Archer Heights Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 4437 South Cicero, Chicago, Illinois 60632
- CMS Provider Number
- 145995
- Inspections on file
- 57
- Latest survey
- February 22, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Archer Heights Healthcare during CMS and state inspections, most recent first.
A resident with asthma and other medical conditions, who was cognitively intact, shared a room with a cognitively intact roommate diagnosed with nicotine dependence and dementia who repeatedly smoked in their room despite a facility smoke‑free interior policy, a documented history of in‑room smoking, a care plan addressing this behavior, and a signed smoking contract prohibiting possession and use of smoking materials in the room. Staff, including an LPN, confirmed that the smoker continued to smoke in the shared room and that the asthmatic roommate complained about the smoke. The smoker admitted he chose to smoke in his room rather than go to designated outdoor areas, resulting in the facility’s failure to maintain a safe, clean, and comfortable environment free from in‑room smoking.
Staff failed to follow Enhanced Barrier Precautions and infection control policies during incontinence care for a cognitively intact resident with multiple comorbidities, including diabetes with foot ulcer, kidney failure, and dialysis dependence. A CNA wore contaminated gloves in the hallway, accessed the linen cart without changing gloves, and provided incontinence care without a gown, despite posted EBP instructions requiring gown and gloves for high-contact care. The privacy curtain was not used, the room door remained open, and a soiled brief was left on the floor. An LPN and the DON confirmed that facility policy requires gown and glove use for EBP residents and proper bagging and disposal of soiled linens and incontinent products.
Multiple residents reported and surveyors observed persistent uncleanliness in resident rooms, including trash and debris on floors and under beds, despite facility policies requiring daily cleaning. Staff interviews revealed inconsistencies in cleaning practices, and care plans did not address potential hoarding behaviors, resulting in a failure to provide a safe and homelike environment.
A resident with intact cognition was given medication at the medication cart and took it without a nurse present to observe ingestion. The LPN responsible was multitasking and did not ensure the medication was swallowed. There was no physician's order or assessment for self-administration, and facility policy requires direct observation during medication administration.
Multiple residents and staff reported and surveyors observed persistent cleanliness and maintenance issues, including unemptied garbage, insect infestations, soiled and unsanitary shower rooms, and broken equipment. These deficiencies were present throughout the facility, affecting resident rooms, shared bathrooms, dining areas, and staff spaces, despite facility policies requiring daily cleaning, pest control, and regular maintenance.
A resident who was cognitively intact but required substantial assistance for daily activities and had hand contractures was unable to access their call light, which was found out of reach. Staff confirmed the call light's placement prevented the resident from requesting help, despite facility policy and the care plan requiring it to be accessible.
A nurse administered an antihypertensive medication to a resident without assessing or documenting blood pressure as required by the physician's order and facility policy. Both the LPN and DON confirmed that blood pressure should be checked before giving such medications to ensure safe administration.
Multiple incidents of resident-to-resident physical abuse occurred, including altercations on the smoking patio, in a shared room, and in the dining room. In each case, verbal disputes escalated to physical violence, with staff intervening after the events. Some residents had documented behavioral issues or prior conflicts, but preventive measures were not effectively implemented, resulting in physical harm and distress.
The facility did not ensure proper cleaning or maintenance of water and ice machines, resulting in visible mineral buildup, leaks, and unsanitary conditions. Staff and residents accessed water and ice from these machines and from sinks also used for handwashing, which were not properly maintained. Facility leadership and staff were unclear about responsibilities for cleaning and servicing the machines, and established policies for regular cleaning and maintenance were not followed.
The facility did not provide enough seating in day/dining rooms for ambulatory residents and failed to maintain cleanliness and timely repairs in resident rooms and common areas. Multiple residents reported having to stand or use uncomfortable alternatives due to a lack of chairs, and observations revealed persistent issues such as sticky floors, stained walls, and delayed maintenance of reported problems. Housekeeping and maintenance staff were unclear about cleaning schedules, and resident council minutes reflected ongoing concerns about room cleaning.
Two residents with cognitive and behavioral impairments were involved in an incident where one physically struck the other over a wheelchair, with staff failing to provide adequate supervision or immediate intervention. In a separate case, a resident assessed as a moderate fall risk did not receive recommended side rails and alarms, resulting in a fall and head injury, despite staff and assessment documentation supporting the need for these interventions.
A resident with a history of substance abuse and mental health conditions became intoxicated and reported non-consensual sexual activity while under the influence of alcohol and drugs. Multiple residents were able to access and use alcohol and illicit substances within the facility, despite existing policies prohibiting contraband. Staff only checked residents' bags and not their persons, leading to lapses in supervision and enforcement, and resulting in harm to at least one resident.
Several instances were identified where medications, including pills, inhalers, and insulin pens, were left unsecured at the bedside or in unlocked carts, and residents were not on self-administration programs. Staff interviews and record reviews confirmed that medications were not always administered or stored according to facility policy, with some medications lacking physician orders and being left accessible to residents without proper authorization.
A resident dependent on staff for ADLs did not receive timely personal hygiene, including nail care, and was found in soiled conditions with unkempt hair, dirty hands, and a foul-smelling room. The assigned CNA had not provided required morning care or checked on the resident since the start of the shift, despite the care plan indicating a self-care deficit and the need for staff assistance.
A resident with chronic respiratory conditions did not receive prescribed BIPAP therapy at night as ordered following hospital discharge. Facility records showed no documentation of BIPAP or CPAP treatment, and staff interviews revealed a lack of communication and follow-through in reconciling and implementing hospital recommendations. The resident's care plan did not address the required therapy, and the necessary equipment was not available, resulting in a failure to provide and document appropriate respiratory care.
A resident with COPD and other medical conditions was given oxygen at 5L/min via nasal cannula, despite a physician's order for 3L/min. An LPN did not check the oxygen concentrator setting during her shift and was unaware of the incorrect dosage until it was pointed out by a surveyor. Both the DON and a nurse practitioner confirmed that the order was for 3L/min and that oxygen should be administered as prescribed.
A resident with a history of COPD and bilateral below-knee amputations did not receive prescribed morphine for pain management, despite documentation indicating administration. The facility failed to manage the medication process effectively, as narcotic sheets were missing and the medication was not found in the narcotic drawer. Staff interviews revealed inconsistencies in documentation and administration, leading to unmanaged pain for the resident.
The facility failed to adhere to proper food storage and sanitation practices, potentially affecting all 207 residents on an oral diet. Observations included undated and unlabeled food items, staff storing personal food in resident areas, and a lack of sanitizer in the kitchen. These actions violate the facility's policies on food safety and sanitation.
The facility failed to maintain a sanitary and comfortable environment for four residents. One resident reported infrequent room cleaning, while another's room had missing furniture parts and stained floors and curtains. A resident with a g-tube had a dried substance on the pole and dust on the oxygen concentrator. Staff were unclear about cleaning responsibilities, leading to these deficiencies.
The facility failed to secure and properly manage medications, particularly narcotics, on the fourth floor. An unlocked medication refrigerator allowed access to narcotics, and expired medications were found. Controlled substances like Diazepam were improperly stored, and inhalers lacked clear labeling. Discrepancies in narcotic medication documentation were noted, contrary to facility policies requiring secure storage and accurate inventory reconciliation.
The facility failed to monitor personal refrigerator temperatures and ensure thermometers were present for four residents, leading to expired food being found. Staff interviews revealed confusion about who was responsible for these checks, contrary to the facility's policy requiring daily temperature logs and monitoring.
The facility failed to ensure proper infection control measures, including PPE use during wound care, posting EBP signage, and maintaining PPE bins outside isolation rooms. Staff did not perform hand hygiene when passing meal trays, even after touching personal items. Interviews revealed a lack of adherence to infection control protocols, with the absence of an IP nurse contributing to these deficiencies.
The facility failed to ensure call light accessibility for two residents, affecting their ability to request assistance. One resident, with multiple diagnoses including osteoarthritis and dementia, had her call light on the floor behind her bed, out of reach. Another resident, also with dementia and other health issues, had the call light on the floor underneath the bed. Both residents' care plans required the call light to be within reach, but this was not adhered to, as confirmed by facility staff.
