Aperion Care Oak Lawn
Inspection history, citations, penalties and survey trends for this long-term care facility in Oak Lawn, Illinois.
- Location
- 9401 South Ridgeland Avenue, Oak Lawn, Illinois 60453
- CMS Provider Number
- 145197
- Inspections on file
- 50
- Latest survey
- January 16, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Aperion Care Oak Lawn during CMS and state inspections, most recent first.
A cognitively intact, bedbound resident reported that after giving a credit card to the Business Office Manager for payment, the card was returned to the overbed table and later found missing, followed by unauthorized charges and a cash withdrawal. The resident notified staff and later spoke with police, identifying who she believed took the card. Facility leadership and staff were aware of the missing card, suspicious transactions, and information suggesting a CNA might be involved, yet no reportable incident was completed despite an abuse prevention policy that defines misappropriation as wrongful use of a resident’s belongings or money without consent.
A resident who was bedridden and cognitively intact reported that after giving a credit card to the Business Office Manager for payment, the card went missing and later showed large unauthorized charges and an ATM withdrawal. The Business Office Manager notified the Administrator, and the Resident Liaison assisted the resident in contacting the bank, which indicated it would investigate and reimburse fraudulent charges. The Social Services Director became involved after some investigation had already occurred but did not verify card possession with the resident’s POA. A police report documented that the Administrator suspected a CNA, previously linked to another stolen debit card and alleged to have discussed a scam, might be responsible. Although facility policy requires immediate reporting of suspected misappropriation of resident property to the state within a defined timeframe, no reportable was submitted for this allegation, resulting in a failure to follow the abuse prevention and reporting policy.
A resident who was bedridden and cognitively intact reported that after giving a credit card to the Business Office Manager for payment, the card went missing and later showed large fraudulent charges, including a florist purchase and an ATM withdrawal. The resident notified staff, the bank, and police, and the bank ultimately reimbursed the fraudulent transactions. The Administrator told police he believed a CNA, previously linked to another stolen debit card and reportedly talking about a scam, was responsible. However, the facility did not follow its abuse prevention policy: it did not initiate or document a thorough internal investigation, did not obtain witness statements, did not formally interview the resident or the alleged staff perpetrator, and did not file a reportable event, despite policy requirements to document and investigate all allegations of exploitation or misappropriation of resident property.
A resident dependent on staff for all ADLs and unable to communicate was found with a black eye and facial bruising. Staff did not observe the injury occur, and accounts of the incident were inconsistent and undocumented. The facility failed to report the injury of unknown origin to authorities as required by its abuse policy, and internal documentation was incomplete.
A resident dependent on staff for all ADLs and unable to communicate was found with a black eye and facial bruising. The injury was reported by a family member, but staff did not initiate a timely or thorough investigation, and there was a lack of documentation from both nursing and activity staff. The DON completed risk management documentation days after the incident, and interviews revealed no staff had witnessed the injury, contrary to initial claims. The facility did not follow its abuse policy requiring investigation and documentation of injuries of unknown origin.
A leaking toilet in a shared bathroom, used by four residents, was not effectively repaired, resulting in ongoing water leakage and wall damage. Staff and maintenance confirmed the issue persisted despite previous repair attempts, and surveyors observed water on the floor and makeshift measures to address the leak, indicating the facility did not maintain plumbing fixtures in good repair as required.
The facility did not maintain an effective pest control program, as flying pests were observed in a bathroom shared by two residents and in the dining room. Staff reported seeing bugs and a flying pest on a resident's bed, and a leaking toilet was noted. The Maintenance Director confirmed the presence of gnats and stated pest control visits occur regularly, but there was no documentation of additional pest control notification. Surveyors also observed that interior doors were left open, contrary to facility policy requiring measures to prevent pest entry.
Two residents, both with psychiatric diagnoses and identified risks for aggression and abuse, were involved in a physical altercation in the dining room after one resident backed into the other with a wheelchair. Despite care plans outlining interventions to prevent escalation, staff did not prevent the incident, resulting in minor injuries.
A resident with a history of psychiatric and behavioral issues fell in the dining room and, while attempting to get up, grabbed another resident's arm and bit her, causing a full-thickness wound that required hospital evaluation and antibiotic treatment. The incident was witnessed by staff and other residents, and the biting resident had a documented history of similar behaviors.
A CNA failed to use a mechanical lift for a dependent transfer as required by a resident's care plan, instead performing a stand and pivot transfer at the resident's request. The resident, who had morbid obesity and knee pain, sustained a non-displaced fracture and required hospitalization and surgery. Staff interviews confirmed that the correct transfer method was not followed and that refusals should be reported to nursing leadership.
A resident with Peripheral Vascular Disease and cognitive impairment did not receive proper foot care as required by facility policy. Staff failed to observe or document the resident's toenail condition during routine assessments and bathing, and the resident was not seen by the podiatrist for an extended period. This led to the development of onychomycosis, painful elongated toenails, and other foot complications, which were only addressed after a family complaint.
The facility failed to provide scheduled showers to several residents who were dependent on staff assistance, leading to unmet hygiene needs. Residents expressed dissatisfaction with not receiving showers as per their preferences, and documentation was inconsistent, with missing records for several scheduled days. The DON acknowledged the issue, confirming that showers were not consistently provided according to the schedule.
A resident with significant mobility impairments was injured during a mechanical lift transfer when a CNA attempted the procedure alone, contrary to the facility's policy requiring two staff members. The CNA placed the sling incorrectly, causing the resident to fall. Staff interviews confirmed the policy breach, and the resident's care plan specified the need for two-person assistance.
A resident with multiple health conditions reported giving cash and gifts to a CNA due to financial hardship claims. The CNA admitted to receiving gifts but denied taking cash. The facility's policy prohibits staff from accepting gifts or money from residents, highlighting a deficiency in protecting resident rights and property.
The facility failed to label food items in the walk-in refrigerator, affecting 109 residents on oral diets. Additionally, two residents' personal refrigerators were not maintained, with unlabeled food and thick ice accumulation. Staff interviews revealed confusion over responsibility for refrigerator checks, which were not conducted daily as required by policy.
The facility failed to maintain a safe environment by leaving intravenous medication and hazardous pesticides at residents' bedsides, contrary to safety protocols. Additionally, the facility did not follow physician orders for fall precautions, as residents at risk of falls lacked necessary interventions like floor mats and non-slip materials, and their care plans were not updated after fall incidents.
