Arc At Bradley
Inspection history, citations, penalties and survey trends for this long-term care facility in Bradley, Illinois.
- Location
- 650 North Kinzie Ave, Bradley, Illinois 60915
- CMS Provider Number
- 146112
- Inspections on file
- 36
- Latest survey
- June 18, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Arc At Bradley during CMS and state inspections, most recent first.
Two residents dependent on staff for bathing did not consistently receive scheduled showers or bed baths, as confirmed by resident interviews, staff statements, and documentation review. Both residents reported missed hygiene care, which was also noted in grievances and council meetings, and were observed with unpleasant body odor. Facility records showed gaps in documentation and failure to follow care plans and policy regarding bathing frequency.
A resident with multiple medical conditions and moderate cognitive impairment, who required a mechanical lift with two staff for transfers, was improperly transferred by a CNA without assistance, resulting in a fall and an acute nondisplaced proximal tibia-fibula fracture. The CNA was aware of the correct procedure but failed to follow it, leading to the resident's injury.
A resident was unable to use his urinal due to a malfunctioning bed, leading to him urinating on himself while in a wheelchair. Despite the resident's requests and the staff's awareness of the issue, the bed was not repaired in a timely manner. The resident, who required substantial assistance for transfers and toileting, remained in urine-soaked clothes during dinner. The facility's policy to report malfunctioning equipment immediately was not followed, contributing to the deficiency.
A resident with multiple health conditions developed an unstageable sacral pressure ulcer due to the facility's failure to implement pressure ulcer prevention interventions. The facility did not complete and document physician-ordered weekly skin assessments, missing several scheduled assessments. Despite being dependent on staff for care, the resident's skin issues were not documented or reported until discovered by a wound physician.
The facility failed to ensure call light access for two residents, one with quadriplegia and another with hemiplegia, as required by their care plans. The first resident's call light was out of reach when in a wheelchair, and the second resident's call light was tied to a stuffed duck on a nightstand, making it inaccessible. Both residents reported difficulties in calling for assistance, and staff confirmed the call lights should be within reach.
A resident, who required total assistance for showering, did not receive scheduled showers since admission. Despite being scheduled for showers twice a week, the facility only documented one bed bath, and the resident reported not receiving any showers. The facility's policy required offering showers according to the resident's preference, but this was not honored, leading to a lack of proper hygiene care.
The facility failed to provide routine bathing care for two residents requiring extensive assistance with ADLs. One resident, with multiple medical conditions, did not receive consistent bed baths despite a preference due to a tracheostomy. Another resident, with arthritis, was found unkempt and received infrequent showers, lacking regular hygiene care. The facility's policy on maintaining resident hygiene was not followed, leading to inadequate personal care and documentation issues.
The facility failed to provide a dignified dining experience to residents requiring feeding assistance and did not ensure privacy during wound care. Several residents were not fed promptly, and a resident was exposed during wound care due to missing window blind panels.
The facility failed to provide activities for four residents based on their care plans. One resident did not receive any 1:1 activities for the last 30 days, another was not observed in any 1:1 activities during multiple tours, and a third resident with severe dementia was given an unsuitable word puzzle. The Activities Director confirmed that the facility had not provided 1:1 services for the last 2 to 3 months.
The facility failed to securely store a portable oxygen tank, leaving it in a resident's closet for several days. This affected six residents, including those with mobility and respiratory issues, and violated the facility's storage policy for oxygen cylinders.
The facility failed to properly contain, replace, and date respiratory equipment for four residents, including leaving oxygen concentrators on and not storing masks in plastic bags, contrary to the facility's infection control policy.
The facility failed to provide adequate staffing, resulting in insufficient assistance with ADLs, delayed responses to call lights, and a lack of dignified dining experiences. Residents were often found soaked in urine and soiled with stool, and several were not fed in a timely manner. The facility's policies on morning care and nail care were not followed, leading to significant deficiencies in resident care and hygiene.
The facility failed to follow proper infection control protocols, including wearing appropriate PPE, tracking residents on isolation, obtaining physician orders for isolation, and performing hand hygiene during wound care. These deficiencies were observed in multiple residents with infections such as ESBL and MRSA.