The facility failed to refer three residents for a Level II PASARR evaluation after new mental disorder diagnoses. One resident was admitted with bipolar and adjustment disorders, but the PASARR did not reflect these conditions. Another resident had Major Depressive Disorder, but the PASARR documentation did not indicate this, and the care plan did not address it. A third resident's PASARR documentation was incomplete, missing the Major Depressive Disorder diagnosis. The facility's policy requires PASARR screening prior to or shortly after admission, which was not followed.
The facility failed to update the PASARR for three residents with new mental health diagnoses, including Major Depressive Disorder and bipolar disorder. The initial screenings did not reflect these conditions, and necessary Level II screenings were delayed or not conducted. The Business Office Manager acknowledged the oversight and initiated corrective actions, but the facility did not adhere to its policy requiring timely PASARR screenings.
A resident with a history of diabetes and foot ulcers did not receive daily wound care as ordered, leading to dirty dressings and self-care by the resident. Facility records showed multiple days without documented care, and staff confirmed the expectation for daily dressing changes.
The facility failed to investigate a fall incident involving a resident with multiple medical conditions and did not implement fall interventions as per the care plan. Additionally, the facility did not ensure adequate supervision to prevent a resident from smoking in a room, despite policies prohibiting indoor smoking. These deficiencies highlight lapses in adhering to safety protocols and resident supervision.
The facility failed to provide proper respiratory care for two residents receiving oxygen therapy. One resident's nasal cannula tubing was not changed weekly, and their CPAP mask was improperly stored. Another resident received oxygen without a physician's order, and their tubing was found on the floor. Both residents were cognitively intact and had diagnoses requiring supplemental oxygen. The facility did not adhere to its policies for equipment change and physician orders.
A resident with severe cognitive impairment was prescribed and administered Remeron for depression without obtaining informed consent beforehand. The facility's policy requires informed consent prior to prescribing psychotropic medications, but consent was only obtained verbally after the medication had been administered for several weeks.
Two residents in a facility experienced abuse due to inadequate protection measures. One resident was pushed by another, resulting in a head injury, while another resident was physically assaulted during a verbal altercation. The facility's investigation and response were insufficient, failing to acknowledge and address the aggressive behaviors effectively.
A resident with a surgical wound did not receive necessary treatment and services, leading to wound deterioration and avoidable pain. The resident's dressing was not changed as ordered, and pain medication was not documented as administered. Staff interviews revealed a lack of proper documentation and assessment for self-care, contributing to the resident's condition worsening.
The facility failed to maintain a clean environment, affecting all 208 residents. Observations showed dirty floors with food particles and dirt in dining areas and hallways. Staff and residents acknowledged the unclean conditions, with some residents cleaning their own rooms due to housekeeping shortages. The facility's administrator confirmed recent housekeeping issues and the appointment of a new manager.
The facility failed to report suspected abuse incidents within the required timeframe, affecting four residents. In one case, a resident was pushed and injured by another resident, but the incident was reported six days late. In another case, a verbal disagreement escalated to physical abuse, but the administrator was not informed of the physical aspect. Staff did not follow the facility's policy for immediate reporting to the state survey agency and the abuse prevention coordinator.
The facility failed to investigate a fall incident where a resident was allegedly pushed by another, resulting in a head injury. Additionally, an allegation of verbal and physical abuse between two residents was not investigated. Key witnesses were not interviewed, and relevant records were not reviewed, leading to deficiencies in addressing potential abuse.
A resident left the facility unsupervised for an appointment and did not return for four days, as the facility failed to complete a timely community survival skills assessment. The resident's intact cognition was noted, but the assessment was delayed, leading to a lack of awareness of the resident's whereabouts. Staff interviews revealed communication gaps regarding pass privileges and monitoring processes.
The facility failed to maintain the third-floor community shower room in a sanitary and functional condition, affecting 52 residents. Observations revealed a stained toilet bowl, accumulated dust on the toilet water tank, and a broken shower faucet. An LPN confirmed the issues, and the Housekeeping Director acknowledged staffing challenges, with plans to hire more staff. The facility's housekeeping policy mandates daily cleaning, which was not followed.
A facility failed to protect two residents from abuse by another resident with known violent behavior. The aggressive resident was admitted without timely background checks or a care plan, despite a history of aggression and a criminal record. This oversight led to physical assaults on two residents, causing significant injuries. The facility's assessments and care planning were inadequate, contributing to the failure to prevent these incidents.
A resident with multiple diagnoses, including legal blindness and dementia, was inaccurately assessed, leading to unaddressed aggressive behaviors. The resident assaulted two other residents, causing significant harm to one. Facility staff confirmed the inaccuracies, noting the absence of a specific policy for aggression screening and trauma assessments.
A facility failed to develop a care plan for a resident with known aggressive behaviors, leading to two incidents where the resident physically assaulted other residents, causing harm. Despite prior knowledge of the resident's history of aggression and dementia, the care plan was not updated until after these incidents, contrary to facility policies requiring timely updates to care plans.
A resident with a known history of aggression was inadequately supervised, leading to assaults on two other residents, causing significant injuries. Despite prior incidents and staff awareness of the resident's violent tendencies, the care plan was not updated to address these behaviors, and no specific supervision measures were implemented.
The facility failed to conduct quarterly QAPI meetings and did not address abuse data collection, affecting all 200 residents. Meeting minutes from March 2024 lacked abuse reporting, and no further minutes were available until October 2024. Staff confirmed that incidents of physical abuse were not reviewed in QAPI meetings, and facility policies did not adequately address abuse prevention.
The facility failed to submit a final investigation report regarding a physical altercation between two residents to the state survey agency within the required five business days. The incident was initially reported, but the final report was delayed by 20 days. The administrator, who is also the abuse prevention coordinator, acknowledged the oversight and resubmitted the report. This failure to comply with the facility's policy affects the residents involved.
The facility failed to protect residents from verbal and physical abuse, leading to significant incidents. A resident with schizoaffective disorder was harassed by another resident, resulting in a physical altercation and self-inflicted injury. Another incident involved two residents in wheelchairs who engaged in a verbal and physical confrontation. The facility's policies on abuse prevention were not effectively enforced, leading to harm and distress among residents.
A resident on anticoagulants fell and sustained a head injury, but the LTC facility failed to assess, document, and inform the physician promptly. The resident was not sent to the hospital immediately, despite the risk of a subdural hematoma. Staff inconsistencies in reporting and documentation were noted, and facility protocols for neurological assessment were not followed.
A diabetic resident in an LTC facility suffered severe complications due to inadequate foot care and monitoring. Despite requiring substantial assistance, the resident's foot condition was neglected, leading to a wound infested with maggots. The nurse practitioner discovered the issue during a routine check, resulting in the resident's hospitalization and amputation of the right big toe due to gangrene. Staff interviews revealed inconsistencies in care and documentation, highlighting a failure to adhere to facility policies on skin assessments and foot care.
A resident reported that a nurse called them a 'crackhead' and threatened to transfer them, but the facility failed to report this allegation to IDPH within the required two-hour timeframe. The administrator did not initially consider it an abuse allegation, leading to a delay in reporting.
A facility failed to coordinate outside services and maintain complete medical records for a resident, leading to missed and uncoordinated follow-up appointments after hospitalizations. Staff were unaware of the resident's past and future appointments, resulting in a lack of transportation arrangements and incomplete records. The facility lacked an appointment policy, contributing to the deficiency.
A resident's medical records inaccurately listed a diagnosis of schizophrenia, which the resident did not have. The facility staff, including the DON and a psychiatric nurse practitioner, could not determine the source of this incorrect diagnosis. The facility's medical record policy requires accurate documentation, but this was not followed, leading to the error.
A resident with a history of aggressive behavior ran over another resident's foot with a wheelchair, causing significant pain and swelling. The incident occurred after a disagreement at the nurse's station, and staff failed to adequately monitor and manage the situation. The facility's delayed reporting to the state agency highlights a deficiency in protecting residents from harm.
A survey revealed that a facility failed to maintain a clean and safe environment for its 221 residents. Observations included missing handrails, dirty and tattered chairs, and broken shower equipment across multiple floors. Residents with severe cognitive impairments were affected by these conditions. Staff interviews indicated that maintenance requests were not consistently logged or addressed. The facility's maintenance and housekeeping protocols were inadequate, as evidenced by the poor condition of the environment.
