Aperion Care West Chicago
Inspection history, citations, penalties and survey trends for this long-term care facility in West Chicago, Illinois.
- Location
- 201 West North Avenue, West Chicago, Illinois 60185
- CMS Provider Number
- 145830
- Inspections on file
- 41
- Latest survey
- January 31, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Aperion Care West Chicago during CMS and state inspections, most recent first.
A resident with intact cognition was suddenly attacked from behind by another resident, who placed his arms around the resident’s upper torso and neck in a headlock until staff and another resident intervened. The incident was described by staff as unprovoked physical abuse, and video review confirmed the aggressor’s physical contact. After the assault, the resident developed new, severe left shoulder pain unrelieved by current analgesics, with nursing assessments documenting high pain scores and limited ROM; imaging later showed an acute or subacute glenoid fracture. The resident also reported increased anxiety, hypervigilance, sleep disturbance, depressed mood, and fear of using common areas after hearing the aggressor state he was “here for murder,” and a psychiatric NP noted these symptoms were not consistent with the resident’s baseline and reflected an acute traumatic response.
The facility failed to maintain safe and palatable food temperatures for all residents receiving meals from the kitchen. Several residents reported that their meals were not served hot, and one resident stated that staff would not reheat her food or obtain a new tray, leaving her to eat it cold. During observation, hot food items such as broccoli, sweet and sour pork, rice, and grilled cheese were found held well below 135°F, while some pureed items and carrots were at 120°F. A test tray with chili, carrots, cornbread, and cookies was served on a Styrofoam plate. The Dietary Director reported that, due to budget constraints, meals are served on Styrofoam, there is no plate warmer, and delivery carts are not insulated, all of which affect temperature maintenance, and also noted that trays sometimes sit on units up to 20 minutes before being passed. Facility policy requires hot foods to be held at 135°F or above.
The facility failed to maintain a functional call light system for an entire hall, affecting 28 residents whose room call lights were not activating signals at the nurses’ station or outside their doors. Cognitively intact residents who required moderate to substantial assistance with ADLs reported that their call lights had not worked since the prior day and that this was a recurrent issue, forcing them to yell or bang on walls to obtain help, including for toileting. A visually impaired resident with cognitive impairment and needing moderate to maximal ADL assistance was observed repeatedly yelling for help with hydration without staff response. A CNA confirmed that the hall’s call lights were not working at the start of her shift and that she received no instructions on alternative monitoring. Maintenance staff and the Maintenance Director reported recurrent wiring problems with the main call light panel, acknowledged that some rooms’ call lights had stopped working multiple times in the past month, and indicated there were no work order logs for these issues, while facility documentation of rounding was limited and nonspecific.
Two residents were involved in a resident-to-resident physical altercation in which one resident placed the other in a headlock, resulting in severe shoulder pain and later psychosocial distress for the affected resident. The Administrator/Abuse Coordinator viewed security footage confirming the event but did not initially classify it as abuse or report it to the state agency within the time frames required by facility policy, and an internal investigation with staff statements and incident documentation was not promptly completed. Neither resident’s EMR or care plan was updated at the time of the incident to include new interventions, protections, or behavior-related approaches, despite one resident’s psychiatric diagnoses and the other’s ongoing pain and distress, and abuse- and behavior-related care plan sections were only added during the survey.
Two residents were involved in a physical altercation in which one resident reportedly charged at another, grabbed him, and placed him in a headlock, after which the affected resident complained of severe shoulder pain. The Administrator/Abuse Coordinator reviewed security camera footage and was aware of the incident the same day but did not immediately report it to the state agency or initiate a thorough abuse investigation as required by facility policy. The incident was reported to the state and an investigation was initiated only several days later, contrary to the facility’s abuse reporting and investigation procedures.
A resident developed new, sharp, severe left shoulder pain after an altercation, with pain scores frequently in the 7–10/10 range and compromised shoulder ROM, despite receiving PRN acetaminophen-codeine and acetaminophen. The resident repeatedly reported that existing pain medications were ineffective and requested further evaluation, yet staff did not promptly initiate a comprehensive pain assessment or timely revise the pain management plan as required by the facility’s pain management policy, resulting in prolonged unrelieved pain until imaging later identified a left glenoid fracture.
The facility did not maintain hot water temperatures within the required range in bathrooms and showers, resulting in cold or tepid water for all residents over an extended period. Multiple residents reported discomfort and avoided bathing, while staff and maintenance logs documented ongoing complaints. Water temperature checks confirmed readings well below policy standards, and maintenance staff acknowledged delayed and insufficient monitoring and response.
A resident with multiple medical conditions reported pain and rough treatment during care by a CNA, leading to distress and complaints to staff. Several staff members observed the resident's distress, reported the incident, and wrote statements, but the administrator did not report the abuse allegation to the Department of Public Health as required by facility policy.
Two residents with multiple medical conditions experienced excessive heat in their room due to a malfunctioning air conditioner that was not promptly repaired. Despite reports from the residents and high heat index readings, staff did not monitor the room temperature as required by facility policy, resulting in prolonged exposure to uncomfortable and potentially unsafe conditions.
Two cognitively intact sisters residing in different units were denied the right to visit each other, despite repeated requests and no behavioral issues. Staff failed to address or document their visitation rights in care plans, and ignored or dismissed the requests until the issue was raised during a survey. This was not in accordance with the facility's policy, which allows 24-hour access for immediate family.
Two residents experienced unprovoked physical abuse from another resident with a history of aggression and cognitive impairment. The aggressor struck both individuals with a closed fist, causing significant pain but no visible injuries. The incidents were reported to staff and confirmed through interviews and record review, highlighting a failure to protect residents from physical abuse.
Two residents with intact cognition reported being physically abused by another resident, with one incident witnessed by CNAs and reported to psychiatric rehabilitation staff. Despite these reports, the allegations were not communicated to the Abuse Coordinator or State Agency as required by facility policy, resulting in a failure to initiate timely investigation.
A resident with psychiatric conditions left the facility unsupervised and was found deceased the next morning. The resident signed out with a red pass, which allowed unsupervised outings, but did not return as expected. The receptionist failed to notify the nursing staff, leading to a delay in recognizing the resident's absence. The nursing staff was unaware until after 11:00 PM, and the resident was found deceased the following morning.