The facility failed to use the McGeer's criteria form to determine the necessity of antibiotics for six residents with various infections. The Assistant Director of Nursing/Infection Preventionist acknowledged the oversight, and the facility could not locate antibiotic log sheets for two months, indicating lapses in infection control practices.
A resident with multiple mobility-related diagnoses was not provided with a comfortable wheelchair, leading to his refusal to use the facility-provided wheelchair, which was too small and painful. The process to obtain a custom wheelchair was not initiated, and there was no documentation explaining the resident's refusal.
A facility failed to ensure a resident was free from physical restraints used for staff convenience. The resident was observed at the nurses' station with his chair pushed against a table to prevent him from standing and wandering, despite being able to walk. The facility's administrator confirmed that restraints should not be used, and the resident's care plan did not include any orders for restraints.
The facility failed to provide necessary communication support for two Spanish-speaking residents, resulting in unmet needs. A CNA was unable to communicate with the residents due to a language barrier, and the residents did not have access to a communication board or interpreter as outlined in their care plans. The facility's administrator acknowledged the deficiency and the absence of a communication policy.
The facility failed to provide timely ADL care to three dependent residents, resulting in unmaintained personal hygiene, feelings of neglect, and inadequate incontinent care. The residents' care plans indicated a need for assistance, which was not consistently provided.
A resident with multiple diagnoses did not receive wound care as ordered by the physician. The resident's dressing was not changed daily as required, leading to an increase in the wound size and a failure to adhere to the facility's policy on pressure injury and skin condition assessment.
A resident with multiple diagnoses, including cerebral infarction and contractures, did not receive the recommended passive range of motion (PROM) exercises after being referred to restorative nursing. The facility failed to document or implement the necessary PROM, leading to a deficiency in care.
The facility failed to provide working sinks for residents' use, affecting five out of six residents reviewed. Residents reported being unable to use the sinks for basic hygiene tasks for at least a month, and no room changes were offered. CNAs had to use alternative methods to assist with grooming and incontinence care. Maintenance issues were logged but not addressed, and maintenance request forms were incomplete.
Failure to Provide Scheduled Bathing Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide adequate bathing assistance to residents who were dependent on staff for activities of daily living, specifically bathing. Two residents reported missing scheduled showers or bed baths, with one resident stating she was not on the list for her scheduled shower and another reporting missed bed baths, which she had brought up in both a grievance form and a resident council meeting. Both residents were observed to have unpleasant body odor at the time of interview, indicating a lack of proper hygiene care. Documentation reviewed showed inconsistencies and gaps in the recording of provided baths, with some scheduled baths not documented as completed and no evidence of computer documentation for certain periods. Staff interviews confirmed that residents are scheduled for two showers per week, with refusals to be documented and signed by the resident. However, the affected residents and the social services director confirmed that concerns about missed showers and bed baths had been raised multiple times. The care plans for both residents indicated a need for substantial or maximal assistance with bathing, yet records showed missed or delayed care. Facility policy requires that bathing be offered at least once per week or according to resident preference, but this standard was not met for the residents in question.
Improper Transfer Technique Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the safe transfer of a dependent resident, resulting in an acute nondisplaced proximal tibia-fibula fracture. The incident involved a resident with multiple medical conditions, including multiple sclerosis, reduced mobility, and moderate cognitive impairment, who was dependent on staff for transfers. The resident's care plan required the use of a mechanical lift with two staff members for transfers. However, a CNA attempted to transfer the resident alone without using the mechanical lift, leading to the resident falling and sustaining a fracture. Interviews and record reviews revealed that the CNA was aware of the correct transfer technique but chose to lift the resident without assistance, resulting in the resident being lowered to the floor and complaining of leg pain. The Director of Nursing confirmed that the CNA used the wrong transfer technique, and the Nurse Practitioner stated that the fracture could have been prevented if the proper transfer method had been used. The facility's policies on transfers and fall prevention emphasized the use of mechanical lifts for residents requiring two-person assistance, which was not followed in this case.