Failure to Prevent In‑Room Smoking Exposing Roommate to Smoke
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, comfortable, and smoke‑free environment for a resident sharing a room with a known smoker. One resident with medical diagnoses including anxiety disorder, bipolar disorder, paraplegia affecting the right side, cerebral infarction, and asthma, and who was documented as cognitively intact, reported that his roommate was constantly smoking in their room. The roommate had medical diagnoses including nicotine dependence, cognitive communication issues, dementia, major depressive disorder, memory deficit following cerebral infarction, and chronic osteomyelitis, and was also documented as cognitively intact. Despite a facility policy that the interior of the facility remain smoke‑free and that smoking occur only in designated areas, the smoking roommate admitted to smoking in the shared room and stated he did so because he did not feel like going outside and did not care about the rules. The smoker’s record showed a long-standing pattern of smoking in his room, with social service notes documenting multiple dates over several months when he was observed smoking in his room. His care plan identified a behavior of smoking cigarettes in his room, and a Smoking Risk Review concluded he may not be capable of handling or carrying smoking materials and required supervision when smoking. A smoking contract specified that he would not smoke anywhere else in the building, would surrender all smoking materials, and would not possess smoking materials in his room or clothing, with stated consequences for violating the policy. Nonetheless, staff, including an LPN, confirmed that the resident continued to smoke in his room while he was roommates with the resident who had asthma, and that the asthmatic resident complained about the smoking because he did not want his asthma to flare up. These actions and inactions resulted in the resident with asthma being exposed to cigarette smoke in his room, contrary to the facility’s smoking safety policy and the resident’s right to a safe, clean, and comfortable environment.
Failure to Follow Enhanced Barrier Precautions During Incontinence Care
Penalty
Summary
Surveyors identified a failure to follow the facility’s Enhanced Barrier Precautions (EBP) and infection control policies during incontinence care for one resident. On 1/17/2025 at 3:45 PM, a CNA (V7) was observed exiting and re-entering the resident’s room and walking down the hallway while wearing contaminated gloves, then going to the linen cart to obtain a facecloth without removing the gloves. V7 then returned to the resident’s room and performed incontinence care without wearing a gown, despite an EBP sign posted on the resident’s door stating that staff must wear both gown and gloves for high-contact resident care activities such as changing briefs or assisting with toileting. During this care, the privacy curtain was not pulled, the room door remained open, and a soiled brief was observed on the floor next to the resident’s bed. In subsequent interviews, V7 acknowledged that the resident was on EBP and stated she should not have been wearing gloves in the hallway. An LPN (V8) confirmed that the resident was on EBP and stated that to prevent the spread of infection, staff should wear a gown and gloves during care and that soiled linen and incontinent products should not be thrown on the floor but placed in a bag and disposed of properly. Another LPN (V9) and the DON (V2) both stated that staff should wear gown and gloves when performing incontinence care for residents on EBP and that soiled linen and incontinent products should be bagged and disposed of properly. The resident involved was cognitively intact, with diagnoses including Type 2 diabetes mellitus with foot ulcer, unspecified kidney failure, dependence on renal dialysis, and acquired absence of the right leg above the knee. The facility’s EBP policy required gowns and gloves for high-contact care activities, and the Infection Control Policy required all personnel to adhere to the Infection Control Program in their daily assignments.
Failure to Maintain Clean and Homelike Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for several residents, as evidenced by observations of uncleanliness and debris in multiple resident rooms. Surveyors observed trash, paper, and other debris on the floors and under beds in the rooms of four residents. One resident reported that housekeeping had not cleaned his room despite repeated requests over a two-week period, and trash was observed on the floor and under his bed. Another resident confirmed that trash was consistently present on the floor in his room. In another room, surveyors found multiple empty bottles, paper, napkins, and a meal tray slip stuck to the floor, which the housekeeper acknowledged was present despite stating the room had been cleaned that morning. The same resident reported that her room had not been cleaned for about ten days and that the bathroom remained uncleaned even after she reported the issue to staff multiple times. Interviews with staff revealed inconsistencies in cleaning practices, with the regional nurse consultant stating that rooms are cleaned daily and that floor nurses are responsible for ensuring cleanliness, while the housekeeper admitted to cleaning a room that still contained significant debris. Residents' care plans did not document any focus on hoarding behaviors, and the facility's policies require a safe, clean, and comfortable environment. The observations and resident interviews directly contradict the facility's stated cleaning protocols and policies, resulting in a failure to provide the required homelike environment.
Failure to Ensure Proper Medication Administration
Penalty
Summary
A deficiency occurred when a resident with intact cognition was observed taking medication at the medication cart without a nurse present to ensure the medication was swallowed. The resident's physician order sheet did not document a focus for self-administration of medication, and there was no evidence of a physician's order, resident education, care plan, or assessment for self-administration. The resident reported that the LPN handed her the medication and then walked away for a few seconds, during which time the resident took the medication and drank water without supervision. The LPN confirmed she did not observe the resident take the medication because she was multitasking. The Director of Nursing stated that self-administration of medication requires specific interventions for safety, including a physician's order and assessment, and that nurses are required to observe residents to ensure medications are swallowed. Facility policy requires medications to be administered in accordance with good nursing practices and only by authorized personnel, with sufficient staff and systems in place to ensure safe administration without unnecessary interruptions.
Widespread Environmental Cleanliness and Maintenance Failures
Penalty
Summary
The facility failed to maintain a clean, safe, and comfortable environment for all 196 residents, as evidenced by multiple observations, interviews, and record reviews. Residents and staff reported and surveyors observed widespread cleanliness issues, including garbage not being emptied daily in resident rooms, accumulation of food waste, and the presence of flies and gnats throughout the facility. Specific instances included garbage cans in resident bathrooms and rooms remaining unemptied for several days, leading to infestations of fruit flies and gnats, and residents expressing dissatisfaction with the frequency and quality of cleaning services. Significant sanitation concerns were documented in shared shower rooms, where surveyors observed soiled and wet paper products, brown-stained towels, suspected fecal matter, and mold or mildew on ceiling tiles and grout. The shower drains were covered in hair and infested with small flying insects. Equipment in the shower rooms was found to be in disrepair, such as a shower head pole that was not properly secured to the wall, and a handheld shower nozzle left dangling without a mounting pole. Staff acknowledged these issues, with housekeepers and CNAs noting the persistent dirtiness, presence of mold or mildew, and lack of proper equipment maintenance. Maintenance staff were unaware of some of the problems, indicating a breakdown in communication and reporting. Additional observations included sticky and debris-laden dining room floors, a shower bed with a drain pan containing foul-smelling, murky liquid with solid brown particles, and further insect infestations in various facility areas, including staff bathrooms. Facility policies and job descriptions provided by the facility require daily cleaning, prompt garbage removal, pest control, and regular maintenance, but these standards were not met. Residents involved had intact cognition and were able to clearly articulate their concerns and dissatisfaction with the environment, and some were dependent on staff for all activities of daily living and mobility.
Call Light Not Accessible to Resident Requiring Assistance
Penalty
Summary
Facility staff failed to ensure that a resident's call light was within reach, as required by facility policy and the resident's care plan. The resident, who was cognitively intact but required substantial to maximal assistance for most activities of daily living and had left hand contractures, was observed attempting to sit up in bed and searching for the call light to request assistance. The call light was found hanging on top of the overhead light, far from the resident's reach, making it inaccessible for the resident to use when needed. Interviews with staff, including a CNA, the ADON, and the DON, confirmed that the call light was not within reach and that this would prevent the resident from being able to request help. The resident's care plan specifically instructed staff to ensure the call light was within reach and to encourage its use for assistance. The facility's policy also required that all residents have the call light system available and easily accessible at the bedside or another reasonable location.