The facility failed to adhere to infection control practices, with observations of improperly stored nebulizer and CPAP masks, and lapses in hand hygiene by staff. Respiratory equipment was found uncovered and not dated, contrary to facility policy, and staff admitted to forgetting hand hygiene protocols. The Director of Nursing confirmed the expectations for proper storage and hand hygiene to prevent infection.
A resident's call light was ignored by staff, leaving her in distress after a bowel movement. Despite multiple calls to the facility, no assistance was provided promptly. Additionally, two CNAs entered another resident's room without knocking, violating the facility's dignity policy.
The facility failed to ensure call lights were within reach for two residents, leading to unmet needs for assistance. One resident was found yelling for help with a water pitcher spilling, while another was unable to reach their call light or water. Both residents had significant medical conditions requiring assistance, and staff acknowledged the oversight. Facility policy mandates call lights be accessible at all times.
A facility failed to accurately document a resident's advance directive, resulting in a discrepancy between the resident's signed DNR form and their health records, which listed them as full code. This inconsistency was confirmed by the Social Service Director, who found no documentation of any change in the resident's advance directives. The facility's policy requires that advance directives be documented and included in the care plan, which was not followed in this instance.
A resident with a stage 4 pressure ulcer was improperly cared for by using a low air loss (LAL) mattress with multiple layers of linen and a disposable brief, contrary to standard practice. The facility lacked a specific policy for LAL mattress usage, contributing to the improper care. The resident had multiple diagnoses, including a stage 4 sacral pressure ulcer, and was at high risk for developing pressure ulcers.
A facility failed to follow a physician's order for a resident's tube feeding administration. The resident, diagnosed with dysphagia and gastrostomy status, was observed with a disconnected feeding bottle and an off machine, contrary to the order requiring feeding to start at 10 AM. Both a nurse and the DON confirmed the oversight, which violated the facility's policy on medication administration.
A survey found that a medication cart was left open and unattended with keys attached, and pre-poured, unlabeled medications were found inside. Additionally, a medication room refrigerator containing controlled substances was unlocked. The facility's policies require secure storage of medications, which was not adhered to, leading to this deficiency.
A resident at moderate risk for skin breakdown developed three facility-acquired pressure ulcers, and an existing stage 2 ulcer deteriorated due to the facility's failure to provide necessary care. The resident, dependent on staff for all ADLs, did not receive consistent wound assessments or timely treatment orders, and there was a lack of documentation regarding noncompliance with care plans.
Two residents in a LTC facility experienced neglect by a CNA, who failed to provide timely incontinence care, leaving them in soiled briefs for hours. One resident reported severe discomfort and burning sensations due to the neglect, while the other felt unappreciated and ignored. The facility's documentation showed no record of care provided during the shift, and the incident was not initially investigated as neglect despite the facility's zero-tolerance policy.
A malfunction in the call light system affected 26 residents on the North Hall Unit. A resident experienced a delay in response after activating the call light, and staff confirmed the system was down. The Maintenance Director was not informed until the next day, and the issue was linked to older systems affected by power surges. The facility lacked documentation on the outage duration and how residents' needs were managed without the system.
Two residents reported an incident where a CNA failed to respond to a call light, resulting in discomfort due to incontinence. The CNA was described as confrontational and did not return to provide care for the remainder of the shift. The facility's policy requires immediate protection of residents and timely investigation of allegations, which was not followed.
A resident with no cognitive impairment expressed that her request to be put to bed by 8 PM was ignored by a CNA, who instead put her to bed around 9:30 PM. This made the resident feel upset and disrespected. The facility's policy emphasizes respecting residents' preferences, but interviews and Resident Council Minutes suggest that CNAs sometimes ignore such requests.
A resident with a history of chronic pulmonary embolism experienced leg swelling and pain, prompting a nurse to order a stat venous doppler ultrasound. Despite the urgency, the ultrasound was delayed until several days later, revealing a blood clot. The facility's EMR lacked documentation of the physician's notification and the delay, and there was no policy on testing timeframes.
A resident with mobility issues fell during a transfer when a CNA failed to use a gait belt, as required by the care plan. The resident was unsteady and fell while attempting to turn, despite the facility's policy mandating the use of transfer conveyances.
A resident's medications were left unattended at the bedside, contrary to the facility's policy. The LPN responsible for the resident's care incorrectly charted the medications as administered. The resident's care plan did not authorize self-administration, and the DON confirmed that medications should not be left at the bedside.
A resident, who was always incontinent and cognitively intact, did not receive timely incontinence care, resulting in her being soaked with urine and experiencing skin redness. Despite requesting assistance, the resident was ignored by a CNA. The care plan required checks every two hours, but this was not followed, as confirmed by other CNAs. Previous Resident Council Meeting Minutes also noted similar complaints about untimely care.
The facility failed to implement CDC COVID-19 guidelines by not ensuring proper PPE use for residents on isolation. A resident with COVID-19 had their door left open, and another resident visited without wearing a face shield, contrary to the facility's infection control policy.
A facility failed to supervise a high fall risk resident with cognitive impairment, resulting in falls and injuries. Another resident with Alzheimer's and exit-seeking behavior eloped, found a mile away, confused and cold. Staff were unaware of risks, and alarm systems failed, contributing to these incidents.
A resident with vascular dementia and hemiplegia was left cold, wet, and uncomfortable due to the facility's failure to provide timely incontinence care. Despite being dependent on staff for toileting, the resident did not receive care during the day shift, as confirmed by a CNA and the DON. The facility's policy requires care every two to three hours, but records showed the last care was provided early in the morning.
A resident with a seizure diagnosis did not have their Keppra levels monitored weekly as ordered, with only one nontherapeutic level documented. Additionally, nurses crushed the resident's Keppra tablets despite pharmacy recommendations against it, potentially affecting the medication's absorption and efficacy.
Failure to Report and Protect Resident From Suspected Misappropriation of Credit Card
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse prevention policy and protect a resident from staff-to-resident misappropriation of property. A cognitively intact, bedbound resident with a BIMS score of 15/15 and a documented moderate risk for abuse reported that after admission, she gave her credit card to the Business Office Manager to process a payment. The Business Office Manager returned the card and receipt, placing them on the resident’s overbed table. Later, when the resident attempted to put the card back into her zippered pouch, she could not find it and notified the Business Office Manager. The resident subsequently became aware of two unauthorized transactions on her account: a $500 charge to a florist and an $800 cash withdrawal plus a $2.50 fee. The resident stated she was instructed to freeze the card and later spoke with police, to whom she identified who she thought could have taken the card. She reported feeling unnerved and scared that this occurred in the nursing home. Interviews and record reviews showed that facility leadership and staff were aware of the missing credit card and suspicious charges but did not treat the event as a reportable misappropriation under the abuse prevention policy. The Administrator acknowledged that the resident’s credit card was missing and that there were unfamiliar charges, and indicated that the Resident Liaison knew more details. The Resident Liaison reported the missing card to the Social Services Director and contacted the bank with the resident, learning that the bank would investigate and potentially reimburse the charges, but stated she did not know why a reportable was not completed. The Social Services Director stated that by the time she followed up, the bank had already reimbursed the resident and she did not confirm with the resident’s POA that the card was in the POA’s possession. A police report documented that the Administrator told law enforcement he believed a CNA, previously associated with another resident’s stolen debit card and who had spoken about having a “scam system” at the facility, was responsible. Despite this information and the facility’s written policy defining misappropriation of resident property as wrongful use of a resident’s belongings or money without consent, no reportable incident was made by the facility for this event.