Failure to Accommodate Resident's Urination Needs Due to Bed Malfunction
Penalty
Summary
The facility failed to accommodate a resident's need to urinate by not ensuring his bed was functional, which led to the resident urinating on himself. The resident, who was cognitively intact and required substantial assistance for transfers and toileting due to impairments in both lower extremities, was left in his wheelchair from 11:00 AM until 7:00-7:30 PM because his bed was not working. Despite the resident's repeated requests to use the urinal, which he could only do while lying flat in bed, the staff did not resolve the issue in a timely manner. The resident ended up urinating on himself and remained in urine-soaked clothes during dinner. The issue was compounded by a lack of communication and timely action from the staff. The CNA who initially noticed the bed's malfunction did not report it, and the maintenance director was not informed until after he had left for the day. The CNA on the afternoon shift attempted to page maintenance, but the bed was not fixed until the maintenance director returned to the facility after being called at home. The facility's policy requires malfunctioning equipment to be reported immediately, but this protocol was not followed, resulting in the resident's discomfort and compromised dignity.
Failure to Implement Pressure Ulcer Prevention Leads to Unstageable Ulcer
Penalty
Summary
The facility failed to implement pressure ulcer prevention interventions for a resident, leading to the development of a sacral pressure ulcer. The resident, who had multiple health conditions including type 2 diabetes, hypertension, and a leg amputation, was identified as being at risk for pressure ulcers. Despite this, the facility did not complete and document the physician-ordered weekly skin assessments, missing several scheduled assessments. The resident was dependent on staff for mobility and care, and there was no documentation of skin issues during his stay until a wound physician discovered an unstageable sacral pressure ulcer. Interviews with facility staff revealed that skin observations were supposed to be conducted biweekly on shower days, and any physician-ordered assessments should have been documented on the Treatment Administration Record (TAR). However, the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) acknowledged that some assessments were missed, and the staff failed to document the resident's showers and any skin issues. The resident's family informed the facility of scrotal bleeding, which led to the wound physician's assessment and discovery of the pressure ulcer. The wound physician noted two wounds: an unstageable sacral pressure ulcer and a non-pressure wound on the scrotum, attributed to Moisture Associated Skin Damage (MASD). The facility's policy required daily skin observations during care and on bath days, with any changes promptly reported to the charge nurse. However, the staff did not adhere to these protocols, resulting in the failure to identify and treat the pressure ulcer in a timely manner.
Failure to Provide Call Light Access to Residents
Penalty
Summary
The facility failed to provide call light access to two residents, R2 and R3, which is a violation of their care plans. R2, who has quadriplegia, type 2 diabetes, and epilepsy, was observed in his motorized wheelchair without access to his call light, which was placed out of reach on the left side of his bed. R2 reported that the call light is never left near him when he is in his wheelchair, forcing him to seek assistance in the hallway. A CNA confirmed that all residents should have access to a call light to notify staff when they need assistance. R3, who has hemiplegia and hemiparesis following a cerebral infarction, carcinoma in situ of the anus and anal canal, hypertension, and dysphagia, was found lying in bed with her call light tied to a stuffed duck on her nightstand, out of her reach. R3 stated that her call light is always left on the nightstand, and she sometimes needs help but cannot call for staff. An RN observed the situation and noted that R3's call light could not be placed within reach due to a knot in the string. The Director of Nursing acknowledged that both residents are alert and able to make their needs known, and their call lights should be within reach. The facility's policy requires that all residents capable of using a call light should have it accessible at all times.
Failure to Provide Scheduled Shower Assistance
Penalty
Summary
The facility failed to provide shower assistance to a resident, identified as R1, who was admitted on an unspecified date. R1's admission Minimum Data Set (MDS) indicated that the resident was cognitively intact and required total assistance from the staff for showering. The facility's care plan task report scheduled R1 to receive showers on Tuesdays and Fridays in the morning. However, the facility could only present one shower sheet dated January 27, 2025, which was signed by a CNA, V10. V10 later stated that she did not provide a shower to R1 on that date but instead provided a bed bath. On February 4, 2025, R1, who was alert and oriented, stated in the presence of the Director of Nursing (V2) that she had not received any showers since her admission. R1's hair was observed to be greasy, and she expressed that she could smell herself, indicating a lack of proper hygiene care. R1 also mentioned that she was informed she would receive showers twice a week but was never asked for her preferred shower day and time. Despite asking the nursing staff daily for a shower, she was not assisted. The facility's policy required offering showers according to the resident's preference, no less than once a week, and as needed or requested. V2 acknowledged the failure to honor R1's shower preference and the expectation for nursing staff to provide ADL assistance, including showers, to maintain residents' hygiene and grooming.