The facility failed to ensure monthly Medication Regimen Reviews (MRR) were conducted for several residents, as required by their policies. This deficiency was identified through interviews and record reviews, revealing missing MRRs for multiple residents with various medical conditions. The facility could not provide documentation of pharmacy recommendations or follow-up actions, despite the consulting pharmacist's responsibility to complete and email the MRRs.
A resident was observed in the dining room wearing an improperly closed gown, exposing her skin and undergarments, which compromised her dignity. Despite being cognitively intact and having clothing available, the resident was not assisted to dress appropriately, contrary to the facility's dignity policy.
A resident with intact cognition and a long-standing vegan diet was not provided with adequate vegan protein sources at the facility, leading to allergic reactions from consuming dairy products. Despite multiple discussions with staff, the facility failed to document or accommodate her dietary preferences, resulting in meals lacking protein and a care plan that did not address her vegan diet.
A resident with multiple health conditions had an exposed central venous catheter due to a missing end cap, which was not promptly addressed by the facility's staff. The Infection Control Nurse and the assigned RN failed to apply a sterile barrier, contrary to the facility's policy, leaving the catheter exposed for two days until a suitable end cap was found.
A facility failed to document a resident's assessment after dialysis sessions, despite the resident's dependence on hemodialysis and multiple diagnoses. The resident's care plan required assessments, including vital signs and fistula site condition, which were not documented until late November. Additionally, there was a lack of consistent communication regarding the avoidance of taking blood pressure from the resident's right arm, where a fistula was located.
A resident did not receive pregabalin for several days after admission due to a failure in submitting a prescription to the pharmacy. The medication was supposed to start shortly after admission, but was delayed until the issue was identified and addressed by the staff. The facility's policy requires a valid prescription for controlled substances, which was not followed.
A resident with a vegan diet and dairy allergy was not provided with appropriate meals at the facility. Despite her dietary needs being communicated, she was forced to consume dairy products due to a lack of alternative protein sources, leading to allergic reactions. The facility's dietitian and food service director acknowledged the issue, but the resident's clinical record lacked documentation of her dietary preferences and allergy.
A resident with a documented dairy allergy and preference for a vegan diet was repeatedly provided with dairy products as protein sources, leading to allergic reactions. Despite the resident's complaints and discussions with the facility's dietitian and food service director, the facility failed to offer adequate vegan protein options or document the resident's dietary needs, resulting in continued exposure to allergens.
A facility failed to reassess a resident's capacity for sexual consent after a cognitive decline, leading to an inappropriate incident with another resident. Despite severe dementia, staff initially believed the interaction was consensual. The incident was not reported promptly, violating facility policies.
A facility failed to timely report a sexual abuse incident involving two residents, one of whom had severe cognitive impairment. Staff intervened and separated the residents, but the facility did not immediately report the incident to authorities, believing it was consensual based on outdated assessments. Further evaluations revealed the resident's inability to consent, leading to a delayed report to the Illinois Department of Public Health and local law enforcement.
A facility failed to promptly investigate a sexual abuse incident involving two residents in a secure behavioral unit. Despite initial reports of consensual interaction, witnesses described inappropriate behavior, and one resident's cognitive impairment indicated she could not consent. The facility delayed reporting the incident to authorities, relying on outdated assessments, and did not follow its abuse prevention policy.
A facility failed to update a care plan after a resident's cognitive status declined, affecting her ability to consent to sexual activity. Initially assessed as capable, the resident's BIMS score later indicated severe impairment, but the care plan lacked specific interventions to address this change, leaving her at risk for sexual abuse.
The facility failed to protect residents from physical abuse by their peers, as multiple incidents involving ten residents were not reported to the Illinois Department of Public Health. The administrator believed only incidents causing emotional distress or physical injury needed reporting, following a directive from corporate. Incidents included physical altercations between residents with various mental health diagnoses, such as schizophrenia and bipolar disorder, which were not documented as required by the facility's policy.
The facility failed to report multiple allegations of abuse to the Illinois Department of Public Health within the required two-hour timeframe. Incidents involving residents with psychiatric and cognitive impairments, such as physical altercations and aggressive behaviors, were documented but not reported as mandated by the facility's policy. This deficiency was identified for all residents reviewed for abuse allegations.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Shoulder Fracture and Psychosocial Harm
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident from resident-to-resident physical abuse. Late in the evening, one resident was suddenly attacked by another male resident who approached from behind while the victim was standing at the ice machine holding a cup. The aggressor placed both arms around the resident’s upper torso and neck area, putting him in a headlock. Staff and another resident intervened to separate them. Multiple staff, including an RN and a CNA, as well as the resident’s roommate, described the event as an unprovoked physical attack or physical abuse. The Administrator, who serves as the Abuse Coordinator, reviewed security camera footage and confirmed that the aggressor made physical contact and had his arms around the resident from behind. Following the incident, the resident reported new, severe left shoulder pain that began after the attack, distinct from his pre-existing chronic cervical and back pain from a decades-old accident. He consistently rated his shoulder pain as 8–10/10, described it as severe and unbearable, and reported that it was not relieved by his current pain medications. Nursing documentation reflected ongoing high pain scores and limited range of motion in the left shoulder. An X-ray later showed an acute or subacute inferior glenoid fracture fragment of the left shoulder, and the resident continued to experience significant pain with shoulder movement. The resident stated he had repeatedly requested an X-ray and to be sent to the hospital to assess the injury. The resident also experienced psychosocial distress after the assault. He reported feeling on edge, anxious, fearful of encountering the aggressor again, and hesitant to use common areas where the abuse occurred. He described intrusive recollection of the aggressor’s statement, “I’m here for murder,” which he heard during the altercation and which replayed in his mind, causing fear and distress. He reported difficulty sleeping, frequent nighttime awakenings, feeling more depressed and withdrawn, and no longer feeling safe in the facility. A psychiatric NP noted that the resident’s reported symptoms of heightened anxiety, hypervigilance, disrupted sleep, and worsening mood were not consistent with his baseline and were characteristic of an acute traumatic response. Both the in-house NP and psychiatric NP emphasized that pain and psychological distress are subjective experiences that must be taken seriously regardless of mental or psychiatric status. The facility’s own abuse policy affirms residents’ rights to be free from abuse and defines abuse as the willful infliction of injury or intimidation resulting in physical harm, pain, or mental anguish.