Failure to Timely Report Alleged Staff-Related Credit Card Theft
Penalty
Summary
The facility failed to follow its abuse prevention and reporting policy by not reporting an allegation of staff-to-resident theft to the State Survey Agency within the required timeframe. A cognitively intact resident with a BIMS score of 15/15, assessed as at moderate risk for abuse, reported that after admission she provided her credit card to the Business Office Manager to process a payment. The card and receipt were returned and placed on the overbed table, but later, when the resident attempted to put the card back into her zippered pouch, she could not find it. The resident, who is bedridden and does not leave her room, subsequently became aware of unusual activity on her bank account, including a large florist charge and a cash withdrawal with an associated fee, and was instructed to freeze the card. The resident reported the missing card to the Business Office Manager, who stated she informed the Administrator and that the police were notified and a report made. The Administrator acknowledged that the resident’s credit card was missing and that there were unfamiliar charges, and indicated that the Resident Liaison had more information because she had been on the phone with the resident and the bank. The Resident Liaison reported that she contacted the bank with the resident, was told the bank would investigate the pending charges and reimburse the resident if they were fraudulent, and stated she did not know why a reportable was not completed. The Social Services Director stated she was asked to see the resident about the missing card, that the Resident Liaison had already done some of the investigation, and that by the time she followed up, the bank had reimbursed the resident; she did not confirm with the resident’s POA that the POA had the card. A police report documented that the officer spoke with the Administrator, who indicated he believed a CNA assigned to the resident’s room on the day the card was used at an ATM was responsible, and that this CNA had previously been assigned to another resident whose debit card had been stolen and had spoken about having a scam system at the facility. The police contacted the resident’s POA, who was aware of the incident but did not know all the details, and received the resident’s bank statement. The facility’s abuse prevention and reporting policy requires employees to immediately report any incident, allegation, or suspicion of misappropriation of resident property to the Administrator and to inform the Department of Public Health’s regional office by telephone or fax not later than two hours after forming the suspicion, with a complete written report within five working days. Despite these policy requirements and the Administrator’s expressed suspicion of staff involvement, no reportable was made to the State Survey Agency for this event, constituting the deficiency.
Failure to Investigate Alleged Misappropriation of Resident Credit Card
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse prevention and reporting policy in response to an allegation of misappropriation of a resident’s property. A cognitively intact resident with a BIMS score of 15/15, who is bedridden and does not leave her room, reported that after admission she provided her credit card to the Business Office Manager to process a payment. The card was returned and placed on her overbed table, but when the resident later attempted to put it back into her zippered pouch, she could not find it. The resident subsequently became aware of unusual activity on her bank account, including a $500 charge to a florist and an $800 cash withdrawal plus a $2.50 fee, and she was instructed by the bank to freeze the card. The resident reported the missing card to facility staff, including the Business Office Manager, who stated she notified the Administrator and that the police were contacted. The Administrator, Resident Liaison, and Social Services Director each acknowledged awareness of the missing credit card and the fraudulent charges, and the Resident Liaison assisted the resident in contacting the bank. The bank later reimbursed the resident for the fraudulent charges. The resident told surveyors she felt unnerved and scared by the event, especially given that she had been robbed before in the community and did not expect this to occur in a nursing home. The resident also informed police whom she suspected might have taken the card, referencing a CNA who had asked her about how she picked her lucky numbers. A police report documented that the Administrator told law enforcement he believed a CNA assigned to the resident’s room on the day the card was used at an ATM was responsible, and that this CNA had also been assigned to another resident whose debit card had been stolen and had spoken about having a scam system at the facility. Despite this, the facility was unable to provide any documentation that an internal investigation was initiated in accordance with its abuse prevention policy. There was no evidence of an investigation file, no witness statements, no documented interview of the resident, and no interview of the alleged perpetrator. The facility’s written policy requires that all incidents or allegations involving exploitation or misappropriation of resident property be documented and investigated, including interviews with the reporter, the resident, and others with direct knowledge, but these steps were not carried out or documented in this case, and no reportable event was filed by the facility.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to follow its abuse policy by not reporting an injury of unknown origin for a resident who was dependent on staff for all Activities of Daily Living (ADLs) and unable to communicate verbally. The resident, who had a history of epilepsy, cerebral palsy, pressure ulcers, falls, and required full staff assistance, was found by a family member to have a black eye and bruising around the left eye. The family member reported the injury to staff, but the administrator stated that staff had witnessed the resident hitting her head on a table, attributing the injury to self-harm. However, the family member disputed this, stating the resident did not exhibit such behaviors. The resident's assessment indicated no documented mood or behavioral issues and a high level of cognitive impairment, making self-reporting impossible. Further investigation revealed inconsistencies in staff accounts. The activity aide who was believed to have witnessed the incident was unsure if the resident had actually hit her head and did not report the incident immediately. The nurse on duty did not document the event or complete the required risk management process, which was only finalized by the DON nearly two weeks later. Multiple staff interviewed could not confirm witnessing the injury or explain its origin. The facility's abuse prevention policy required reporting injuries of unknown source, especially when the source was not observed and the injury was suspicious. Despite this, the injury was not reported to the state agency as required, and internal documentation was incomplete.
Failure to Investigate and Document Injury of Unknown Origin
Penalty
Summary
The facility failed to follow its abuse policy by not initiating and thoroughly investigating an injury of unknown origin for a resident who was dependent on staff for all activities of daily living (ADLs) and unable to communicate verbally. The resident, who had a complex medical history including epilepsy, cerebral palsy, pressure ulcers, a history of falls, and was frequently incontinent, was found by a family member to have a black eye and bruising around the left eye. The family member reported the injury to staff, but the administrator stated that staff had witnessed the resident hitting her head on the table, attributing the injury to self-harm. However, the family member disputed this explanation, stating the resident did not have such behaviors. Further investigation revealed inconsistencies and lack of documentation. The Director of Nursing (DON) indicated that an activity aide reported the incident to a nurse, but the nurse did not document the event or complete a risk management report at the time. The DON later completed the risk management documentation days after the incident. Interviews with staff who worked with the resident around the time of the injury showed that none witnessed the resident hitting her head, and there was no progress note or assessment documenting the injury. The facility's abuse prevention policy required all incidents, including those of unknown origin, to be documented and investigated, but this was not followed in this case.