Failure to Provide Routine Bathing Care for Residents
Penalty
Summary
The facility failed to provide routine shower or bed bath care for residents who require extensive assistance with activities of daily living (ADL). Resident 1 (R1), who has multiple medical diagnoses including chronic respiratory failure and morbid obesity, requires substantial assistance for bathing. Despite being alert and oriented, R1 did not receive a bed bath from June 4 to June 24, 2024, except on June 25 and 26. R1 expressed a preference for bed baths due to a tracheostomy and requested a schedule change from night to evening shift, which was not consistently honored. Documentation of R1's bathing schedule was inconsistent, and there was no record of R1 refusing care. Resident 2 (R2), who is alert and oriented with conditions such as rheumatoid arthritis and diabetes, also requires substantial assistance for bathing. R2 prefers showers due to arthritis relief but was found unkempt with overgrown nails and facial hair, indicating a lack of regular hygiene care. R2's shower records for June 2024 showed only three instances of bathing, with no documentation of refusals or additional care such as shaving and nail care. The facility's policy, last reviewed in January 2018, emphasizes the importance of maintaining resident hygiene and dignity through regular bathing. However, the facility's failure to adhere to this policy resulted in inadequate personal care for R1 and R2, as evidenced by the lack of consistent bathing and documentation. The staff's inability to provide the necessary care and document it properly contributed to the deficiency identified by the surveyors.
Failure to Provide Dignified Care
Penalty
Summary
The facility failed to provide a dignified dining experience to residents who require feeding assistance. Observations revealed that several residents, including a female with severe cognitive impairment and a male with intact cognition, were not fed promptly during lunch. Despite the presence of staff members feeding other residents, some residents expressed hunger and were not attended to in a timely manner. The Assistant Director of Nursing acknowledged that more staff should have been called to ensure all residents received a dignified feeding experience. Additionally, the facility failed to maintain dignity during wound care. A resident receiving wound care to her lower abdominal area was exposed due to missing panels in the window blinds, leaving her visible from the sidewalk leading to the patio and gazebo. The Assistant Director of Nursing attempted to close the blinds but was unsuccessful, resulting in the resident being exposed from her abdomen to her upper thighs. The facility's dignity policy emphasizes the importance of maintaining or enhancing each resident's dignity and respect, which was not upheld in this instance.
Failure to Provide Activities Based on Care Plans
Penalty
Summary
The facility failed to provide activities for four residents (R17, R29, R50, and R44) based on their care plans. R17 was observed in her room without any 1:1 activities for the last 30 days, despite her care plan indicating she should have 1:1 visits twice weekly. R17's son confirmed that no one has been spending time with her since a previous staff member passed away. Similarly, R29 was not observed in any 1:1 activities during multiple tours, and there was no documentation of such activities in the last 30 days, contrary to the care plan that required 1:1 visits twice weekly. The administrator acknowledged that R17 should have been receiving daily activities. R50, who has severe dementia and severely impaired cognition, was observed with a word puzzle he could not complete and no other stimuli like music or TV. His care plan indicated he should engage in activities like listening to music and watching television, but there was no documentation of 1:1 activities in the last 30 days. The administrator admitted that R50 should not have been given a word puzzle and should have been provided with suitable activities according to his care plan. R44, who has multiple diagnoses including aphasia and depression, also did not receive any 1:1 activities as required by the care plan. The Activities Director confirmed that the facility had not been able to provide 1:1 services for the last 2 to 3 months, despite the facility's policy requiring daily recording of residents' activity attendance and participation.
Failure to Securely Store Oxygen Tanks
Penalty
Summary
The facility failed to identify and address environmental hazards that posed risks for potential accidents. Specifically, a portable oxygen tank was stored unsecured in a resident's closet for several days, despite the resident not using oxygen and being unaware of its presence. The Assistant Director of Nursing confirmed that oxygen tanks should be stored in a designated oxygen room and secured in a holder to prevent accidents. The unsecured oxygen tank was observed on multiple occasions over three days, indicating a lapse in proper storage protocols. This deficiency affected six residents, including the resident in whose closet the oxygen tank was stored and five other residents in nearby rooms. These residents had various medical conditions, such as lack of coordination, reduced mobility, diabetes, and respiratory issues, which could increase their vulnerability to accidents. The facility's storage policy for oxygen cylinders mandates that they be secured and stored away from combustibles, which was not adhered to in this case, creating a potential hazard for the residents and staff in the area.