Failure to Maintain Safe and Palatable Food Temperatures
Penalty
Summary
The facility failed to ensure that food and drink were served at palatable and safe temperatures for all residents receiving meals from the kitchen. Multiple residents reported that their meals were not served hot, with one resident stating the food is not always served hot, another stating the food is usually barely warm, and another stating the meals are usually not served hot. One resident reported that when she requested staff to reheat her food, she was told they could not do so and would not obtain a new tray from the kitchen, leaving her to eat the food cold. The DON confirmed that all residents in the facility at the time of the survey received services from the Dietary department. During a meal service observation with the Dietary Director and a cook, several hot food items were found to be held below the facility’s stated standard of 135°F, including broccoli at 100°F, sweet and sour pork (carbohydrate-controlled, low concentrated sweets) at 95°F, plain rice at 100°F, and grilled cheese sandwiches at 90°F, while some pureed items and carrots were at 120°F. A test tray contained chili, carrots, crumbly cornbread, and cookies served on a Styrofoam plate. The Dietary Director stated that due to budget constraints, the facility uses Styrofoam instead of real plates, acknowledged that Styrofoam affects the maintenance of food temperatures, and reported there is no plate warmer and the delivery carts are not insulated. He also stated that there have been occasions when meal trays remained unpassed on the units for up to 20 minutes after leaving the kitchen. The facility’s undated policy stated that foods meant to be held for a long time require elevated temperatures and should be held at 135°F or above.
Failure to Maintain Functional Call Light System for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure a functioning call light system for all residents on one hall, affecting 28 residents whose rooms were connected to a faulty call light panel. Multiple residents reported that their call lights had not worked since the previous day and that this was a recurrent problem over the past month. One cognitively intact resident who required moderate to maximal assistance with ADLs demonstrated that pressing his call light did not activate a signal outside his door or at the nurses’ station and stated he had no way to get assistance or help in an emergency. Another cognitively intact resident who required touch to substantial assistance with ADLs reported significant difficulty obtaining toileting assistance due to the nonfunctioning call light and described having to yell or bang on the wall to get staff attention. A visually impaired resident with cognitive impairment and needing moderate to maximal ADL assistance was observed yelling repeatedly for help with hydration without staff response. Staff interviews confirmed that the call lights for the unit had stopped working the previous afternoon and that this had occurred multiple times in the prior month. A CNA assigned to the affected hall stated that when she started her morning shift, the room call lights were not working and that she had not been given instructions on how residents would be monitored while the system was down. Maintenance staff reported that the main call light panel at the nurses’ station had a missing wiring connection, that they had just rewired it, and that the wiring problem had recurred at least three times in the past month. The Maintenance Director acknowledged that some rooms’ call lights had stopped working, that an outside vendor had been called previously, and that there were no work order logs for the call light issues. An untitled facility document showed 30‑minute rounding for a limited time period on one date but did not specify which residents were rounded on, what type of rounds were done, or any entries covering the time from when the call lights again stopped working through the following morning, despite the facility’s policy requiring prompt reporting of call bell system defects and room checks until repair.
Failure to Identify, Investigate, and Report Resident-to-Resident Abuse and Update Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify, investigate, protect, and report an incident of resident-to-resident abuse, and to implement care plan interventions afterward. One resident reported severe left shoulder pain that began after another resident suddenly charged at him, grabbed him from behind, and placed both arms around his upper torso in a headlock. During observation, the resident was seen in bed holding his left shoulder and wincing in pain, and later verbalized psychosocial distress related to the incident. The Administrator/Abuse Coordinator acknowledged reviewing security camera footage the night of the incident, which showed the aggressor resident approaching from behind and placing both arms around the other resident’s upper torso. Despite this, the Administrator did not consider the event to meet the facility’s definition of abuse at that time and did not report it to the state agency until nine days later, contrary to the facility’s policy requiring immediate or timely reporting of allegations and incidents. The facility did not conduct an internal investigation of the incident in a timely manner and was unable to provide staff statements, interviews, incident reports, or other related documentation during the survey. Review of the injured resident’s EMR showed no new care plan interventions or protective measures were initiated following the incident to address his severe shoulder pain or psychosocial distress, and his care plan was not updated until during the survey. The other resident involved had diagnoses including anxiety disorder, insomnia, schizophrenia, and schizoaffective disorder, yet his care plan was also not updated after the incident. Care plan sections addressing abuse, behaviors, mood triggers, and physical and verbal aggression for both residents were only added during the survey, indicating that the facility did not promptly implement or document interventions or protections following the reported abuse, as required by its Abuse and Retaliation Prevention and Reporting policy.
Failure to Timely Report and Investigate Resident-on-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to promptly report and thoroughly investigate an allegation of physical abuse between two residents. On 1/27/2026 at 10:37 AM, one resident (R131) was observed sitting in bed, holding his left shoulder and wincing in pain, and reported experiencing severe left shoulder pain that began on 1/18/2026 after being physically attacked by another resident (R200). R131 stated that R200 suddenly charged at him, grabbed him, and placed both arms around his upper torso, putting him in a headlock. The facility’s Administrator/Abuse Coordinator (V1) acknowledged that he had reviewed security camera footage from 1/18/2026 and was aware of the incident that same night. Despite this awareness, V1 stated he did not report the incident to the Illinois Department of Public Health (IDPH) at that time because he did not believe it met the definition of abuse, citing the absence of serious injury, bodily harm, or psychosocial effects. The incident was not reported to IDPH until 1/27/2026, as confirmed by a fax confirmation sheet showing the initial report was sent at 2:59 PM with a documented occurrence date of 1/18/2026 and categorized as resident abuse. The report also indicated that a thorough investigation was to be conducted, demonstrating that the investigation was initiated nine days after the incident. This delay and failure to immediately initiate an investigation conflicted with the facility’s Abuse and Retaliation Prevention and Reporting policy, which requires that all incidents be documented and that any incident or allegation involving abuse result in an investigation initiated by the administrator or designee upon learning of the report, including interviews of the reporter, individuals with direct knowledge, and the resident, as well as review of written statements and pertinent medical records or documents.