Failure to Assess Blood Pressure Prior to Antihypertensive Administration
Penalty
Summary
A deficiency occurred when a nurse failed to assess and document a resident's blood pressure prior to administering an antihypertensive medication, Procardia XL (Nifedipine), as ordered by the physician. The physician's order specified that the medication could be held if blood pressures were persistently 130/80 mmHg, and the facility's policy required medications to be administered as prescribed, including adherence to the five rights of medication administration. Despite these requirements, the resident's electronic medication administration record (eMAR) showed that blood pressure readings were not assessed or documented before administering the medication on multiple dates. Interviews with the LPN and the Director of Nursing confirmed the importance of checking blood pressure prior to administering antihypertensive medications to prevent unnecessary or potentially harmful dosing. The Director of Nursing stated that medications should not be given outside of physician parameters and that nurses are expected to assess blood pressure before administration. The facility's own policy also emphasized the need for medications to be administered in accordance with prescriber orders and good nursing practices.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in multiple incidents of resident-to-resident altercations. In one incident, a resident with intact cognition and a history of anger issues physically struck another resident during a dispute over seating on the smoking patio. The altercation was preceded by verbal exchanges and escalated to physical contact, with staff intervening after the event. The involved residents had no prior history of conflict, but both had behavioral concerns documented in their care plans. Another incident involved two roommates with a history of verbal arguments. One resident, who had previously threatened the other and had a diagnosis of paranoid schizophrenia, physically assaulted her roommate, causing visible injury. Staff were aware of ongoing verbal conflicts between the two but did not separate them prior to the physical altercation, citing lack of available rooms and resident refusals to move. The altercation resulted in one resident being sent to the hospital for psychiatric evaluation. A third incident occurred in the dining room, where a verbal argument between two residents escalated to physical violence. One resident, who had a history of mood distress and anger, was punched and pulled to the ground by another resident following an exchange of insults. Staff responded promptly to separate the residents, and both later apologized. The residents involved had no prior history of conflict, and the aggressor was a new admission who discharged herself against medical advice the same day. In all cases, the facility's policies on abuse prevention and resident rights were not effectively implemented to prevent these incidents.
Failure to Maintain Sanitary Water and Ice Machines
Penalty
Summary
The facility failed to maintain sanitary conditions for drinking water and ice by not properly cleaning or servicing water and ice machines used by residents and staff. Observations revealed significant mineral buildup and residue on the machines and surrounding areas, including the spouts, collection trays, and counters. The machines were also found to be leaking and in poor repair, with one machine's supporting panel split open and brown residue leaking out. Staff interviews confirmed that residents and staff accessed water and ice from these unsanitary machines, as well as from sinks that were also used for handwashing and had visible mineral buildup or personal items left on them. Housekeeping staff reported difficulty removing the buildup, and maintenance staff indicated that the machines had not been serviced by an outside company for an extended period. Further interviews with facility leadership revealed a lack of clarity regarding responsibility for the maintenance and cleaning of the water and ice machines. The Director of Nursing and Administrator were unaware of when the machines were last serviced or who was responsible for their upkeep. Facility policies indicated that the Dietary Department was responsible for monthly cleaning and disinfecting of the ice machines, while the Maintenance and Housekeeping Directors were to conduct regular safety audits. However, these procedures were not being followed, resulting in unsanitary conditions that affected nearly all residents who received oral hydration.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by insufficient seating in the day/dining rooms and inadequate cleaning and maintenance of resident rooms and common areas. Observations revealed that the first and second-floor day/dining rooms did not have enough chairs to accommodate ambulatory residents, resulting in some residents having to stand, sit on rollators, or lean on windowsills and heaters. Multiple residents reported difficulty finding seating, and staff confirmed the number of ambulatory residents exceeded the available chairs. Environmental issues were also noted throughout the facility. In one resident's room, there were black spots on the ceiling, bubbling paint on the wall, and a malfunctioning bathroom light that had not been repaired despite being reported. Other areas of concern included a hole in the second-floor hallway wall, chipped paint and stains in resident bathrooms, sticky and stained floors in dining rooms and hallways, and long-standing marks and smudges on walls and floors. Residents and staff reported that cleaning was not thorough, with some areas not being deep cleaned or stripped as needed, and maintenance issues such as water leaks and possible mold were not promptly addressed. Resident council minutes documented ongoing concerns about room cleaning, and interviews with housekeeping and maintenance staff indicated a lack of clarity regarding cleaning schedules and maintenance follow-up. Facility policies required regular environmental tours and quality control observations, but these were not effectively implemented, as evidenced by the persistent cleanliness and maintenance issues observed and reported by residents.
Failure to Provide Adequate Supervision and Fall Prevention Interventions
Penalty
Summary
The facility failed to provide adequate supervision and immediate intervention during an incident involving two residents with cognitive impairments and behavioral disturbances. One resident, diagnosed with dementia and a history of physical aggression, physically struck another resident who was using a wheelchair. Staff statements and interviews revealed that the incident occurred when the aggressive resident believed the wheelchair belonged to them and, upon the other resident exiting the chair, struck the individual in the head before taking the chair. Multiple staff members did not witness the event directly, and the facility was unable to provide a witness statement from a hospice CNA who initially reported the incident. The care plans for both residents identified risks related to their cognitive and behavioral conditions, including the need for monitoring and supervision, but these interventions were not effectively implemented at the time of the incident. Additionally, the facility failed to implement necessary fall prevention interventions for another resident assessed as a moderate fall risk with a history of falls and left-sided weakness. Despite a completed assessment indicating the need for side rails and alarms, and the resident's consent for these devices, these interventions were not put in place. Instead, only floor mats and non-skid socks were used, which did not prevent the resident from rolling out of bed and sustaining a head injury. Staff interviews confirmed that side rails and alarms were considered appropriate and beneficial for this resident, but these measures were not included in the care plan or implemented in practice. Facility policies require that supervision and safety interventions be tailored to each resident's assessed needs and that the care team use assessment information to identify and address specific accident hazards. In both cases, the facility did not follow through with the interventions identified as necessary by assessment and care planning, resulting in preventable incidents affecting the safety and well-being of the residents involved.
Failure to Prevent Resident Access to Alcohol and Illicit Drugs
Penalty
Summary
The facility failed to prevent residents from accessing alcohol and illicit drugs while on the premises, resulting in at least one resident becoming intoxicated and subsequently reporting non-consensual sexual activity. One resident, with a history of substance abuse and mental health diagnoses, was found to be intoxicated and later tested positive for cocaine and marijuana. This resident reported engaging in drinking and drug use with other residents and described an incident of sexual activity that she claimed occurred while she was under the influence, leading to emotional harm and hospitalization. Multiple residents with documented histories of substance abuse and mental health disorders were identified as having access to alcohol and drugs within the facility. Progress notes and interviews revealed that residents were able to bring in contraband substances, often by concealing them on their person, as staff only checked bags and not individuals. Staff interviews confirmed that supervision was limited, and there were lapses in monitoring residents' activities, particularly during nighttime hours. Several residents admitted to drinking and using drugs together, and staff acknowledged that some residents had been found intoxicated or under the influence. Facility policies required the removal of contraband and outlined procedures for searching rooms and involving administration if contraband was suspected. However, these policies were not effectively implemented, as evidenced by repeated incidents of residents accessing and consuming alcohol and drugs. The lack of adequate supervision and enforcement of contraband policies directly contributed to the incidents of intoxication and associated harm among residents.
Failure to Securely Store and Administer Medications
Penalty
Summary
Multiple instances were observed where medications and biologicals were not securely stored according to facility policy and professional standards. In one case, a family member found a pink capsule and a white tablet on a resident's bed, which the resident stated were left by the night nurse. The resident reported that the nurse left the medication on the table and departed before ensuring the medication was taken, and that staff do not return even if called. The pills were later identified as melatonin, which was ordered, and Benadryl, for which there was no physician order. The resident's electronic medical record confirmed the absence of an order for Benadryl. Another resident was found with an inhaler left on top of an oxygen concentrator in their room. The resident stated the nurse left it for use as needed, but there was no physician order for self-administration, and the resident was not on a self-administration program. Additionally, insulin pens intended for another resident's son were found at a resident's bedside, and a cup containing eight pills was observed on a bedside table. Staff confirmed that these medications should not have been left at the bedside and that the residents were not authorized for self-administration. Further observations included medication and treatment carts left unlocked and unattended in the hallway, with staff acknowledging that carts should be locked when not in use or not in the immediate presence of a nurse. The facility's policy, last revised in 2018, requires that medications and biologicals be stored safely, securely, and only accessible to authorized personnel. These lapses in medication storage and administration practices were confirmed through staff interviews, resident statements, and review of medical records.