Failure to Properly Manage Respiratory Equipment
Penalty
Summary
The facility failed to properly contain, replace, and date respiratory equipment for four residents. During an initial tour, a surveyor observed that a resident's AVAPS machine face mask was not dated or contained in a plastic bag. Another resident's oxygen concentrator was left on, and their nasal cannula was uncontained and undated. Additionally, a third resident's nasal cannula, BIPAP mask, and nebulizer mask were not covered, and the oxygen humidifier container was dated 23 days prior, despite orders to change it weekly. The facility's policy requires respiratory equipment to be stored in clean plastic bags and dated when changed, which was not followed in these instances. A fourth resident with mild cognitive impairment and multiple respiratory conditions was observed with a nasal cannula on, while their nebulizer mask and C-PAP mask were not contained in plastic bags. The Assistant Director of Nursing confirmed that respiratory equipment should be stored in plastic zip lock bags. These observations indicate a failure to adhere to the facility's infection control policy, potentially increasing the risk of infection transmission among residents.
Inadequate Staffing and Care Deficiencies
Penalty
Summary
The facility failed to provide adequate staffing to meet the care needs of residents, resulting in insufficient assistance with Activities of Daily Living (ADLs), a lack of dignified dining experiences, and delayed responses to call lights. Observations and interviews revealed that the facility had only four CNAs on night shifts and weekends, which was insufficient to meet the needs of the residents. Multiple residents reported that they often heard others calling out for help during these times, and staff confirmed that residents were frequently found soaked in urine and soiled with stool due to inadequate incontinence care. The facility also had a strong stench of urine, indicating a lack of proper hygiene and care for incontinent residents. Specific incidents highlighted the deficiencies in care. For example, one resident was found with a thick watery bowel movement smeared around her perineum, despite the care plan requiring checks and changes every two hours. Another resident was observed with long jagged nails and facial hair, which had not been maintained for dignity and hygiene. Additionally, several residents were not fed in a timely manner during lunch, with one resident explicitly stating that they were hungry. The Assistant Director of Nursing acknowledged that residents should have a dignified feeding experience and that more staff should have been called to assist. The facility's policies on morning care and nail care were not followed, as evidenced by residents with untrimmed nails and unshaven facial hair. One resident reported feeling neglected due to the lack of assistance with showers, and records showed that there was no documentation of bathing for several days. The Assistant Director of Nursing confirmed that night shift staff were expected to reposition and provide incontinence care every two hours, but this was not being done, especially on weekends when agency staff were involved. The overall lack of adequate staffing and failure to adhere to care plans and policies led to significant deficiencies in resident care and hygiene.
Failure to Adhere to Infection Control Protocols
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, resulting in multiple deficiencies. Staff did not wear appropriate PPE when entering isolation rooms, failed to monitor and track residents on isolation, did not obtain physician orders for isolation, and did not develop care plans for residents in isolation. Specifically, a housekeeper was observed cleaning a room of a resident with ESBL without wearing a gown and gloves, and the infection preventionist admitted to not maintaining a log of residents on isolation precautions. Additionally, there were no physician orders or care plans for residents with ESBL and MRSA, and these conditions were not documented in progress notes or infection charting notes as required by facility policy. One resident with ESBL was observed outside his room, and the housekeeper cleaning his room was not wearing the required PPE. Another resident readmitted from the hospital with ESBL had no documentation of isolation or contact precautions in his progress notes or care plans. Similarly, a third resident with MRSA and ESBL had no isolation orders or care plans documented. The facility's policies on infection prevention and control, infection surveillance, and care plan coordination were not followed, leading to these deficiencies. Additionally, during wound care for a resident, the Assistant Director of Nursing did not perform hand hygiene after cleaning the wound and before applying new gloves, which is against the facility's hand hygiene policy. The administrator confirmed that the nurse should have cleaned her hands before putting on new gloves. These actions and inactions demonstrate a failure to adhere to established infection control protocols, putting residents at risk of infection.