Failure to Maintain Sanitary and Homelike Environment Due to Unrepaired Leaking Toilet
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment by not effectively repairing a leaking toilet in a shared bathroom used by four residents. A CNA reported observing the leak early in her employment, and the Maintenance Director confirmed that the toilet had been previously repaired but continued to leak, resulting in water damage to the wall extending into the residents' room. During facility tours, surveyors observed a white sheet placed on the floor to absorb water and a puddle of water present in the bathroom, indicating the issue persisted despite reported repairs. Facility records and interviews confirmed that the plumbing fixtures were not maintained in good repair, as required by facility policy and resident rights.
Failure to Maintain Effective Pest Control Program for Flying Pests
Penalty
Summary
The facility failed to maintain an effective pest control program and policy for the treatment of flying pests, specifically affecting two residents. A CNA reported observing bugs in the bathroom shared by two residents and witnessed a flying pest land on one resident's bed while providing care. During a tour of the bathroom with the Maintenance Director, flying pests, identified as gnats, were observed, and a leaking toilet was also noted. The Maintenance Director stated that pest control services the facility twice a month and is available for additional visits if concerns arise, but there was no documentation provided to show that pest control was notified for an as-needed appointment in response to the observed pests. Further observations during lunch revealed the presence of flying pests in the dining room. The facility's entrance consists of automatic doors leading to a foyer and another set of automatic closing doors to the interior. During the survey, the interior doors were observed to be left open, which could allow pests to enter. The facility's pest control policy requires regular and as-needed pest control, as well as environmental measures such as keeping doors closed to prevent pest entry. However, the facility did not adhere to these procedures, as evidenced by the open doors and lack of documentation of pest control notification.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to follow its abuse prevention policy and did not prevent a resident-to-resident physical altercation involving two residents. One resident, with a diagnosis of schizoaffective disorder and a history of poor impulse control, was identified in the care plan as having the potential to be physically or verbally aggressive, with interventions specified to de-escalate agitation and guide the resident away from sources of distress. The other resident, diagnosed with schizophrenia, was care planned for risk of abuse with interventions to observe the resident when in the company of peers. Despite these care plans, an incident occurred in the dining room where one resident backed into another with a wheelchair, leading to a physical altercation in which both residents struck each other, resulting in minor scratches to one resident's face. Staff were present during the incident and intervened immediately, but the altercation had already escalated to physical contact. Interviews and statements from the residents and staff confirmed that the incident was intentional and not accidental. The facility's abuse prevention policy requires identification of residents at risk for abuse and implementation of interventions to reduce the chances of abuse, as well as ongoing monitoring and updating of care plans. However, the failure to effectively implement these interventions and supervise the residents led to the occurrence of physical abuse between residents.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to ensure that a resident was free from physical abuse by another resident, resulting in a significant incident in the dining room. Early in the morning, a non-verbal resident with a low BIMS score and multiple psychiatric diagnoses, including delusional disorder, schizophrenia, and intellectual disability, stood up from his wheelchair, lost his balance, and fell to the floor. While attempting to get up, he inadvertently grabbed the forearm of another resident who was seated nearby. Startled by the contact, the second resident attempted to pull her arm away, which led to her arm pressing against the first resident's mouth, resulting in a human bite to her right forearm. The incident was witnessed by staff and other residents, who confirmed that the biting occurred quickly as the first resident tried to regain his balance. The injured resident was immediately escorted to the nurse's station, evaluated, and sent to the hospital for further assessment and treatment, which included antibiotics and a tetanus shot. The wound was described as a full-thickness, open area with no signs of infection at the time of evaluation. The biting resident was also assessed and transferred to the hospital for psychiatric evaluation. Prior to the incident, the biting resident had a documented history of physical abuse toward staff and other residents, related to poor impulse control, and his care plan had been revised to reflect these behaviors. The facility's policy affirms the right of residents to be free from abuse and outlines steps for prevention and reporting, including immediate evaluation and separation of residents involved in altercations. Despite these policies and the known behavioral risks, the incident occurred, resulting in physical harm to a resident.
Failure to Use Mechanical Lift Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to use a mechanical lift for a dependent resident transfer, as required by the resident's care plan and facility policy. The resident, who had diagnoses including morbid obesity, right knee pain, and osteoarthritis, requested incontinence care and refused the mechanical lift, insisting on a stand and pivot transfer. The CNA, despite knowing the care plan required a mechanical lift with two staff, complied with the resident's request and performed a stand and pivot transfer alone. After the transfer, the resident complained of right leg pain, which led to the discovery of a non-displaced oblique fracture through the lateral plateau of the right tibia and fibula. The resident was subsequently transferred to the hospital and underwent surgery. Interviews with staff revealed that the CNA was aware of the correct transfer method by referencing the care card and acknowledged that she should have informed the nurse of the resident's refusal and sought assistance. Other staff members confirmed that they follow the care card instructions and notify the charge nurse if a resident refuses the recommended transfer method. The Director of Nursing and Administrator both stated that staff are expected to follow the care plan and report refusals to ensure resident safety. The facility's policy mandates the use of mechanical lifts for residents requiring two-person assistance or who cannot be safely transferred by normal techniques, and staff are trained annually on these procedures.
