased oxygen saturation and signs of dehydration noted on December 22, 2024. The primary care physician was contacted, and the decision was made to transfer the resident to the emergency room, where she was diagnosed with a urinary tract infection and dehydration. Interviews with the facility staff revealed a lack of communication and follow-up regarding the resident's condition. The registered nurse who initially noted the change in condition did not recall the specific orders given and did not work again until December 21, 2024, by which time the resident's condition had not improved. The facility did not provide a change in condition policy, only a notification of change in condition policy, which outlines the need for timely communication with the resident's physician and family in the event of a significant change in the resident's status. However, this policy was not effectively implemented, as evidenced by the lack of timely assessment and communication regarding the resident's deteriorating condition. The resident's power of attorney expressed concerns about the lack of communication from the facility regarding laboratory results and the resident's condition, highlighting the deficiency in the facility's response to the resident's change in condition.
Failure to Verify Medication Orders Before Administration
Penalty
Summary
The facility failed to ensure medication orders were verified prior to administering medications for a resident who had recently returned from a podiatrist appointment with new medication orders. The resident, who had undergone joint replacement surgery and had a history of major depressive disorder and falls, was prescribed Oxycodone to replace Hydrocodone for pain management. Despite the updated orders, an agency nurse administered the discontinued Hydrocodone to the resident, relying on the resident's statement rather than verifying the current physician's orders. The incident occurred when the agency nurse, without checking the Medication Administration Record (MAR), gave the resident Hydrocodone after the resident mentioned having an order for it. Upon later review, it was discovered that the order for Hydrocodone had been discontinued, and the Oxycodone prescription was in place. The nurse found both medications in the locked narcotic box, indicating a failure to update and verify medication orders before administration. This oversight led to the administration of a medication that was no longer prescribed, highlighting a lapse in following proper medication administration protocols.
Failure to Remove Staff During Abuse Investigation
Penalty
Summary
The facility failed to implement its abuse policy by not removing a staff member from resident care during an abuse investigation. On the morning of 9/12/24, a Certified Nursing Assistant (CNA) was asked to assist a resident, who later alleged that the CNA pushed his shoulder, causing him distress. Despite the allegation, the CNA continued to provide care to other residents on the north hall for at least an hour before being called into a meeting and eventually sent home. The facility's policy mandates that employees accused of abuse be removed from resident contact immediately, which was not followed in this instance. The incident involved a resident with a history of making false allegations and cognitive impairments. The Social Services Director and the Administrator were informed of the allegation, but the CNA was allowed to continue working until nearly three hours after the incident. The CNA's timesheet confirmed she worked from 7:26 AM to 10:52 AM on the day of the incident. The failure to adhere to the facility's abuse prevention policy compromised the safety protocols intended to protect residents during an abuse investigation.
Deficiencies in Supervision, Transfer Practices, and Equipment Safety
Penalty
Summary
The facility failed to provide adequate supervision and safe practices for several residents, leading to multiple deficiencies. One resident, who was at risk for aspiration due to dysphagia, was observed eating a pureed breakfast without supervision, contrary to her care plan which required supervision during meals. This lack of supervision was confirmed by the Director of Rehabilitation, who acknowledged the resident's need for a pureed diet and supervision due to her risk of aspiration. Additionally, the facility did not ensure safe transfer practices for two residents. One resident, who required assistance and a gait belt for transfers, was transferred by a CNA without a gait belt, using the resident's arm instead, despite the resident's recent fall and arm fracture. Another resident, also dependent on staff for transfers, was transferred without a gait belt, contrary to the facility's policy mandating its use. Furthermore, medical equipment for three residents was improperly connected to power strips instead of wall outlets, as confirmed by the Maintenance Director, who stated that medical equipment should be plugged into wall outlets for reliable power.
Failure to Maintain Food Service Safety Standards
Penalty
Summary
The facility failed to adhere to professional standards for food service safety during the preparation and distribution of pureed diets. On July 15, 2024, a cook was observed picking up an oven mitt that had fallen on the floor and placing it back onto the clean food prep table without washing her hands. This action occurred near the blender used for preparing pureed pasta and meat. The Food Service Director confirmed that items that fall on the floor should be placed in a dirty area and not near clean food, and that hand washing should be performed after picking up items from the floor. This deficiency affected five residents who were on pureed diets.
Failure to Provide Necessary Treatment and Monitoring
Penalty
Summary
The facility failed to provide necessary treatment for a resident with a fractured arm. The resident, identified as R34, experienced an unwitnessed fall and was diagnosed with a fracture of the left ulna. Despite a physician's order to maintain a splint at all times, observations revealed that R34 was without a splint, cast, sling, or compression wrap on multiple occasions. The resident expressed discomfort and pain, indicating that the cast was missing. A Certified Nursing Assistant (CNA) confirmed the absence of the cast and transferred the resident without proper support, allowing the injured arm to dangle freely. Additionally, the facility failed to obtain daily weights for a resident with congestive heart failure, identified as R18. Despite a physician's order for daily weights to monitor for significant weight changes, numerous dates were recorded without any weight measurements. The resident, who is cognitively intact, reported having to remind staff to weigh her and noted that some staff cited a broken scale as a reason for not weighing her. The Director of Nursing acknowledged the responsibility of a restorative person to assist with daily weights and the need to document any refusals, which were not recorded in this case.