Failure to Utilize Standardized Tool for Antibiotic Necessity
Penalty
Summary
The facility failed to utilize a standardized tool, specifically the McGeer's criteria form, to determine the necessity of antibiotics prescribed to six residents. This deficiency was identified through interviews and record reviews. For each of the six residents, the Physician Order Sheets (POS) indicated various antibiotics prescribed for infections such as skin infections, urinary tract infections (UTIs), and eye infections. However, none of these residents had the required McGeer's criteria form in the infection control binder or uploaded into their electronic medical records. The absence of these forms indicates that the facility did not follow its own policy for tracking and monitoring antibiotic use, as outlined in their Infection Prevention and Control Program and Antibiotic/Antimicrobial Stewardship Program guidelines. The Assistant Director of Nursing/Infection Preventionist acknowledged the oversight and mentioned that both the nurses and she were responsible for completing the McGeer's criteria forms, but this was not being done consistently. Additionally, the facility could not locate the antibiotic log sheets for October and November 2023, further indicating lapses in their infection control practices. The specific cases included a resident with a skin infection on the left lower leg, another with a UTI showing symptoms like tea-colored urine and mental status changes, and another with a UTI confirmed by lab results showing E.coli. Other cases involved a resident with an eye infection secondary to MRSA, another with a UTI showing symptoms like burning and itching, and a resident with a skin infection presenting as a red, irritated lump under the armpit. In each case, the required McGeer's criteria form was missing, and the facility's policies were not adhered to, leading to the deficiency noted by the surveyors.
Failure to Provide Comfortable Wheelchair for Resident
Penalty
Summary
The facility failed to provide a comfortable wheelchair for a resident (R65) who was reviewed for mobility. R65, who is cognitively intact and has multiple diagnoses including morbid obesity, abnormal posture, lack of coordination, reduced mobility, osteoarthritis, and chronic gout, was admitted to the facility and required a wheelchair for mobility. Despite his needs, the facility did not document the reason for his refusal to use the provided wheelchair, which he found too small and painful. The resident was observed lying in bed and stated that the facility did not have a wheelchair suitable for his size and body type. The Director of Rehab (V17) confirmed that R65 refused the offered wheelchair because it was too low for him and acknowledged that a custom wheelchair, which would be more suitable, was never ordered. The process to obtain a custom wheelchair would require coordination with the Nurse Practitioner and the wheelchair company, but this process was not initiated. Additionally, the Facility Consultant (V16) did not have documentation explaining why R65 refused the previously provided wheelchair.
Failure to Ensure Resident is Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints imposed for staff's convenience. On 05/15/24, a nurse stated that the resident was brought to the nurses' station because he frequently tried to stand up. The resident was observed sitting at a table with his chair pushed up against it and the wheels locked, preventing him from standing. The nurse admitted that the table was used to keep the resident from standing and wandering, despite the resident being able to walk, albeit unsteadily. The nurse also mentioned that the resident was usually placed at the nurse's station to prevent him from standing and wandering in the hallway. The facility's administrator confirmed that staff should not be restraining residents and that there was a fall prevention care plan in place that did not include the use of restraints. A review of the resident's electronic health record showed no orders to restrain the resident's movement or mobility, nor did the care plan include any interventions involving restraints. The facility's restraint policy indicated that physical restraints should not be used for staff convenience and defined freedom of movement as any change in place or position that the resident is physically able to control.
Failure to Provide Communication Support for Spanish-Speaking Residents
Penalty
Summary
The facility failed to provide necessary care and services to maintain the ability of two Spanish-speaking residents to carry out activities of daily living, specifically in terms of communication. On multiple occasions, a Certified Nurse's Assistant (CNA) was unable to communicate with the residents due to a language barrier, resulting in unmet needs. The CNA admitted to not understanding the residents and left the room without addressing their needs. This lack of communication was observed during a survey, and it was confirmed that the residents did not have access to a communication board or interpreter as outlined in their care plans. Resident R45, a Spanish-speaking female with poor cognition, had a care plan that included the use of a communication board or a Spanish-speaking employee, but these interventions were not implemented. Similarly, Resident R77, who also required an interpreter, did not receive the necessary communication support. The facility's administrator acknowledged the deficiency and noted the absence of a communication policy, which contributed to the failure in meeting the residents' needs.