Failure to Adequately Assess and Manage New Onset Severe Shoulder Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate assessment and management for a resident’s new onset of severe left shoulder pain following a physical altercation with another resident. The resident, who had previously reported only mild, occasional pain that did not affect sleep and had intact cognition and no upper extremity ROM limitations per the MDS, began experiencing sharp, non-radiating left anterior shoulder pain rated 8–10/10 after the incident. The N Adv – Long Term Care Evaluation identified this as a new issue, with documented severe pain and facial expressions consistent with pain. Despite this, the resident reported that his existing pain medication regimen, which predated the incident, was not relieving the new shoulder pain, and he repeatedly requested an X-ray and hospital evaluation. Medication records showed that after the incident, the resident received PRN Acetaminophen-Codeine 300-30 mg and Tylenol Extra Strength 500 mg on multiple occasions, yet pain assessments documented ongoing moderate to severe pain levels (4–10/10) on numerous days. The resident consistently reported severe, unrelieved left shoulder pain, including during surveyor interviews, and described worsening pain with shoulder movement. Nursing documentation and interviews confirmed that the resident’s pain remained severe and that his left shoulder ROM was compromised, indicating a change in condition and ineffective pain control. However, there was no evidence that the pain management plan was promptly reassessed or modified in response to the resident’s persistent high pain scores and reports of inadequate relief. The facility’s own Pain Management Program policy required initiation of a pain assessment protocol whenever there is a change in condition requiring pain control or a change in the identification of pain, recognition of pain as the fifth vital sign, ongoing monitoring, and review and updating of care plans when pain management is ineffective. Interviews with the in-house NP and psychiatric NP emphasized that pain is subjective and must be taken seriously regardless of psychiatric status, and that uncontrolled pain can exacerbate psychological symptoms. Despite these expectations and the DON’s stated requirement that pain rated above 6/10 necessitates immediate action, the resident’s severe, ongoing pain after the new injury was not adequately assessed or managed in a timely manner, and the pain management plan was not effectively adjusted in accordance with facility policy until much later, when imaging ultimately revealed a left glenoid fracture.
Failure to Maintain Safe and Comfortable Hot Water Temperatures
Penalty
Summary
The facility failed to maintain hot water temperatures within a comfortable and safe range for residents in bathrooms and showers, affecting all 206 residents. Multiple residents reported that the water had been cold or freezing for at least one to three weeks, making showering uncomfortable and leading some to avoid bathing altogether. Residents consistently documented their complaints in maintenance logs and voiced their concerns to staff, including the resident council president, who highlighted the issue multiple times. Staff interviews confirmed that complaints had been ongoing, and maintenance logs reflected repeated reports of inadequate hot water. Direct observations and water temperature testing conducted by the Maintenance Director and other staff on various dates revealed that hot water temperatures in resident bathrooms and shower rooms ranged from 65.2 to 84 degrees Fahrenheit, well below the facility's policy requirement of 100-110 degrees Fahrenheit. The Maintenance Director acknowledged awareness of the issue and stated that water temperatures were only being checked twice a week, and that he did not take further action initially, opting to wait and see if the mixing valve would resolve the problem. Maintenance logs and resident council meeting minutes further documented ongoing concerns about insufficient hot water. Staff, including CNAs and RNs, confirmed that they had received numerous complaints from residents about the lack of hot water and had communicated these concerns to maintenance. Despite these reports, the issue persisted for an extended period, with maintenance staff only beginning to address the problem in the days immediately preceding the survey. The facility's own policy required staff to ensure water was at a comfortable and safe temperature before bathing residents, but this standard was not met during the period in question.
Failure to Report Abuse Allegation as Required
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident who was cognitively intact and dependent on staff for bathing and showers. The resident, who had multiple diagnoses including hemiplegia, major depressive disorder, seizures, osteoarthritis, contractures, and schizophrenia, reported experiencing pain during care, specifically when being changed and showered by a particular CNA. The resident expressed to staff that she did not want this CNA to care for her anymore due to the pain caused during these interactions. Multiple staff members, including CNAs and a nurse, observed or were informed of the resident's distress and complaints of rough care, including being pulled and having cold water put on her during a shower. On the day of the incident, the nurse on duty heard the resident crying and, upon inquiry, was told by the resident that the CNA had been rough during the shower. The nurse reported the incident to the supervisor, who then sent the CNA home pending investigation. Several staff members wrote statements about the incident and placed them in the administrator's mailbox, as per facility protocol. The Director of Nursing was notified and instructed that an assessment be completed to check for bodily injury, and a grievance form was filled out. The administrator was also notified but did not respond to the allegation until after the weekend. Despite the facility's policy requiring immediate reporting of abuse allegations to the Department of Public Health and documentation of all incidents, the administrator did not report the incident to the Illinois Department of Public Health. There was also uncertainty among staff regarding the status and handling of the investigation, with some staff not being interviewed and the Director of Nursing stating she had not received any written statements. The failure to report the abuse allegation as required by policy and regulation constitutes the deficiency.
Failure to Maintain Safe and Comfortable Room Temperatures During Extreme Heat
Penalty
Summary
The facility failed to provide a comfortable, homelike environment for two residents who experienced inadequate cooling in their shared room. Both residents, who were cognitively intact and had multiple medical diagnoses including major depressive disorder, hypertension, and type 2 diabetes mellitus, reported that their room felt warm and that the air conditioning was not functioning properly. One resident stated that he had reported the issue on a Friday, but the air conditioner had not been fixed, leading him to leave his room early in the morning due to discomfort. The other resident confirmed that the air conditioning had not been working for a long time and that the air coming from the unit was not cold, despite the windows being closed. Temperature readings taken in the room showed a heat index above the recommended maximum, with the highest recorded at 84.8 degrees Fahrenheit and humidity at 69%. Maintenance staff acknowledged that attempts to repair the air conditioner were unsuccessful and that temperature monitoring was not conducted in the affected room as required by the facility's extreme weather policy. Instead, temperatures were only taken in facility hallways and in one location on each floor, with no documentation showing that temperatures were monitored every two hours in the residents' room during the period of extreme heat. The facility's policy requires maintaining room temperatures between 71 and 81 degrees Fahrenheit and monitoring every two hours during extreme weather, but these procedures were not followed in this case.