Failure to Provide and Document Required Foot Care for Resident with PVD
Penalty
Summary
The facility failed to follow its nail care policy by not observing or documenting the condition of a resident's toenails during weekly skin assessments and bathing. Despite the resident's care plan specifying daily foot inspections and reporting of changes, there was no documentation of toenail overgrowth or fungal presence in the resident's records from January to April. Shower sheets and weekly nursing skin assessments lacked any mention of the toenail condition, and some assessments were not documented at all. The resident involved had multiple diagnoses, including Peripheral Vascular Disease, Alzheimer's Disease, hypertension, and chronic kidney disease, and was at risk for skin integrity issues. The resident's toenails became overgrown, thickened, yellow, and developed onychomycosis, with associated pain and subungual debris. The podiatrist had not seen the resident for nine months, despite the facility's process for scheduling podiatry visits and the resident's risk factors requiring regular foot care. The omission was only identified after a family grievance prompted an emergency podiatry visit. Interviews with staff revealed that the resident was not included on the podiatrist's list due to an oversight, and there was no documentation of communication with the family regarding concerns about foot care. The facility's own assessment and nail care policy required observation and documentation of nail conditions, especially for residents with PVD, but these procedures were not followed, resulting in the resident developing significant toenail and foot issues.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to provide showers to residents who were dependent on staff for assistance, according to the facility's protocol and the residents' preferences. This deficiency was observed in eight out of twelve residents reviewed for showers during March 2025. Residents expressed dissatisfaction with not receiving showers as scheduled, leading to feelings of uncleanliness and discomfort. The facility's documentation was inconsistent, with several instances where there was no record of showers being given or refused. Specific cases highlighted include a resident with hemiplegia and hemiparesis who only received one shower during the month, despite being scheduled for two showers per week. Another resident, dependent on two or more helpers, reported not receiving daily showers as preferred, with documentation missing for several scheduled days. A resident with diabetes and difficulty walking reported not receiving any showers during their stay, despite being scheduled for twice-weekly showers. The Director of Nursing (DON) acknowledged the lack of documentation and confirmed that showers were not consistently provided as per the schedule. The facility's policy requires showers to be offered according to residents' preferences and documented if refused. However, the report indicates a failure to adhere to this policy, resulting in unmet hygiene needs for several residents.
Failure to Follow Two-Person Assist Policy During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure resident safety by not adhering to the policy requiring two staff members to be present during a mechanical lift transfer. This deficiency was highlighted when a Certified Nursing Assistant (CNA) attempted to transfer a resident, identified as R4, using a mechanical lift by herself. The CNA placed the sling on backwards, resulting in the resident sliding out of the sling and onto the floor. Interviews with staff members, including the Director of Nursing and Licensed Practical Nurses, confirmed that mechanical lift transfers are supposed to be a two-person assist, which was not followed in this incident. The resident involved, R4, has a medical history that includes conditions such as morbid obesity, cerebral palsy, and paraplegia, making her highly dependent on assistance for mobility and self-care. Her care plan specifically indicates the need for a mechanical lift with two staff members for transfers. The incident report and staff interviews revealed that the CNA did not request assistance, citing insufficient staffing during night shifts as a reason for performing the transfer alone. The facility's policy on transfers and fall prevention program emphasizes the necessity of using mechanical lifts with two caregivers to ensure resident safety, which was not adhered to in this case.
Failure to Prevent Staff from Accepting Gifts from Resident
Penalty
Summary
The facility failed to adhere to its abuse policy and employee handbook by allowing a staff member, identified as a Certified Nursing Assistant (CNA), to accept gifts from a resident. The resident, who has a history of cerebral palsy, paraplegia, epilepsy, neuromuscular dysfunction of the bladder, and bipolar disorder, reported giving the CNA cash and physical gifts over several months. The resident stated that the gifts were given because the CNA mentioned facing financial hardships, and there was an understanding that the money would be repaid, which did not occur. The resident's mental status was assessed as alert and oriented times three. The facility's investigation revealed that the CNA admitted to receiving physical gifts from the resident but denied accepting any cash. The CNA claimed to have immediately reported the gifts to the management and returned them to the administrator. However, the resident insisted that cash was also given, although there were no receipts to substantiate this claim. The facility's policy prohibits staff from accepting any gifts or money from residents, and the CNA was educated on this policy after the incident. Interviews with the resident's family member and facility staff, including the Social Service Director and Director of Nursing, confirmed the resident's tendency to offer gifts and money to staff. The facility's employee handbook and abuse prevention policy clearly state that accepting gifts or money from residents is prohibited and considered a form of abuse or misappropriation of property. Despite the CNA's denial of accepting cash, the facility's failure to prevent the acceptance of gifts from the resident constitutes a deficiency in protecting the resident's rights and property.
Deficiencies in Food Storage and Refrigerator Maintenance
Penalty
Summary
The facility failed to adhere to its Food Storage Policy by not labeling two bowls of gelatin with the date in the walk-in refrigerator, which could potentially affect 109 residents on an oral diet. During an observation, the Dietary Manager acknowledged the oversight and removed the gelatin. The Dietary Director confirmed that the facility's policy requires all food items to be labeled to determine their freshness. This deficiency was identified during a survey, highlighting a lapse in following established food storage protocols. Additionally, the facility did not maintain personal refrigerators for two residents, R42 and R106, as observed during the survey. Both residents' refrigerators contained multiple unlabeled and undated food containers, and the freezers had thick ice accumulation. The temperature logs for these refrigerators had not been updated since October 21st. Interviews with staff revealed confusion over responsibility for checking and maintaining these refrigerators, with the Maintenance Director admitting to checking them only weekly due to time constraints. The facility's policy mandates daily temperature checks and proper labeling of resident food items, which was not followed in these cases.
Failure to Ensure Resident Safety and Adherence to Physician Orders
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents. Observations revealed that intravenous medication and hazardous pesticides were left at residents' bedsides, which is against the facility's policy. Specifically, a resident was found with intravenous medication on their bedside table, and another resident had a pesticide spray on their bedside table. Both the Assistant Director of Nursing and the Director of Nursing confirmed that these items should not be left at the bedside, indicating a lapse in adherence to safety protocols. Additionally, the facility did not follow physician orders regarding fall precaution measures for residents at risk of falls. One resident, who had a history of falls and was at risk due to multiple health conditions, did not have a floor mat as ordered by the physician, and their fall care plan was not updated after a fall incident. Another resident, also at risk of falls, did not have the required non-slip material in their wheelchair, and their fall care plan was similarly not updated after a fall. These oversights demonstrate a failure to implement necessary interventions and update care plans based on root cause analysis after fall incidents.
Infection Control Deficiencies in Respiratory Equipment Handling and Hand Hygiene
Penalty
Summary
The facility failed to ensure proper infection control practices in handling oxygen and respiratory equipment, as well as in performing hand hygiene during resident care. Observations revealed that nebulizer masks were improperly stored, with some hanging from drawers without plastic coverings or dates, and nebulizer machines placed on the floor. Staff members, including the Restorative Nurse and Director of Nursing, acknowledged the improper storage and lack of labeling, which is against the facility's policy that requires respiratory equipment to be stored in plastic bags with the date of the last change. Additionally, staff failed to perform hand hygiene as required by the facility's policy. A Certified Nursing Assistant was observed removing gloves and exiting a resident's room without performing hand hygiene, admitting to forgetting the procedure. The Director of Nursing confirmed that all staff are expected to follow hand hygiene protocols, which include washing hands before and after glove use and when entering or exiting a resident's room. Further deficiencies were noted in the handling of CPAP and oxygen equipment. Several residents' CPAP masks were found uncovered and improperly stored, either on the floor or on bedside tables, without being placed in plastic bags as required. The Director of Nursing and other staff members confirmed that CPAP masks should be cleaned and stored in bags to prevent contamination. The lack of proper labeling and storage of oxygen tubing and canisters was also observed, with staff acknowledging the importance of dating these items to track when they need to be changed to prevent bacterial growth.