Failure to Provide Timely ADL Care
Penalty
Summary
The facility failed to provide timely ADL (Activities of Daily Living) care to three dependent residents. One resident was observed on multiple occasions with long, jagged nails and facial hair, despite being dependent on staff for personal hygiene. The resident's care plan indicated a need for assistance with personal hygiene, which was not provided, leading to potential safety and dignity concerns. The administrator acknowledged that the resident's nails and facial hair should have been maintained for hygiene and safety reasons. Another resident was observed with long facial hair and reported feeling neglected due to not receiving showers when requested. The resident's care plan indicated a need for assistance with bathing, but documentation showed inconsistent provision of showers. The administrator confirmed that the resident should receive showers or bed baths as needed. Additionally, a third resident was found with a strong urine/feces smell in her room and was discovered with a thick watery bowel movement smeared around her perineum. The CNA stated that the resident was last checked several hours earlier, despite the care plan requiring checks every two hours. The DON confirmed that incontinent care should be provided every two hours and as needed.
Failure to Provide Physician-Ordered Wound Care
Penalty
Summary
The facility failed to provide wound care as ordered by the physician for a resident with multiple diagnoses, including metabolic encephalopathy, lack of coordination, reduced mobility, malignant neoplasm of the prostate, and hypertension. The resident had a physician's order to cleanse the area on the coccyx with wound cleanser, pat dry, apply calcium alginate, and secure with border gauze daily. However, the resident reported that his dressing had only been changed once during the week, and the Assistant Director of Nursing (ADON) confirmed that the dressing had not been changed as required on one of the days. The ADON observed that the dressing removed was dated two days prior, indicating a failure to follow the daily dressing change order. The resident's wound was initially discovered on 5/12/24 and measured 0.5 cm x 0.5 cm. By 5/14/24, the wound had increased in size to 0.8 cm x 0.6 cm x 0.1 cm. During the dressing change on 5/16/24, the wound was observed to have white slough with a perimeter of redness approximately 1 inch. The facility's policy on pressure injury and skin condition assessment states that dressings should be checked daily for placement, cleanliness, and signs of infection, which was not adhered to in this case, leading to the deficiency in wound care management for the resident.
Failure to Provide Restorative ROM Program
Penalty
Summary
The facility failed to provide a restorative range of motion (ROM) program to a resident with limited ROM. The resident, who had multiple diagnoses including cerebral infarction, hemiplegia, and contractures, was observed in bed with a contracted left leg and complained of pain. Despite being referred to restorative nursing for lower extremity ROM after completing occupational and physical therapy, there was no documentation or order for passive range of motion (PROM) exercises for the resident. The Assistant Director of Nursing confirmed the lack of documentation and was unaware of the referral for PROM, acknowledging that the contractures could worsen without the recommended exercises. The facility's policy stated that residents should be screened for restorative nursing programs and that ROM programs should be implemented as needed. However, the interdisciplinary team had identified the resident as needing PROM, but the facility failed to follow through with the recommendations. The resident's progress notes indicated a high risk for further decline and a willingness to perform ROM exercises in bed, yet the necessary PROM was not provided, leading to a deficiency in care for maintaining or improving the resident's ROM.
Facility Failed to Provide Working Sinks for Residents
Penalty
Summary
The facility failed to provide working sinks for residents' use, affecting five out of six residents reviewed for physical environment. On October 13, 2023, it was observed that the sinks in the rooms of residents R1, R2, R3, R4, and R5 were either clogged or had standing water, with signage indicating 'Do not use.' Residents R1 and R2, who were cognitively intact, reported that they had been unable to use the sinks for basic hygiene tasks such as washing hands and brushing teeth for at least a month. R1 and R2 also stated that no room changes were offered to them. Certified Nursing Assistants (CNAs) confirmed that they had to use sinks in other residents' rooms or bring water from the shower room to assist with grooming and incontinence care for residents R3, R4, and R5, who required total assistance and were either confused or non-interviewable. The facility's Administrator, V1, acknowledged that the Maintenance Director's position had been vacant since September 22, 2023, and that the maintenance assistant was on vacation. The Social Service Director, V3, who handles grievances and concerns, confirmed that she had logged maintenance issues for the clogged sinks but did not offer room changes due to high occupancy. Maintenance request forms for the clogged sinks were found to be incomplete, with sections for request received, work assigned to, and approval left blank. The facility's maintenance policy mandates that plumbing fixtures and piping should function properly and be maintained in good repair, which was not adhered to in this case.
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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