Failure to Provide Timely Personal Hygiene and ADL Care
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for activities of daily living (ADLs) did not receive necessary personal hygiene care, including nail care, in a timely manner. On observation, the resident was found in a wheelchair, wearing a hospital gown that left the front of the body exposed, without an incontinent brief, and was wet. The resident had long nails with blackish particles underneath, dirty hands, and was eating food with their hands without cutlery. Food was observed on the resident's lap, between their legs, and on the floor. The room had a foul urine odor, and the resident's hair was unkempt and matted. The resident, who was unable to move both lower extremities, had dry, peeling, and swollen skin on the legs. The resident stated that no staff had come to assist since the previous day. Staff interviews revealed that the assigned CNA had not provided morning ADL care or incontinent care to the resident and had not checked on the resident since the start of the shift. The CNA confirmed that the resident had not refused care that morning. The resident's care plan indicated a self-care deficit and required staff assistance with personal hygiene and maintaining skin integrity, including keeping fingernails short. Facility policy and CNA job descriptions required staff to provide ADL care, including bathing, grooming, and incontinence care, but these were not carried out as required for this resident.
Failure to Provide and Document Prescribed BIPAP Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with chronic hypercapnia who required nocturnal BIPAP therapy. Upon re-admission from the hospital, the resident was supposed to receive BIPAP treatment at night as per hospital discharge instructions. However, there was no evidence in the Medication Administration Record (MAR) or Treatment Administration Record (TAR) that the resident received any BIPAP or CPAP therapy during the specified period. The resident confirmed that BIPAP treatment was only administered in the hospital and not at the facility, and stated that he did not refuse the therapy while at the facility. Additionally, the facility did not have the necessary equipment available for the resident's use. Review of the resident's care plan revealed that it did not include any plan of care for CPAP/BIPAP therapy, despite clear hospital instructions for nightly BIPAP use. There was also no physician order or documentation seeking clarification of the hospital's order for respiratory therapy. Interviews with facility staff, including LPNs, nurse practitioners, and the DON, indicated a lack of communication and follow-through regarding the reconciliation and implementation of the hospital's recommendations. Staff were unclear about their responsibilities for clarifying and carrying out admission orders, and there was no documentation that nursing staff sought clarification on the discrepancy in respiratory treatment orders. Facility policies and job descriptions required nurses to administer and document all treatments as ordered by the physician, including BIPAP/CPAP therapy. Despite these requirements, the resident's records showed no documentation of respiratory care being provided, and staff interviews confirmed that the necessary therapy was not consistently administered or documented. The lack of documentation and failure to implement the prescribed therapy constituted a deficiency in providing appropriate respiratory care as needed.
Failure to Administer Oxygen as Ordered by Physician
Penalty
Summary
A deficiency occurred when a male resident with multiple diagnoses, including chronic obstructive pulmonary disease (COPD), was administered oxygen at a rate of 5 liters per minute via nasal cannula, despite a physician's order specifying 3 liters per minute. The discrepancy was discovered during an observation, where the oxygen concentrator was found set at 5 liters. The LPN present confirmed that the correct setting should have been 3 liters, as per the active physician order, and acknowledged that oxygen is considered a medication that must be administered as ordered. The LPN also admitted that she had not checked the oxygen concentrator that day and was unaware of the incorrect setting until it was pointed out by the surveyor. Further interviews with the Director of Nursing and a Nurse Practitioner confirmed that the physician's order was for 3 liters per minute and that administering a higher dose was not appropriate for a resident with COPD unless specifically ordered. The facility's policy on medication administration requires that medications, including oxygen, be administered exactly as prescribed by the physician. The failure to follow the physician's order resulted in the resident receiving a higher dose of oxygen than intended.
Failure to Administer Pain Medication
Penalty
Summary
The facility failed to manage a resident's pain effectively and administer the prescribed pain medication, morphine, as documented. The resident, identified as R114, who is cognitively intact with a BIMS score of 15, reported not receiving his morphine medication since Thursday night, despite the Medication Administration Record (MAR) indicating that doses were given. The resident's medical history includes COPD, atherosclerosis, peripheral vascular disease, a pacemaker, and bilateral below-knee amputations, which necessitate pain management for phantom pain. Upon investigation, discrepancies were found between the MAR and the actual administration of the medication. The LPN, V32, could not locate the narcotic sheet or the morphine in the narcotic drawer, indicating a failure in the medication management process. The Director of Nursing (DON), V2, was also unable to find the narcotic sheet, and the medication was not present in the narcotic drawer, confirming the resident's claim of not receiving the medication. The facility's policy requires that controlled substances be regularly reconciled with the MAR, but this was not adhered to, leading to the resident's unmanaged pain. Further interviews with staff revealed inconsistencies in the documentation and administration of the medication. Several nurses, including V39, V45, and V14, claimed to have administered the medication as documented, but the lack of morphine in the narcotic box and missing narcotic sheets suggest otherwise. The pharmacist confirmed that a sufficient quantity of morphine was delivered to the facility, which should have lasted until March 27th. However, the medication was not available for the resident, indicating a breakdown in the facility's medication management and documentation processes.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to ensure proper food storage and labeling practices in the kitchen, which could potentially affect all 207 residents receiving an oral diet. During a kitchen tour, the surveyor observed several deficiencies, including undated and unlabeled food items such as a box of tomatoes and a plastic bag containing various meats. Additionally, staff members were storing personal food items in the walk-in refrigerator, which could lead to cross-contamination. In the dry storage area, there were open packages and ingredient bins without labels or dates, which is against the facility's policy for food safety. Furthermore, the facility did not maintain proper sanitation levels in the kitchen. A sanitation bucket at the preparation station registered a sanitation level of 0 parts per million, indicating that no sanitizer was present. This lack of sanitizer could prevent the proper sanitization of food preparation areas, increasing the risk of spreading germs. The facility's policies clearly outline the need for proper food storage, labeling, and sanitation practices to prevent contamination and ensure food safety, but these were not followed as observed during the survey.
Failure to Maintain a Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment for four residents, as observed during a survey. One resident reported that their room was cleaned infrequently. Another resident's room was found to have a missing closet door and dresser drawer, with the floor and privacy curtain stained. A housekeeper confirmed the presence of dirt and trash on the floor and was unsure about the stains on the privacy curtain. Additionally, another resident's room was observed to be dirty with stains on the floor and no bedsheets on the bed. A resident with a gastrostomy tube was observed to have a dried brown substance covering the g-tube pole and dust on the oxygen concentrator. A Licensed Practical Nurse suggested that the substance was likely g-tube feeding and that housekeeping was responsible for cleaning the equipment. The Director of Nursing stated that housekeeping, nurses, and Certified Nursing Assistants were responsible for cleaning the g-tube and oxygen concentrator. The facility's policies and job descriptions outlined the responsibilities for maintaining a clean and homelike environment, but these were not adhered to, resulting in the deficiencies observed.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure the security and proper management of medications, particularly narcotics, on the fourth floor. Observations revealed that the medication refrigerator was unlocked due to a non-functional latch, allowing access to narcotic medications without a key. An LPN admitted that the narcotic medication box inside the refrigerator was not locked, contrary to the facility's policy. Additionally, expired medications, including Lorazepam and Morphine Sulfate, were found in the refrigerator, and a multi-dose vial of Tuberculin Purified Protein solution was not labeled with an open date. Further deficiencies were noted with the storage and labeling of medications on the medication carts. Diazepam, a controlled substance, was improperly stored in an unlocked drawer instead of a locked compartment. Inhalers for several residents were not clearly labeled with open or expiration dates, leading to confusion among staff about their status. The facility's policy requires that opened medications be labeled with the open date and expiration date, but this was not consistently followed. Discrepancies in the documentation and inventory of narcotic medications were also identified. For instance, the controlled drug receipt form for a resident's Lorazepam showed a different count than the actual number of tablets present. The facility's policies mandate regular reconciliation of controlled substances with the Medication Administration Record and immediate reporting of any discrepancies, but these procedures were not adequately implemented, leading to potential risks for residents on the fourth floor.
Failure to Monitor Personal Refrigerators and Expired Food
Penalty
Summary
The facility failed to monitor personal refrigerator temperatures and ensure that personal refrigerators had thermometers for four residents. This deficiency was identified through observations, interviews, and record reviews. Specifically, the refrigerators of residents with various medical conditions, including cerebrovascular disease, chronic obstructive pulmonary disease, and paraplegia, were found without temperature log sheets or thermometers. Expired food items, such as milk and yogurt, were also discovered in one resident's refrigerator, indicating a lack of proper monitoring and maintenance. Interviews with facility staff revealed confusion regarding the responsibility for checking the residents' refrigerators. A Certified Nursing Assistant (CNA) was unaware of who should perform these checks, while the Director of Nursing (DON) and a Nurse Consultant believed it was the responsibility of housekeeping. The facility's policy mandates that staff monitor personal refrigerators for food safety and ensure that all refrigerators have internal thermometers with daily recorded temperatures. However, this policy was not followed, leading to the potential risk of residents consuming expired food.