Deficiencies in Medication Administration and Documentation
Penalty
Summary
The facility failed to provide prescribed medications to two residents, resulting in deficiencies in pharmaceutical services. For one resident, the Medication Administration Summary indicated that they should receive Farxiga and Memantine at specific times. However, on a particular day, the RN administering medication omitted these drugs because they were not available in the medication cart. The Director of Nursing was aware of the issue and contacted the pharmacy, which indicated that the medication was reordered too soon, but the reason for this was unclear. Another resident was found to be self-administering eye drops that were not documented in their Physician Orders. The resident had been instructed by an eye doctor to use specific eye drops, but these orders were not reflected in the facility's records. A CNA discovered the eye drops on the resident's nightstand and informed the resident that medications could not be kept at the bedside. The Director of Nursing acknowledged that the nurse should have clarified the orders with the eye doctor and updated the resident's medication orders accordingly.
Failure to Evaluate and Monitor Residents on PRN Antipsychotic Medications
Penalty
Summary
The facility failed to ensure proper evaluation and monitoring of residents on PRN antipsychotic medications. One resident, identified as R32, had an active PRN order for Seroquel, an antipsychotic medication, without a stop date, which is against state and federal guidelines that limit PRN antipsychotic orders to 14 days. The attending physician did not evaluate the resident after 14 days to determine the appropriateness of continuing the medication, as required. The Director of Nursing acknowledged that the PRN order should have been limited to 14 days, and a physician evaluation should have been conducted before reordering. Additionally, the facility did not adequately monitor another resident, identified as R11, for side effects of antipsychotic medication using the AIMS assessment. The facility's policy requires AIMS assessments every 6 months to monitor for tardive dyskinesia, a potential side effect of antipsychotic drugs. However, R11's AIMS assessments were conducted 13 months apart, and psychiatry notes indicated assessments were done 9 months apart, failing to meet the 6-month requirement. The Director of Nursing confirmed that AIMS assessments should be conducted every 6 months.
Medication Administration Errors Exceeding Acceptable Rate
Penalty
Summary
The facility failed to administer physician-prescribed medications as ordered, resulting in a medication error rate of 10.34%, which exceeds the acceptable threshold of 5%. This deficiency was observed in two residents during a medication pass. Resident R2 was supposed to receive Farxiga 5 mg and Memantine 10 mg at 9:00 AM, with an additional dose of Memantine at 5:00 PM. However, on the morning of July 16, 2024, the RN did not administer these medications because they were not available in the medication dispensing system. The Director of Nursing confirmed the omission of these medications. Resident R12 was prescribed a delayed-release Aspirin, 325 mg, to be administered once daily at 9:00 AM. Instead, an LPN administered an 81 mg enteric-coated Aspirin tablet. The facility's Medication Administration policy mandates that medications should be administered according to physician orders, which was not adhered to in these instances.
Failure to Explain Arbitration Agreement to Resident
Penalty
Summary
The facility failed to adequately inform a resident, identified as R68, about the binding arbitration agreement upon admission. During an interview, R68 stated she did not recall signing the arbitration agreement and mentioned that it was not explained to her. She expressed that she would not have signed the document if she had understood it, as she did not want to waive her right to litigation. The facility's administrator, V1, confirmed that the arbitration agreement is completed upon admission but clarified that signing it is not a requirement for admission, and residents have 30 days to rescind it. The resident's Minimum Data Set (MDS) indicated a BIMS score of 15, showing she was cognitively intact at the time. The arbitration agreement was signed on 12/3/23, but the resident did not recall being informed about it.
Failure to Adhere to PPE Protocols for Isolation and Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff wore Personal Protective Equipment (PPE) for residents on Contact Isolation and Enhanced Barrier Precautions. In the first instance, two staff members, a CNA and an LPN, entered the room of a resident on contact isolation without wearing PPE. The resident was on isolation due to a urinary tract infection caused by ESBL-producing organisms, which are resistant to common antibiotics. The CNA acknowledged that they should have worn a gown and gloves while providing care to the resident. In the second instance, a CNA provided incontinence care to another resident on Enhanced Barrier Precautions without wearing a gown. This resident had a urinary catheter and was under Enhanced Barrier Precautions as per a physician's order. The facility's policy required staff to wear gowns and gloves during high-contact care activities for residents on Enhanced Barrier Precautions. Both the RN and the Director of Nursing confirmed that staff should adhere to these requirements.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident who is dependent on staff for assistance with activities of daily living. The resident, who is cognitively intact, was observed lying in bed with a faint odor of urine and reported not being changed since 5 AM, despite being incontinent of urine and wearing a brief. The resident also mentioned taking a water pill, which could increase the frequency of urination. A Certified Nursing Assistant confirmed that the resident had not been changed that morning and acknowledged that incontinence care should be performed every 2 hours and as needed. The facility's Incontinence Care Policy, revised in 2018, also states that care should be provided every 2 hours and as needed to prevent skin breakdown.
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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