Failure to Honor Visitation Rights Between Family Members
Penalty
Summary
The facility failed to provide visitation rights to two cognitively intact sisters, both residents, who wished to visit each other. One sister resided on a secured third-floor unit and the other on the first floor. Despite both residents having no behavioral issues and care plans that encouraged socialization and family involvement, there were no interventions or documentation in their care plans addressing their right to visit each other. The sister on the third floor repeatedly expressed her desire to visit her twin to both nursing and social services staff, but her requests were ignored or dismissed, and she was not allowed to visit her sister for an extended period. During the survey, the resident again requested to see her sister and voiced her frustration about being denied visitation, especially when other residents were allowed visitors. Staff responses were inadequate, with one staff member deflecting responsibility and another ignoring the request. Only after the resident insisted during a group meeting with surveyors and staff was she finally allowed to visit her sister. The facility's own policy states that residents have the right to receive visitors of their choosing, including immediate family, at any time, yet this policy was not followed in the case of these two residents.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by two incidents involving a resident with a history of aggression and cognitive impairment. On the morning of 4/16/2025, a resident with diagnoses including paranoid schizophrenia, dementia with anxiety, and major depressive disorder, who was known to be short-tempered and had a documented history of physical and verbal aggression, struck her roommate on the right side of the face and head with a closed fist. The attack was unprovoked, and the victim reported pain rated 6 out of 10, though no physical injury was sustained. The aggressor then left the room and struck another cognitively intact resident at the nurses' station, also with a closed fist, causing pain rated 7 out of 10 but no visible injury. Both victims reported the incidents to staff, and the events were confirmed through interviews and record review. The aggressive resident's care plan had previously documented her tendency to become physically and verbally aggressive due to medication noncompliance, poor coping skills, and mental illness. Prior incidents of aggression toward peers were also noted in her records. Staff interviews confirmed that the incidents were reported to facility administration and that the facility's abuse policy defines abuse as any physical or mental injury inflicted upon a resident, including deliberate actions by cognitively impaired individuals. The facility's failure to prevent these incidents resulted in residents experiencing pain and emotional distress.
Failure to Report Alleged Physical Abuse to Abuse Coordinator and State Agency
Penalty
Summary
The facility failed to notify the Abuse Coordinator and the State Agency of allegations of physical abuse involving two residents with intact cognition. One resident reported being hit on the head and face by another resident, though she could not recall the exact date. Another resident stated she was hit on the head four times by the same resident, resulting in a headache for two days. This incident was witnessed by two CNAs, and the resident reported it to two Psychiatric Rehabilitation Services Coordinators. Despite these reports, the allegations were not communicated to the Abuse Coordinator as required by facility policy. Staff interviews revealed that while some staff believed they had reported the incidents to appropriate personnel, the Abuse Coordinator and the State Agency were not notified. The facility's guidelines require immediate reporting of any suspected abuse to the administrator or an immediate supervisor, who must then inform the administrator. However, the chain of command was not followed, and the required notifications and investigations were not initiated in a timely manner.
Resident Found Deceased After Leaving Facility Unsupervised
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring of a resident, leading to the resident leaving the facility grounds unsupervised and not returning at the expected time. The resident, who had a history of schizophrenia, delusional disorders, and other psychiatric conditions, was allowed to leave the facility with a red pass, which permitted unsupervised outings for up to two hours. On the day of the incident, the resident signed out at 5:57 PM but did not return, and the receptionist failed to notify the nursing staff of the resident's absence. The nursing staff was unaware of the resident's absence until after 11:00 PM, resulting in a significant delay in initiating a search. The resident's nurse, who was on duty from 3:00 PM to 11:00 PM, did not receive a report from the receptionist about the resident's failure to return. The nurse only realized the resident was missing during the evening medication pass and did not call a code pink or notify the police until much later. The resident was eventually found deceased the following morning, approximately 600 feet from the facility's main entrance. Interviews with staff and other residents revealed a lack of understanding and communication regarding the facility's sign-out and pass privilege protocols. The receptionist, who was relatively new, did not follow the protocol of notifying the nurse when a resident did not return. Additionally, there was confusion among the staff about the resident's pass level and the supervision required, contributing to the oversight and delay in recognizing the resident's absence.
Removal Plan
- R1 is no longer a resident at the facility.
- All Community survival risk assessments were reviewed for accuracy, updated accordingly and all Care plans were reviewed to validate they match. Assessments were reviewed by IDT team composed of Administrator, DON, and Social Service designee.
- All staff have been re-educated on the facilities therapeutic leave of absence policy. Any staff on leave or unavailable staff were educated via phone and again before next scheduled shift. Administrator, Assistant Administrator, DON, and Assistant Director of Nursing/ADON conducted the training. Policy details that all residents leaving the premises should be signed out, establish an agreed upon time frame for return to the facility, sign back in upon return to the facility, and what to do if a resident does not return at the agreed upon time. All new hires and agency staff (if utilized in the future) will be educated on this policy prior to working their first shift.
- Facility receptionists were educated by their supervisor on the pass return protocol; Protocol states Only residents with green pass can leave the facility unsupervised, all residents leaving must sign out and establish an agreed upon time for return. Residents must sign back in upon return from pass. If resident fails to return at the agreed upon time, the 1st floor nurses station will be notified before their next scheduled shift.
- No resident goes out on independent pass without having a current Community survival/elopement risk assessment completed and CP updated.
- The pass privilege list was reviewed by the facility IDT composed of Administrator, DON, and Social Service designee, and compared to the response report of current elopement risk/community survival assessments.
- All residents identified as having exit seeking behaviors were reviewed by a Social Service designee and care plans were updated as appropriate.
- All residents with a history of suicidal ideation/suicidal attempts have their independent pass privilege assessment signed by a physician/provider.
- Updated Medical director on event and details. Medical director notified of incident by the facility DON and reviewed the facility's immediate action plan. He agreed with the immediate action plan.
- Administrator and/or designee will audit 5 residents' 2X per week for 6 months to ensure resident's community skills assessment and care plan are accurate.