Infection Control Deficiencies in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were in place, as evidenced by several observations and interviews. Staff did not don personal protective equipment (PPE) while performing wound care for a resident with methicillin-resistant Staphylococcus aureus (MRSA) infection. Additionally, Enhanced Barrier Precautions (EBP) signage was not visibly posted outside the rooms of two residents who required such precautions due to their medical conditions, including a resident with a hemodialysis catheter and another with wounds from bilateral below-knee amputations. The facility also failed to maintain PPE bins outside isolation rooms, as observed with a resident's room that had a Contact Precautions sign but no PPE bin available. Staff were observed not performing hand hygiene when passing meal trays, even after touching their own body or hair, which is against the facility's infection control policy. This was noted with a Certified Nursing Assistant (CNA) who did not sanitize hands after adjusting personal clothing and hair while distributing meal trays to residents. Interviews with staff, including the Director of Nursing (DON) and Licensed Practical Nurses (LPNs), revealed a lack of adherence to established infection control protocols. The DON acknowledged that staff should perform hand hygiene before and after passing meal trays and that PPE should be donned before entering isolation rooms. The absence of an Infection Preventionist (IP) nurse prior to a recent hire contributed to lapses in maintaining PPE supplies and ensuring compliance with infection control measures.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that the call light devices for two residents, R35 and R41, were within their reach, which is a requirement for accommodating the needs and preferences of each resident. R35, who has a diagnosis including Bilateral Primary Osteoarthritis of the knee, Paralytic Syndrome, Hemiplegia and Hemiparesis, Vascular Dementia, Peripheral Vascular Disease, and Major Depressive Disorder, was observed with her call light on the floor behind her bed, out of reach. Despite her physical limitations, R35 stated she could use the call light if it were accessible. Her care plan emphasized the importance of having the call light within reach, yet the facility did not provide an alternative device for her use, as indicated by the blank response on her Call Light Ability Screen. Similarly, R41, diagnosed with dementia, protein-calorie malnutrition, intracapsular fracture of the left femur, sequela, hypertension, and abnormalities of gait and mobility, was observed with the call light on the floor underneath the bed. Although R41's Call Light Ability Screen indicated she could use the call light, it was not within reach, contradicting her care plan's directive. Both the Registered Nurse and the Director of Nursing acknowledged that the call light should be within reach of the residents at all times, as per the facility's policy. This oversight affected two residents and had the potential to impact all residents in the facility.
Failure to Refer Residents for Level II PASARR Evaluation
Penalty
Summary
The facility failed to refer three residents for a Level II PASARR evaluation after they received new mental disorder diagnoses. Resident R141 was admitted with diagnoses of bipolar disorder and adjustment disorder, but the initial PASARR did not reflect these mental health conditions. The Business Office Manager (V35) acknowledged that the PASARR should have included these diagnoses to ensure the resident was in the appropriate facility and that their needs could be met. A new Level I PASARR was initiated, which triggered a Level II evaluation. Resident R61 had a diagnosis of Major Depressive Disorder and other conditions, but the PASARR documentation did not reflect these mental health issues. The resident's care plan did not address the Major Depressive Disorder, and the PASARR Level I outcome did not indicate a mental health diagnosis. The Business Office Manager confirmed that a new PASARR Level I was submitted due to the new diagnosis, but it was not initially documented correctly. Resident R104 had a diagnosis of Major Depressive Disorder, but the PASARR documentation did not reflect this condition. The resident's PASARR Level I was not documented in the electronic health record, and the Business Office Manager confirmed that a new PASARR Level I was required due to the change in condition. The facility's policy requires each resident to be screened for Level I PASARR prior to or shortly after admission, but this was not adhered to in these cases.
Failure to Update PASARR for New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the completion of a new Pre-Admission Screening and Resident Review (PASARR) when a new mental health diagnosis was identified for three residents. Resident 61 had a diagnosis of Major Depressive Disorder and other conditions, but the PASARR Level I Outcome did not reflect any mental health diagnosis. Despite being prescribed medication for depression, the care plan did not address this condition, and the PASARR was not updated accordingly. Resident 104 had a diagnosis of Major Depressive Disorder, but the initial OBRA-I screen did not suspect any mental illness. Although a PASARR Level I review was eventually conducted, it was not documented in the electronic health record initially, and the necessary Level II screening was delayed. The Business Office Manager confirmed the need for a PASARR Level I to trigger a Level II due to the change in condition. Resident 141 was admitted with diagnoses of bipolar disorder and adjustment disorder, but the initial PASARR did not include these mental health conditions. The Business Office Manager acknowledged the oversight and initiated a new PASARR Level I, which triggered a Level II screening. The facility's policy requires each resident to be screened for Level I prior to or shortly after admission, but this was not adhered to in these cases.
Failure to Follow Wound Care Treatment Orders
Penalty
Summary
The facility failed to adhere to wound care treatment orders for a resident, identified as R138, who was reviewed for wounds. R138 has a medical history that includes orthopedic surgical amputation, Type 2 diabetes with foot ulcers, peripheral vascular disease, and other conditions. Observations on March 24, 2025, revealed that the dressings on both of R138's great toes were dirty, with the left toe dressing showing black dark drainage. R138 reported that the dressings had not been changed since March 21, 2025, despite orders for daily changes. The resident, who is cognitively intact, sometimes changed the dressings themselves due to excessive drainage. The facility's records, including the Treatment Administration Record (TAR), showed multiple days in March 2025 when the wound care was not documented as completed. Interviews with the Wound Care Nurse, Wound Care Coordinator, and Director of Nurses confirmed that the dressings should be changed daily and that the resident should not be responsible for changing their own dressings. The facility's policy emphasizes the importance of following physician orders to promote healing, yet the failure to implement these orders as prescribed led to the deficiency.
Failure to Investigate Fall and Enforce Smoking Policies
Penalty
Summary
The facility failed to thoroughly investigate a fall incident involving a resident, R65, and did not implement fall interventions as listed on the revised care plan. R65, who has a history of multiple medical conditions including polyarthritis, diabetes, and schizoaffective disorder, experienced a fall in the shower room. Despite the presence of a staff member, the fall was not reported immediately, and no nurse assessed R65 following the incident. The fall was only documented the following day after R65 reported pain and bruising. The care plan for R65, which included placing nonskid strips beside the bed, was not followed, as observed by the Director of Nursing. Additionally, the facility failed to ensure adequate supervision to prevent a resident, R172, from smoking in a residential room. R172, who has intact cognition and a history of psychoactive substance abuse, was found with a strong smell of marijuana in his room, and a haze of smoke was observed. Although R172 claimed the smell was from his clothing after smoking outside, the social service staff suspected that R172 was smoking inside the room. The facility's policy prohibits smoking inside the facility, and residents are required to comply with smoking safety contracts. These deficiencies highlight the facility's failure to adhere to its policies and procedures regarding fall prevention and smoking regulations. The lack of immediate assessment and documentation of R65's fall, along with the failure to implement care plan interventions, contributed to inadequate resident safety. Similarly, the inability to enforce smoking policies and supervise residents effectively posed potential safety hazards within the facility.
Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents, R73 and R98, who were receiving oxygen therapy. For R73, the facility did not change the nasal cannula tubing weekly as required, with the tubing observed to be dated 3/4/25, despite the policy stating it should be changed weekly. Additionally, R73's CPAP mask was found lying uncontained on the nightstand, which is against the facility's policy for equipment storage and infection control. R73, who is cognitively intact, was receiving oxygen at 3 liters per nasal cannula, but there was no documentation of a physician's order for this administration. For R98, the facility failed to obtain a physician's order for oxygen administration, despite the resident receiving 4 liters of oxygen. The oxygen tubing for R98 was observed lying on the floor, and there was no order for pulse oximetry checks, which are necessary to monitor the resident's oxygen needs. R98, who is also cognitively intact, was admitted with diagnoses including dependence on supplemental oxygen and COPD. The facility's policy requires a physician's order for oxygen administration and regular monitoring of oxygen saturation levels, which was not adhered to in this case.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent before prescribing a psychotropic medication to a resident, identified as R61, who was diagnosed with Major Depressive Disorder. The resident's Minimum Data Set indicated severe cognitive impairment. Despite this, the resident was prescribed Remeron (Mirtazapine) for situational depression, with the medication being administered daily from March 1, 2025, to March 25, 2025. However, the consent for the psychotropic medication was only obtained verbally on March 24, 2025, which was after the medication had already been administered for several weeks. The Director of Nursing (DON) confirmed that the facility's policy requires informed consent to be obtained before prescribing psychotropic medications. The policy mandates that psychotropic medications should not be prescribed without the informed consent of the resident, their guardian, or an authorized representative. The DON acknowledged that the consent process was not followed correctly in this instance, as the verbal consent was obtained after the medication had been prescribed and administered.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse, affecting two residents. One resident, identified as R8, sustained a laceration to the back of the head requiring staples and hospitalization after being pushed by another resident, R12, in the dining room. Despite conflicting accounts from staff, a Certified Nursing Assistant confirmed witnessing the incident where R8 attempted to take food from R12's plate, leading to R8 being pushed and hitting their head on the ground. The facility's investigation did not initially acknowledge the push, attributing the fall to R8's anemia, and the Director of Nursing did not review hospital records indicating the push. Another incident involved R3 and R15, where R3 verbally threatened and physically assaulted R15 by slapping him across the face. This incident was witnessed by another resident, R9, and reported to staff, but the facility's administration initially only acknowledged a verbal disagreement. The Social Services Director confirmed being informed of the physical assault, and the police were involved, but the facility's records did not reflect appropriate interventions to address R3's aggressive behaviors. Both incidents highlight the facility's failure to adequately investigate and address resident-to-resident abuse, as well as a lack of appropriate care plan interventions for residents with known aggressive behaviors. The facility's abuse prevention policy and residents' rights documents emphasize the importance of protecting residents from abuse, yet these incidents demonstrate a significant lapse in ensuring resident safety and well-being.
Failure to Provide Adequate Wound Care and Pain Management
Penalty
Summary
The facility failed to provide necessary treatment and services to a resident with a surgical wound, leading to the worsening of the wound and avoidable pain. The resident, who had a surgical amputation and other complex medical conditions, was observed with a poorly maintained dressing on her left foot. The dressing was secured with band-aids, unraveling, and appeared dirty, with no date indicating when it was last changed. The resident reported that her wound dressing had not been changed as per the physician's orders, and she experienced pain due to not receiving her prescribed pain medication. The resident's medical records showed active physician orders for daily wound care and pain management with Oxycodone. However, there was no documentation in the Medication Administration Record (MAR) or Treatment Administration Record (TAR) indicating that these treatments were administered. Interviews with staff revealed that the resident was not assessed for self-care, yet was given supplies to change her own dressing. The Director of Nursing confirmed that medications should be documented when administered and that the resident was not capable of changing her own wound dressing. The resident expressed concerns about her wound not healing and the possibility of further amputation. The Wound Care Nurse confirmed that wound dressings should be dated and documented, and that failure to change dressings as ordered could lead to infection and deterioration. The facility's policies on medication administration and wound care were not followed, contributing to the resident's condition not improving and potentially requiring further medical intervention.
Facility Fails to Maintain Clean Environment for Residents
Penalty
Summary
The facility failed to maintain a sanitary, clean environment, affecting all 208 residents. Observations revealed dirty floors with unidentified food particles, dirt splatters, and sticky surfaces in the dining room and hallways across multiple floors. Staff, including a CNA and the Director of Nursing, acknowledged the unclean conditions, with the Director noting the need for housekeeping intervention. Residents expressed dissatisfaction, with some resorting to cleaning their own rooms due to the lack of housekeeping services. Staff shortages in housekeeping were cited as a contributing factor, with some staff members taking on cleaning duties themselves. The facility's administrator confirmed recent issues with housekeeping, noting the appointment of a new housekeeping manager. Despite the facility's policy on residents' rights to a clean environment, multiple staff members, including a Restorative Technician and a Social Services Director, reported receiving complaints from residents about the cleanliness. The report highlights the facility's failure to provide a safe, clean, and comfortable environment as required by residents' rights, with staff and residents both acknowledging the ongoing cleanliness issues.
Failure to Timely Report Abuse Incidents
Penalty
Summary
The facility staff failed to report suspected abuse incidents to the state survey agency within the required timeframe and did not notify the abuse prevention coordinator as mandated. This deficiency affected four residents. In one incident, a resident fell and sustained a head injury after being pushed by another resident. The incident was not reported to the state survey agency until six days later, and the abuse prevention coordinator was unaware of the pushing incident until much later. The staff involved did not follow the facility's policy of immediate reporting to the administrator or the state survey agency. In another incident, two residents had a verbal disagreement, which escalated to one resident hitting the other. The administrator was aware of the verbal disagreement but not the physical altercation. The social services director and a licensed practical nurse were aware of the physical aspect of the incident but did not ensure it was reported as abuse. The facility's policy requires that any suspicion or allegation of abuse be reported immediately to the administrator and the state survey agency. The facility's policies on abuse prevention and incident reporting clearly outline the need for immediate reporting of abuse incidents to the state survey agency and the administrator. However, in both incidents, the staff failed to adhere to these policies, resulting in delayed reporting and inadequate investigation of the abuse allegations. This lack of timely reporting and communication among staff members contributed to the deficiency identified by the surveyors.
Failure to Investigate Allegations of Abuse and Injury
Penalty
Summary
The facility failed to conduct a thorough investigation following a fall incident involving a resident, R8, who sustained a head injury. The incident occurred when R8 attempted to take food from another resident, R12, who then allegedly pushed R8, resulting in a fall and a laceration to the head. Despite hospital records indicating that R8 was pushed, the facility's investigation concluded that the fall was due to R8's anemia, without interviewing key witnesses or reviewing hospital records. The Director of Nursing, V2, and the Administrator, V1, acknowledged that the hospital records should have been reviewed and that the Certified Nursing Assistant, V14, who witnessed the incident, was not interviewed. In another incident, the facility failed to investigate an allegation of verbal and physical abuse involving residents R3 and R15. R3 was reported to have verbally threatened and physically struck R15 over a misunderstanding about clothing. Although staff were aware of the verbal altercation, the Administrator, V1, was only informed of the verbal disagreement and not the physical assault. The Social Services Director, V19, confirmed that R15 reported being hit by R3, but no investigation was conducted to substantiate the incident. The facility's policies on abuse prevention and incident reporting require thorough investigation of all allegations or suspicions of abuse, neglect, or mistreatment. However, in both cases, the facility did not adhere to these policies, failing to gather necessary witness statements and review relevant documentation. This lack of thorough investigation and documentation led to deficiencies in addressing potential abuse and ensuring resident safety.
Failure to Complete Community Survival Skills Assessment
Penalty
Summary
The facility failed to ensure the timely completion of a community survival skills assessment for a resident, which is necessary to determine if the resident can safely be out in the community independently. This deficiency affected a resident who left the facility for an eye doctor appointment and did not return until four days later. During this time, the facility and the resident's family were unaware of the resident's whereabouts, causing concern for the resident's safety. The resident, who has a BIMS score indicating intact cognition, was admitted to the facility with multiple medical conditions, including orthopedic aftercare and muscle wasting. Despite being cognitively intact, the resident's community survival skills assessment was not completed upon admission, as required by the facility's policy. The assessment was only completed after the resident had already left the facility unsupervised, and the staff was not aware of the resident's absence until the following day. Interviews with facility staff revealed a lack of communication and understanding regarding the resident's pass privileges and the process for monitoring residents who leave the facility. The social service director admitted that the community survival skills assessment was not completed at admission, and the psychosocial rehabilitation services coordinator acknowledged that the assessment was delayed due to oversight. The facility's policy requires the assessment to be completed upon admission, quarterly, and when there is a significant change in condition, but this was not adhered to in this case.