Failure to Respond to Call Light and Ensure Resident Privacy
Penalty
Summary
The facility failed to respond promptly to an activated call light for a resident, identified as R33, who was observed lying on her bed and had attempted to contact the facility multiple times. R33's call light was within reach, and she activated it at 10:15 AM. Despite eight staff members passing by her room between 10:15 AM and 10:30 AM, none stopped to check on her needs. R33 had called the facility's main line three times, indicating she had a bowel movement and needed assistance. She expressed distress over her situation, stating she felt undignified and preferred death over her current state. The facility's policy requires call lights to be answered promptly, but this was not adhered to in R33's case. Additionally, the facility failed to ensure privacy and dignity for another resident, R50, when two CNAs entered her room without knocking. Both CNAs admitted to not knocking before entering. The Director of Nursing stated that all staff should knock and wait for a response before entering a resident's room. The facility's policy on dignity emphasizes maintaining residents' dignity by protecting their private space, which includes knocking on doors and requesting permission before entering.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that residents' call lights were within reach, as observed in two cases. On November 7, 2024, a resident identified as R232 was found yelling for help because their call light was on the floor behind the bed, and they were unable to prevent a water pitcher from spilling. The Licensed Practical Nurse confirmed that the call light should have been within reach. The Director of Nursing also stated that all call lights should be accessible to residents. R232 had a diagnosis of dysphagia and required assistance with personal care, with a care plan emphasizing the need for the call light to be within reach and for prompt responses to requests for assistance. Another resident, R10, was observed in a similar situation on the same day. R10 was lying on their right side in bed, unable to reach their call light, which was on the floor, and requested water. The Assistant Director of Nursing acknowledged the oversight and repositioned the call light and water pitcher within reach. R10 had multiple medical conditions, including a transient ischemic attack, cerebral infarction, Parkinson's disease, and an above-the-knee amputation, which contributed to their limited mobility and need for assistance. The facility's policy requires that call lights be accessible to residents at all times, but this was not adhered to in these instances.
Failure to Accurately Document Advance Directive
Penalty
Summary
The facility failed to ensure that a resident's advance directive was accurately reflected in their health records. During an observation, it was noted that the resident's name was not on the active DNR list at the South nurse's station, despite having a signed DNR/POLST form indicating Do Not Attempt Resuscitation. A review of the resident's clinical dashboard and physician's orders showed the resident was listed as full code, which contradicted the signed DNR form. The care plan also indicated full code status, including resuscitation and mechanical ventilation, which was inconsistent with the resident's documented wishes. The Social Service Director confirmed the discrepancy during an interview, acknowledging the absence of documentation indicating any change in the resident's advance directives. The resident's admission record and order summary report also reflected full code status, despite the signed DNR form. The facility's policy on advance directives requires that such directives be documented in the resident's medical record and included in the care plan, which was not adhered to in this case. This oversight could lead to staff mistakenly attempting resuscitation against the resident's wishes.
Improper Use of Low Air Loss Mattress for Resident with Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to adhere to standard care practices for a resident with a stage 4 pressure ulcer by improperly using a low air loss (LAL) mattress. During an observation, the resident was found lying on their right side on an LAL mattress with a flat sheet and cloth pad, while also wearing a disposable brief. This setup contradicts the facility's standard practice, which requires only a flat sheet over the mattress for residents using LAL mattresses. The Assistant Director of Nursing was unaware of the policy regarding the use of multiple layers of linen with LAL mattresses, and the Director of Nursing confirmed that only a flat sheet should be used. The resident involved was admitted with multiple diagnoses, including a stage 4 sacral pressure ulcer, and was under the care of a wound care physician. The resident's care plan included the use of a pressure-reducing mattress and regular skin assessments, indicating a high risk for developing pressure ulcers. Despite these measures, the facility lacked a specific policy for LAL mattress usage, which contributed to the improper care observed. The facility's policy on pressure ulcer prevention, revised in 2028, outlines the use of specialty mattresses for residents with severe wounds but does not provide specific guidance for LAL mattress usage.
Failure to Follow Physician's Order for Tube Feeding
Penalty
Summary
The facility failed to ensure that the physician's order for tube feeding administration was followed for a resident diagnosed with dysphagia and gastrostomy status. During a facility round, it was observed that the resident's tube feeding bottle was hanging on a pole but not connected to the resident, and the feeding machine was off. The resident mentioned that he receives feeding during the day and that staff usually administers it. A registered nurse confirmed that the feeding should have been on according to the physician's order. The Director of Nursing also acknowledged that the physician's order, which specified the feeding should start at 10 AM, was not followed. The order required the administration of enteral feeding via a pump at 70 ml/hr for 20 hours, starting at 10 AM and stopping at 6 AM. The facility's policy mandates that medications, including tube feedings, are administered as prescribed by the physician.