- Director of Nursing and/or designee will audit the resident sign in/out log daily for 3 months then 2X per week for 3 months to ensure that all residents are accounted for.
- Community pass policy reviewed with IDT and medical director.
- QAPI review with Medical Director to review incident and plan of action. IDT conducts assigned regular rounds during shift to ensure visual monitoring and staff supervision. Action plan will be reviewed monthly at QAPI meeting.
Failure to Conduct Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed monthly Medication Regimen Reviews (MRR) for residents, as required by their policies and procedures. This deficiency was identified through interviews and record reviews, revealing that the pharmacy did not complete monthly MRRs for several residents. Specifically, the facility could not provide documentation showing that residents identified with irregularities in their MRRs were addressed by a physician. The report highlights several cases where the facility did not comply with the monthly MRR requirement. One resident, with multiple diagnoses including chronic obstructive pulmonary disorder and schizoaffective disorder, was missing an MRR for April 2024. Another resident, with conditions such as toxic encephalopathy and bipolar disorder, did not have MRRs for February and April 2024, and the facility failed to provide documentation of pharmacy recommendations or follow-up actions. Additionally, two other residents with various medical conditions also lacked MRRs for the same months. Interviews with facility staff, including the Director of Nursing and the Psychotropic Nurse, revealed that the consulting pharmacist was responsible for completing the MRRs and emailing the recommendations to the facility. However, the facility was unable to provide the necessary documentation to demonstrate compliance with their policy, which mandates regular and reliable consultant pharmacist services and the retention of records.
Resident Dignity Not Maintained During Meal Service
Penalty
Summary
The facility failed to maintain a resident's dignity during meal service in the dining room. A resident, identified as R70, was observed seated at a dining room table wearing a gown that was not properly closed, exposing her skin and undergarments from the bottom of her left armpit to mid-thigh. This exposure was visible from the door of the dining room, where there were six tables of residents and three staff members present. Earlier that day, R70 was also seen walking in the hallway wearing only a gown and bare feet, accompanied by staff. R70's electronic medical record indicated she was cognitively intact and required assistance with activities of daily living, including dressing. Her care plan noted the need for supervision and assistance with dressing but did not address concerns about wearing clothing. A registered nurse, identified as V14, stated that R70 only wears clothing when leaving her room and confirmed that clothing was available in R70's closet. The facility's policy on dignity emphasized encouraging residents to dress in their own clothes rather than hospital-type gowns, which was not adhered to in this instance.
Failure to Honor Resident's Vegan Diet Preference
Penalty
Summary
The facility failed to honor a resident's decision to observe a vegan diet, which was a significant aspect of her self-determination and personal choice. The resident, who had intact cognition, had been vegan for many years prior to her admission to the facility. Despite her clear communication of dietary preferences and allergies, the facility did not provide adequate vegan protein sources, forcing her to consume dairy products to meet her nutritional needs. This led to allergic reactions, including rashes and nasal congestion, as the resident was allergic to cow's milk. The resident had multiple discussions with the facility's staff, including the administrator and corporate dietitian, about her dietary needs. However, these discussions were not documented in her clinical record, and no adjustments were made to accommodate her vegan diet. The facility's menu did not include a vegan option, and the resident was often served meals lacking in protein, contrary to her dietary requirements. The facility's failure to provide alternative protein sources, such as beans or veggie burgers, further exacerbated the issue. The facility's procedures for menu planning and food preferences were not followed, as evidenced by the lack of documentation and failure to address the resident's dietary needs in her care plan. Despite the resident's repeated requests and the facility's acknowledgment of her dietary preferences, the facility did not take appropriate steps to ensure her nutritional needs were met in accordance with her vegan diet. This oversight highlights a significant deficiency in honoring resident choice and ensuring adequate nutrition.
Failure to Maintain Sterile Barrier on Central Venous Catheter
Penalty
Summary
The facility failed to implement its policy regarding the care and management of an implanted central venous catheter, leading to a potential risk of infection for a resident. The resident, who has a medical history including type 2 diabetes mellitus, foot ulcer, osteomyelitis, peripheral vascular disease, Parkinson's Disease, and Schizophrenia, was observed with an exposed central venous catheter. The catheter, implanted in the resident's right upper chest, was missing an end cap, which is crucial for preventing contamination. The Infection Control Nurse, identified as V3, acknowledged the missing end cap but failed to apply a sterile barrier while searching for a replacement, leaving the catheter exposed. Further investigation revealed that the Registered Nurse assigned to the resident, V4, also noticed the missing end cap at the beginning of her shift but did not take action to cover the exposed catheter with sterile gauze. The facility's policy, dated February 2009, mandates that a sterile end cap must be placed on the end of intermittent tubing between administrations to prevent infections. Despite this policy, the resident's catheter remained exposed until an appropriate end cap was found two days later, as confirmed by the Director of Nursing, V2.
Failure to Document Dialysis Assessment
Penalty
Summary
The facility failed to document a resident assessment upon return from dialysis for a resident with multiple diagnoses, including end-stage renal disease, chronic obstructive pulmonary disease, and schizophrenia. The resident, who was dependent on hemodialysis, had a care plan indicating dialysis sessions on Monday, Wednesday, and Friday. However, a review of the resident's progress notes from early November to early December revealed no documentation of assessments upon return from dialysis. The Director of Nursing confirmed that the assessment, including vital signs and the condition of the fistula site, should be documented on the Medication Administration Record (MAR), but this was not done until late November. Additionally, the facility's policy required monitoring and documentation of the presence or absence of bruit and thrill at the fistula site each shift, which was not added to the record until late November. A Registered Nurse stated that the resident had a fistula in the right forearm, and staff should avoid taking blood pressure from that arm. However, there was no consistent communication or signage to inform all staff of this requirement. The nurse also expressed uncertainty about where to document the after-dialysis assessment, indicating a lack of clarity and adherence to the facility's policy on dialysis monitoring and observation.
Failure to Provide Timely Medication Delivery
Penalty
Summary
The facility failed to ensure timely delivery of medications from the pharmacy, resulting in a resident missing doses of pregabalin as ordered by the physician. The resident, who was admitted with multiple diagnoses including major depressive disorder and anxiety disorder, did not receive pregabalin from the time of admission until several days later. The EMR indicated that the medication was supposed to start on November 28, 2024, but was not available or administered until December 4, 2024. Interviews with facility staff revealed that the medication was not delivered because a prescription had not been submitted to the pharmacy. The LPN acknowledged the delay and contacted the pharmacy and physician only after the issue was identified. The Director of Nursing stated that medications should be received within 24 hours of admission and that the nurses should have addressed the unavailability of the medication sooner. The facility's policy requires a valid prescription for controlled substances to be received by the pharmacy before dispensing, which was not adhered to in this case.
Failure to Provide Vegan and Dairy-Free Diet for Resident
Penalty
Summary
The facility failed to prepare and follow a vegan and dairy-free diet for a resident who adhered to a vegan diet and was allergic to dairy. The resident, identified as R196, had a physician order sheet indicating a general diet with regular texture and consistency, and an allergy to dairy products. Despite this, the resident reported being made to drink milk due to a lack of other protein sources, which led to allergic reactions such as rashes and nasal congestion. The resident had been vegan for many years and had communicated her dietary needs to the facility's corporate dietitian and administrator, but her requests for vegan protein options like veggie burgers were not fulfilled. Observations and interviews revealed that the resident's meals typically lacked adequate protein sources, forcing her to consume dairy products despite her allergy. The resident's lunch trays often consisted of items like plain noodles, green beans, and salads without protein, and she reported not receiving requested items such as potato salad. The facility's food service staff indicated that they could not accommodate individual requests for items like beans due to bulk purchasing practices. The resident's clinical record lacked documentation of her dietary preferences, allergy, or any discussions about providing alternative protein sources. The facility's corporate dietitian and food service director acknowledged the resident's dietary preferences and allergy but failed to ensure that her nutritional needs were met. The dietitian admitted that the resident's intolerance was listed as an allergy in the clinical record and that she should not have been receiving dairy products. However, there was no official diet order for a vegan diet, and the facility did not have a pre-planned vegetarian menu. The facility's planned menu spreadsheets showed no vegan diet was planned or served, and the resident's care plan did not address her dietary needs or allergy.
Failure to Accommodate Resident's Dairy Allergy and Dietary Preferences
Penalty
Summary
The facility failed to eliminate a known dairy allergen from a resident's diet, despite the resident's documented allergy to dairy products. The resident, who has a history of major depressive disorder and suicidal ideations, was provided with lactose-free milk and cheese as protein sources, despite reporting allergic reactions such as rashes and nasal congestion. The resident expressed dissatisfaction with the lack of alternative protein sources and felt compelled to consume dairy products due to inadequate vegan protein options provided by the facility. The resident's care plan clearly documented the dairy allergy and instructed staff to ensure the allergy was noted on various records, including the Medication Administration Record and tray care. However, the facility's dietary management failed to adhere to these instructions. The resident's clinical records lacked documentation of any discussions regarding the dairy allergy or the provision of vegan protein options, despite the resident's repeated complaints and discussions with the corporate dietitian and food service director. The facility's planned menus did not include pre-planned vegan diets, and the resident's lunch trays consistently lacked protein items. The corporate dietitian and food service director were aware of the resident's dietary preferences and allergy but did not take appropriate action to accommodate these needs. The facility's failure to document and address the resident's dietary requirements resulted in the continued provision of dairy products, contrary to the resident's allergy and ethical dietary preferences.
Failure to Reassess Capacity for Sexual Consent Leads to Incident
Penalty
Summary
The facility failed to reassess and update a resident's capacity for sexual consent after a significant decline in her cognitive abilities. This oversight led to an incident of sexually inappropriate behavior between two residents in a public area. The resident in question, who was diagnosed with severe dementia, was initially assessed to have the capacity to consent to sexual activities. However, a subsequent assessment revealed a severe cognitive impairment, indicating that she could no longer provide consent. The incident occurred when the resident engaged in sexual acts with another resident in the dining room, witnessed by other residents. Despite the resident's severe cognitive impairment, staff initially believed the interaction was consensual. The facility's policy required reassessment of a resident's capacity to consent following any significant cognitive changes, which was not done in a timely manner. Interviews with staff and other residents revealed that the incident was not immediately reported or addressed according to the facility's abuse prevention and reporting policies. The failure to update the resident's capacity for sexual consent and the delay in reporting the incident contributed to the deficiency identified by the surveyors.
Removal Plan
- R1 has an updated capacity to consent for sex assessment completed.
- R2 has been sent out to the hospital for a psychiatric evaluation.
- An emergency Quality Assurance meeting has been conducted with facility medical director and IDT to review the incident and action plan.
- Residents that have been identified being at risk from sexual exploitation have had their care plans updated to reflect interventions to prevent abuse.
- All residents have been reassessed for capacity for sexual consent.
- Residents that have been identified for being at risk from sexual exploitation were interviewed if they have been taken advantaged of or manipulated to perform sexual acts. None of them responded yes.
- Residents who are identified as at risk to potentially be the perpetrator for sexual abuse or exploitation will be reassessed and placed closer to the nurse's station for increased monitoring, and have their care plans updated to reflect.
- The capacity to consent policy has been revised and updated.
- Social Service staff received an Inservice on updating the capacity for consent assessment whenever a significant change in a resident's cognition is noted.
- Facility wide Inservice, initiated and ongoing. Information included: How to recognize sexual abuse and the facility's abuse protocol to prevent it from happening to other residents. The Abuse prevention reporting policy, specifically the definition of abuse, sexual abuse, sexual assault and internal reporting requirements and identification of allegation and protection of residents. All staff were re-educated prior to their next scheduled shift including staff that are on leave and are on vacation. Staff acknowledged information via signature or via phone call. Administrator and Assistant administrator are conducting the training. Administrator/Managers will continue to monitor all staff for compliance by a competency questionnaire.
- Facility administrator and/or designee will interview 5 staff members to ensure staff is aware of the facility policy related to sexual abuse. (Audit Tool included).
- Facility Administrator and/or designee will interview 5 residents to ensure they are free from abuse.(Audit Tool included).