Medication Storage and Security Deficiency
Penalty
Summary
The facility failed to ensure the safe and secure storage of medications, as observed during a survey. On one occasion, a medication cart in the East side hallway was found open and unattended with keys attached to the cart lock. A Licensed Practical Nurse (LPN) acknowledged that medication carts should be locked when not in use and that keys should be handed over to another nurse if the nurse on duty takes a break. Additionally, the LPN opened the cart to reveal three medication cups with pre-poured, unlabeled medications, which is against the facility's policy that prohibits pre-filled medication cups being left inside the cart. Further observations revealed that the medication room refrigerator was unlocked, despite containing controlled substances that require refrigeration. The Director of Nursing confirmed that medication cart keys should not be left on the cart and that medication room refrigerators should be locked at all times. The facility's policies clearly state that medications and biologicals must be stored securely and that controlled substances requiring refrigeration should be kept in a locked box within the refrigerator. These lapses in following the facility's policies led to the deficiency noted in the survey.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to prevent a resident, identified as being at moderate risk for skin breakdown and totally dependent on staff for all activities of daily living, from developing three facility-acquired pressure ulcers. The resident, who had a history of quadriplegia, colostomy, and a stage 2 pressure ulcer on the left hip upon admission, developed unstageable pressure ulcers on the coccyx, right hip, and right lateral foot. Additionally, the existing stage 2 pressure ulcer on the left hip deteriorated to an unstageable wound. The facility did not provide the necessary care and services to promote healing of the existing wound upon admission. The Wound Care Nurse (V4) was responsible for assessing residents' skin on admission and implementing preventative measures. However, there was no documentation of weekly skin observations for the resident on certain dates, and the facility's policy for skin assessment and monitoring was not followed. The Wound Care Nurse Practitioner (V5) ordered a CRP level due to a new wound, but was not informed of the elevated result. The Director of Nursing (V2) noted the resident's noncompliance with turning and offloading heels, but there was no documentation of this noncompliance or notification to the resident's power of attorney until a care plan was initiated. The resident's treatment administration records lacked documentation of dressing changes on multiple occasions, and there were no physician orders for wound care treatments for the newly identified wounds until much later. The facility's policy required weekly assessments and documentation of changes, but these were not consistently completed. The facility's failure to adhere to its own policies and procedures contributed to the deterioration of the resident's wounds and the development of new pressure ulcers.
Neglect of Residents by CNA
Penalty
Summary
The facility failed to prevent neglect of two residents, R3 and R4, by a Certified Nursing Assistant (CNA), identified as V4. R3, who is dependent on staff for activities of daily living due to conditions such as osteoarthritis, morbid obesity, and chronic respiratory failure, reported being left in soiled incontinence briefs for multiple hours. This neglect caused severe discomfort and burning sensations in areas of open skin. R3's call for assistance was ignored by V4, prompting R3 to contact the front desk and a family member for help. R3 also reported that V4 was confrontational and rough when care was finally provided, and did not return to the room for the remainder of the shift. R4, the roommate of R3, is also totally dependent on staff for all activities of daily living and is incontinent of bowel and bladder. R4 confirmed witnessing the interaction between R3 and V4 and stated that V4 did not return to provide incontinence care for the entire shift. R4 expressed feelings of neglect and being unappreciated. Documentation reviewed for the date in question showed no record of incontinence care being provided to either resident during the shift in question. The facility's policy on abuse prevention and reporting defines neglect as the failure to provide necessary goods and services to avoid physical harm, pain, or mental anguish. Despite the facility's zero-tolerance policy for abuse and neglect, the incident was not initially investigated as neglect. The Administrator in Training, V2, was informed of the complaint but did not speak with R4 or other residents to assess if others were experiencing similar neglect. The grievance form filed did not elaborate on the nature of the concern, and no progress note was available in the health record.
Call Light System Malfunction Affects 26 Residents
Penalty
Summary
The facility failed to ensure that the call light system was operational, affecting 26 residents on the North Hall Unit. A resident reported activating the call light from bed and experiencing a delay in response, later being informed by staff that the system was malfunctioning. The call lights were not operational until the following day. The Maintenance Director confirmed that the call light system was down for the entire building and was not notified of the issue until the morning after it occurred. The system's failure was attributed to older systems being affected by storms or power surges, requiring a manual reset. The Wound Care Coordinator and the Administrator in Training were aware of the call light system's malfunction over two days. A work order maintenance binder indicated requests for repairs on both days, but the facility could not provide documentation on the duration of the outage or how staff managed residents' needs without the system. The facility's call light policy requires defects to be reported promptly to the Maintenance Department, with frequent room checks until repairs are completed.
Failure to Investigate Allegation of Abuse and Neglect
Penalty
Summary
The facility failed to investigate an allegation of abuse and neglect involving two residents. One resident, who is dependent on staff for activities of daily living, reported an incident where a CNA failed to respond to their call light, resulting in discomfort due to incontinence. The resident described the CNA as confrontational, rude, and rough with care, and stated that the CNA did not return to provide care for the remainder of the shift. The resident's roommate, who is also dependent on staff, confirmed witnessing the interaction and the lack of care provided by the CNA. The facility's Wound Care Coordinator received a complaint from the resident and reported it to the Administrator in Training, who spoke with the resident but did not interview the roommate or other residents. The Administrator in Training relayed the information to the Administrator, who did not investigate further as the concern of neglect was not communicated. The facility's policy requires immediate protection of residents and timely investigation of allegations, which was not followed in this case.
Failure to Honor Resident's Bedtime Preference
Penalty
Summary
The facility failed to ensure that a resident, identified as R5, was treated with dignity and respect, as evidenced by the resident's unfulfilled request to be put to bed by 8 PM. R5, who has no cognitive impairment, expressed that she was very tired by 8 PM and had repeatedly asked a Certified Nursing Assistant (CNA), identified as V13, to assist her to bed at that time. However, R5 reported that V13 consistently ignored her request and instead put her to bed around 9:30 PM, which made R5 feel upset and disrespected. Interviews with the CNA, V13, revealed that V13 could not recall the exact time R5 was put to bed, despite confirming that R5 was alert and able to verbalize her needs. Another CNA, V10, noted that R5 was particular about her care and that she followed R5's directions regarding her care needs. The Director of Nursing, V2, acknowledged that residents should be treated with dignity and respect, and their preferences should be honored. Additionally, Resident Council Minutes indicated that CNAs were generally good but sometimes ignored residents' requests. The facility's policy on dignity emphasized the importance of maintaining or enhancing each resident's dignity and respecting their individual needs and preferences.
Delayed Ultrasound for Resident with Leg Swelling and Pain
Penalty
Summary
The facility failed to ensure a venous doppler ultrasound was performed in a timely manner for a resident with a history of chronic pulmonary embolism. The resident reported swelling and pain in her legs on a Friday, and a nurse ordered a stat ultrasound on Saturday. However, the ultrasound was not performed until the following Tuesday, despite repeated calls to the ultrasound company. The delay in performing the ultrasound resulted in the resident being sent to the hospital after the test confirmed a blood clot in her leg. The facility's electronic medical record (EMR) lacked documentation of the physician or nurse practitioner being notified of the resident's condition, the order for the ultrasound, or the delay in performing the test. The Director of Nursing acknowledged the absence of a policy on timeframes for specific testing and the lack of documentation in the EMR. The nurse practitioner expected the ultrasound to be done immediately and to be informed if it was not performed within four hours, which did not occur.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to ensure the safe transfer of a resident by not using a gait belt, which is a required safety measure according to the resident's care plan. The incident involved a female resident with multiple health issues, including difficulty walking and reduced mobility. During an observation, a Certified Nursing Assistant (CNA) assisted the resident in standing up from the bed without using a gait belt. The resident, who was unsteady and holding onto the bed rail and wheelchair arm, fell to the floor as she attempted to turn. The resident's care plan, dated June 2024, indicated that she was at risk for falls and required substantial assistance for transfers, including the use of a gait belt. The facility's Fall Prevention Program Policy also mandated the use of transfer conveyances in accordance with the care plan. Despite these guidelines, the CNA did not use a gait belt during the transfer, leading to the resident's fall. Interviews with facility staff confirmed that the use of a gait belt was standard procedure for transferring this resident.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered properly and not left at the bedside, affecting one of the three residents reviewed for medication administration. On September 6, 2024, a medication cup with three pills was found on the bedside table of a resident who was not present in her room. The resident's roommate confirmed that nurses frequently leave medications at the bedside, raising concerns about the potential for others to take the medications. A Certified Nursing Assistant noted that the resident is hard of hearing and forgetful, which may contribute to the issue. A Licensed Practical Nurse, responsible for the resident's care on the day of the incident, admitted to leaving the medications at the bedside and incorrectly charting that they had been administered. The resident's care plan did not indicate that she was capable of self-administering her medications. The Director of Nursing confirmed that medications should not be left at the bedside and that staff should ensure residents take their medications before leaving the room. The facility's Pharmaceutical Services Policy emphasizes the need for assistance with medication administration as needed or requested.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, identified as R1, who was cognitively intact and always incontinent. On the day of the incident, R1 was found soaked with urine, with her pants and wheelchair pad saturated, and her skin reddened with indentations from the brief. R1 reported not receiving incontinence care since 6:00 am, despite requesting assistance around noon, which was ignored by the assigned CNA, V19. Both CNAs, V8 and V9, confirmed that R1 should have been changed every two hours and as needed, and R1 had never refused care. The resident's care plan indicated that incontinence checks and changes should occur upon waking, before and after meals, and at bedtime. The Resident Council Meeting Minutes from April and May 2024 also documented complaints about CNAs not changing residents in a timely manner. The Assistant Director of Nurses, V2, stated that staff are expected to check residents every two hours and change linens if they are wet, to maintain dignity and prevent skin breakdown. The facility's incontinence care policy, revised in April 2021, emphasized the importance of regular checks to prevent skin issues and maintain resident dignity.
Failure to Implement CDC COVID-19 PPE Guidelines
Penalty
Summary
The facility failed to implement CDC practices for COVID-19 by not ensuring the appropriate use of personal protective equipment (PPE) for residents on contact/droplet precautions and in isolation. This deficiency affected two residents, R10 and R11, who were reviewed for infection control. R10 was documented as COVID-19 positive and required strict isolation with droplet and contact precautions. However, observations revealed that R10's door, which was supposed to remain closed, was left slightly open. Additionally, R11, who was not wearing the required face shield, was observed visiting R10 in the isolation room, despite the signage indicating that only essential personnel should enter. The Assistant Director of Nursing (ADON) acknowledged that R10's door should have been closed and that R11 should not have been in R10's room. R11 was informed that visiting R10 would require her to be placed in a semi-private room, which she declined, opting to wait until R10 was off isolation. Despite being offered a face shield, R11 refused to wear it. The facility's infection control policy and signage required full PPE, including an N95 mask and eye protection, which were not adhered to in this instance.
Inadequate Supervision Leads to Falls and Elopement
Penalty
Summary
The facility failed to adequately monitor and supervise a resident with cognitive impairment, identified as a high fall risk, resulting in two unwitnessed falls. The resident, diagnosed with Vascular Dementia and Altered Mental Status, had a history of falls and required substantial assistance with transfers. Despite these needs, the resident attempted to self-transfer and fell, resulting in a subdural hematoma and a hematoma on the forehead. Interviews with staff revealed that the resident was forgetful and often attempted to perform tasks without assistance, despite being advised to wait for staff help. Another deficiency involved the facility's failure to prevent a resident with Alzheimer's disease and a history of exit-seeking behaviors from eloping. The resident, who required 24/7 supervision, was found a mile away from the facility, confused and inadequately dressed for the cold weather. The resident's care plan indicated a risk for elopement, but staff were not adequately informed or prepared to monitor and prevent such incidents. The facility's alarm system failed to alert staff, and there was no documentation of monitoring the resident's location or wandering behavior. Interviews with staff highlighted a lack of communication and awareness regarding the resident's elopement risk. The nurse on duty was unfamiliar with the resident's needs, and the social service director was unaware of specific monitoring interventions. The maintenance director confirmed that the door alarms were not functioning as intended, and there was no documentation of daily checks for the week of the incident. These failures in supervision and monitoring contributed to the resident's unauthorized exit from the facility.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to adhere to its incontinence care policy for a resident diagnosed with vascular dementia, hemiplegia, and hemiparesis following a cerebral infarction. The resident, who was assessed as cognitively intact and dependent on staff for toileting hygiene, was found cold, wet, and uncomfortable in urine. The care plan for the resident indicated bowel and bladder incontinence, with instructions to check and change per facility protocol and assist with toileting as needed. On the morning of the incident, the resident reported that the last incontinence care was provided during the night shift, and no care had been given during the day shift. A Certified Nursing Assistant (CNA) admitted to not having provided care yet, citing a usual routine of changing the resident after breakfast and a history of the resident refusing care. However, the resident did not refuse care on that day and typically informs staff when a change is needed. The Director of Nursing confirmed that incontinence care should be provided every two to three hours, but documentation showed care was last provided at 2:47 AM, indicating a lapse in care provision.
Failure to Follow Physician Orders and Pharmacy Recommendations for Keppra Administration
Penalty
Summary
The facility failed to adhere to physician orders and pharmacy recommendations regarding the administration of Keppra for a resident diagnosed with seizures. The resident was admitted with a diagnosis of seizures and had an active physician order for weekly monitoring of Keppra levels. However, the medical record did not document any Keppra levels apart from a nontherapeutic level recorded on 4/19/24. The attending medical doctor confirmed that the Keppra levels were expected to be monitored weekly to ensure therapeutic levels, as subtherapeutic levels could increase the risk of seizures. Additionally, the facility did not follow pharmacy recommendations regarding the administration of Keppra tablets. Despite the pharmacy's advice against crushing the tablets due to potential effects on absorption and potency, nurses were observed crushing all of the resident's medications, including Keppra, and administering them with applesauce. The pharmacist confirmed that crushing the medication could affect its absorption and efficacy. This failure to follow both physician orders and pharmacy recommendations represents a deficiency in the care provided to the resident.
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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