Failure to Timely Report Sexual Abuse Incident
Penalty
Summary
The facility failed to timely report an incident of sexual abuse as per their policy and procedure for sexual abuse. The incident involved two residents, R1 and R2, who were observed engaging in a sexual act in the dining room. Staff intervened and separated the residents, and both stated the interaction was consensual. However, the facility did not immediately report the incident to the Illinois Department of Public Health (IDPH) or local law enforcement, as required by their policy. The incident was initially reported by a resident witness, R5, who informed the staff about the inappropriate behavior. The Registered Nurse, V4, assessed R1 and reported the incident to the Administrator, V1, who reviewed R1's capacity to consent based on a previous assessment. Despite concerns about R1's cognitive impairment and the age gap between R1 and R2, the facility did not conduct an immediate investigation or report the incident, as they believed it was consensual based on outdated information. Further assessments revealed that R1 had severe cognitive impairment and lacked the capacity to consent to sexual activity. The facility's Social Service Director, V3, confirmed that R1's cognitive status had deteriorated since the initial assessment. The facility eventually reported the incident to IDPH and local law enforcement after consulting with a psychiatrist and reassessing R1's capacity to consent. The delay in reporting and investigating the incident constituted a failure to adhere to the facility's abuse prevention and reporting policy.
Failure to Investigate Sexual Abuse Incident Promptly
Penalty
Summary
The facility failed to promptly conduct a thorough investigation of an incident of sexual abuse involving two residents, R1 and R2, in the secure behavioral unit. On July 9, 2024, staff reported an interaction between R1 and R2 in the dining room, which was initially described as consensual by both residents. However, R1's electronic medical records indicated socially inappropriate behavior, and witnesses, including R5 and R6, described the incident as inappropriate and public. Despite these observations, the facility did not immediately investigate the incident or interview witnesses. The facility's initial response was inadequate, as staff did not verify R1's capacity to consent, despite concerns about her cognitive impairment. R1's BIMS score had decreased from moderate to severe cognitive impairment, indicating she could not provide consent. The facility's Social Service Director confirmed that R1 was reassessed on June 25, 2024, and found to have severe cognitive impairment, which should have identified her as at risk for sexual abuse. Despite this, the facility relied on an outdated assessment from April 2024, which incorrectly suggested R1 could consent. The facility's policy on abuse prevention and reporting was not followed, as the incident was not promptly reported to the Illinois Department of Public Health (IDPH) or the police. The Administrator, V1, delayed reporting the incident, believing it was consensual based on outdated information. It was only after consulting with a psychiatrist and reassessing R1's capacity that the facility reported the incident to IDPH and the police. This delay in investigation and reporting highlights a failure to adhere to the facility's policy and procedures for abuse prevention and reporting.
Failure to Update Care Plan After Change in Cognitive Status
Penalty
Summary
The facility failed to update and revise a care plan following a significant change in a resident's cognitive status, which affected her ability to consent to sexual activity. The resident, a female with a history of dementia and other mental health conditions, was initially assessed as having the capacity to consent to sexual activity. However, a subsequent assessment revealed severe cognitive impairment, indicating that she could no longer provide consent. Despite this change, the care plan was not updated with specific interventions to address her inability to consent, leaving her at risk for sexual abuse. The deficiency was identified during a review of the resident's electronic medical records and interviews with facility staff. The resident's BIMS score, which measures cognitive function, decreased from 11/15 to 5/15, indicating a severe cognitive decline. The facility's policy requires that care plans be updated when there is a change in a resident's cognitive status, but this was not done in a timely manner. The lack of updated interventions in the care plan was a critical oversight, as acknowledged by the facility's Social Service Director, who stated that the care plan should have been revised to reflect the resident's new cognitive status and associated risks.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by their peers, as evidenced by multiple incidents involving ten residents. The administrator, identified as V1, did not report these incidents to the Illinois Department of Public Health (IDPH) because he believed that only incidents causing emotional distress or physical injury needed to be reported. This directive was reportedly given by corporate. The incidents included physical altercations between residents, such as one where a resident was pushed to the floor in an elevator after a verbal dispute. The report details specific incidents involving residents with various mental health diagnoses, including schizophrenia, bipolar disorder, and dementia. For example, one resident with major depressive disorder and schizophrenia was involved in a verbal and physical altercation with another resident in an elevator. Another incident involved a resident with schizoaffective disorder who was bitten by a roommate, resulting in slight redness on the heel. These incidents were not reported to the state, despite the facility's policy requiring such reports. The facility's failure to report these incidents is a significant deficiency, as it violates residents' rights to be free from abuse. The facility's policy on abuse prevention and reporting was not followed, as evidenced by the unreported incidents. The report highlights the need for proper documentation and reporting of all incidents of abuse, regardless of the perceived severity, to ensure the safety and well-being of all residents.
Failure to Report Abuse Allegations Timely
Penalty
Summary
The facility failed to report allegations of abuse to the Illinois Department of Public Health (IDPH) Regional Office within the required two-hour timeframe after being notified of the allegations. This deficiency was identified for all ten residents reviewed for allegations of abuse. The facility's administrator, V1, stated that he was instructed by the facility's corporation that allegations not causing emotional distress or physical injury did not need to be reported, which led to the failure to report several incidents. The report details multiple incidents involving residents with various psychiatric and cognitive impairments, including schizophrenia, bipolar disorder, and schizoaffective disorder. For instance, an altercation between two residents, R3 and R6, on May 5, 2024, was not reported to the IDPH. R3 claimed that R6 punched her, and in response, she scratched R6's face. Despite the incident being documented in progress notes, no report was submitted to the IDPH Regional Office. Similar reporting failures occurred with incidents involving other residents, such as R1 and R2, R3 and R4, and R7 and R8, where physical altercations and aggressive behaviors were documented but not reported as required. The facility's policy, titled 'Abuse Prevention and Reporting- Illinois,' mandates that any allegation of abuse or incident resulting in serious bodily injury be reported to the Department of Public Health immediately, but not more than two hours after the allegation. However, the facility did not adhere to this policy, as evidenced by the administrator's failure to submit reports for several incidents involving resident-to-resident altercations. This systemic issue highlights a significant deficiency in the facility's compliance with state reporting requirements for abuse allegations.
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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