Sanitation and Maintenance Deficiencies in Third-Floor Shower Room
Penalty
Summary
The facility failed to maintain the community shower room on the third floor in a sanitary and functional condition, potentially affecting all 52 residents on that floor. During an inspection, it was observed that the toilet bowl had visible brown stains and a ring of stains, indicating it had not been cleaned for several days. Additionally, the toilet water tank and cover were covered in accumulated dust. The third shower stall's faucet was broken and non-functional, which was confirmed by an LPN who mentioned that the issues were typically reported via a scanner system, although calling maintenance was considered faster. The housekeeping staff was not adequately assigned to ensure cleanliness on the third floor. A housekeeper was observed cleaning on the second floor and was unaware of who was responsible for the third floor. The Housekeeping Director acknowledged challenges in staffing the second and third floors, noting that they were in the process of hiring additional staff to address these deficiencies. The facility's housekeeping policy requires daily cleaning assignments to maintain a clean and orderly environment, which was not adhered to in this instance.
Failure to Protect Residents from Known Aggressive Resident
Penalty
Summary
The facility failed to protect two residents from abuse by another resident with known violent behavior. The resident in question was admitted without a timely background check or fingerprinting, despite having a history of aggression and a criminal record. This oversight allowed the resident to physically assault two other residents, resulting in significant injuries, including multiple facial fractures to one of the victims. The facility did not develop a care plan for the aggressive resident upon admission, despite being aware of the resident's history of aggression and previous altercations at another facility. The care plan was only updated after incidents of violence occurred, failing to address the resident's behavioral symptoms and wandering as identified in the initial assessments. The facility's social services department acknowledged that the aggressive behaviors should have been addressed in the care plan upon admission. Additionally, the facility's assessments of the resident's aggressive and harmful behaviors were inaccurate, failing to reflect the resident's known history of aggression and mental health diagnoses. Staff interviews revealed that the resident frequently exhibited aggressive behavior, yet there was no documentation of behavior monitoring or interventions. The facility's lack of timely and accurate assessments and care planning contributed to the failure to prevent the assaults.
Inaccurate Assessments Lead to Resident Aggression and Harm
Penalty
Summary
The facility failed to accurately complete assessments for a resident, identified as R3, which led to significant incidents involving aggressive behavior. R3, who was admitted with multiple diagnoses including cerebral infarction, bipolar disorder, Alzheimer's disease, vascular dementia, and legal blindness, was inaccurately assessed in several areas. The Minimum Data Set (MDS) inaccurately documented R3 as having adequate vision despite being legally blind. Additionally, the Screening Assessment for Trauma Factors and the Screening Assessment for Indicators of Aggressive and/or Harmful Behaviors were completed inaccurately, failing to identify R3's criminal history, history of aggression, and psychiatric diagnoses. These assessment inaccuracies resulted in R3's aggressive behaviors going unaddressed, leading to physical altercations with other residents. R3 physically assaulted two residents, R2 and R7, causing significant harm to R7, who suffered multiple facial fractures. The incidents were partly attributed to R3's inability to recognize others due to blindness, as noted by the Social Services Director. The facility's lack of accurate assessments meant that R3's care plan did not address critical needs, such as visual impairment, which could have triggered appropriate interventions. Interviews with facility staff, including the Medical Director and MDS Coordinator, confirmed the inaccuracies in R3's assessments. The MDS Coordinator acknowledged that R3's vision should have been coded as impaired, which would have prompted a Care Area Assessment for visual function. The facility did not have a specific policy for completing aggression screening and trauma assessments, relying instead on the Resident Assessment Instrument (RAI) guidelines. This lack of policy may have contributed to the oversight in accurately assessing and addressing R3's needs.
Failure to Address Aggressive Behaviors in Resident Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, R3, who had a known history of aggressive behaviors and dementia. Prior to admission, R3's referral records indicated a history of physical altercations, anxiety, and confusion, posing a danger to themselves and others. Despite this, the facility did not address these behaviors in R3's care plan upon admission or after subsequent incidents of aggression. On two separate occasions, R3 physically assaulted other residents. The first incident involved R3 hitting a roommate, R2, on the head with a cane, causing a bleeding wound. Staff and other residents expressed concerns about R3's aggressive behavior, noting that R3 was regularly agitated and could potentially harm others. Despite these concerns, R3's care plan was not updated to address these behaviors until after a second incident occurred. The second incident involved R3 physically assaulting another resident, R7, resulting in multiple facial fractures. This incident further highlighted the facility's failure to update R3's care plan in a timely manner. The facility's policies required that care plans be updated to reflect changes in a resident's condition, but R3's aggressive behaviors were not addressed until after both incidents had occurred. This oversight resulted in harm to multiple residents and demonstrated a lack of adherence to the facility's care planning policies.
Failure to Supervise Resident with Violent Behavior
Penalty
Summary
The facility failed to provide adequate supervision for a resident with known violent behavior, leading to physical assaults on two other residents. The resident in question, R3, had a documented history of aggression and was involved in altercations at a previous facility before being admitted to the current one. Despite this history, R3's aggressive behaviors were not addressed in the care plan upon admission, nor were they updated after incidents of violence occurred within the facility. On one occasion, R3 assaulted a roommate, R2, by hitting them on the head with a cane, causing a bleeding wound. This incident was witnessed by staff, who noted R3's regular agitation and aggressive tendencies. Despite these observations, there was no specific supervision plan in place for R3, and staff expressed concerns about R3's potential to harm other residents. The facility's policy on supervision was not adequately followed, as additional supervision measures were not implemented for R3. Another incident involved R3 physically assaulting another resident, R7, resulting in multiple facial fractures. R7, who had severe cognitive impairment, was knocked out of their wheelchair during the altercation. Staff and medical personnel were aware of R3's aggressive behavior, yet the care plan was not updated to address these behaviors until after the incidents occurred. The lack of timely and appropriate care planning and supervision contributed to the harm experienced by the residents involved.
Failure to Conduct QAPI Meetings and Address Abuse Data
Penalty
Summary
The facility failed to conduct Quality Assurance and Performance Improvement (QAPI) meetings quarterly and did not ensure that abuse data collection was implemented or coordinated within these meetings. This deficiency potentially affects all 200 residents in the facility. A review of the facility's QAPI meeting minutes from March 7, 2024, revealed no reporting, tracking, or discussion of abuse or abuse outcomes. The template used for these minutes lacked any section for reporting or tracking abuse allegations. Furthermore, no QAPI meeting minutes were available from March 7, 2024, until October 21, 2024, indicating a significant gap in the facility's quality assurance processes. Interviews with facility staff, including a nurse consultant and the administrator, confirmed that QAPI meetings were not held between April 2024 and August 2024, and that incidents of physical abuse occurring on September 26, 2024, and October 10, 2024, were not reviewed in any QAPI meeting. The facility's policy on Quality Assurance Committee did not mention abuse, and the Abuse Prevention Program policy required quarterly reviews of reports to assess patterns or trends that might indicate abuse. However, these reviews were not conducted, and the incidents were not discussed in the QAPI meetings, highlighting a failure in the facility's abuse prevention and quality assurance processes.
Delayed Submission of Abuse Investigation Report
Penalty
Summary
The facility failed to submit a final investigation report regarding a physical abuse incident to the state survey agency within the required timeframe. The incident involved a physical altercation between two residents, identified as R2 and R3, which was initially reported to the Illinois Department of Public Health on September 26, 2024. However, the final report was not submitted until October 16, 2024, which is 20 days after the incident and the initial report. This delay in reporting is a violation of the facility's policy and state regulations, which require a final report to be submitted within five business days of the incident. The administrator, who is also the abuse prevention coordinator, acknowledged the oversight and stated that they could not find evidence of the final report being submitted within the required timeframe. Consequently, the administrator resubmitted the final report on October 16, 2024. The facility's policy, dated January 4, 2018, clearly outlines the requirement for a completed written report of the investigation's conclusion to be sent to the Department of Public Health within five working days after the occurrence. This failure to adhere to the policy affects the two residents involved in the incident.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect four residents from verbal and physical abuse, resulting in significant incidents. One resident, R2, who had schizoaffective disorder and bipolar disorder, was verbally and sexually harassed by another resident, R3, who was cognitively intact and used a wheelchair. Despite staff attempts to intervene, R3 continued to provoke R2, leading R2 to retaliate physically with a belt. The situation escalated, and R2, in a state of panic, attempted to flee the facility, resulting in a self-inflicted injury that required hospitalization. Another incident involved residents R4 and R5, both of whom were cognitively intact and used wheelchairs. R4, who had a history of bipolar disorder and ADHD, engaged in a verbal altercation with R5, which escalated into a physical confrontation. R4 taunted R5, leading to a struggle that caused both residents to fall. The facility's staff did not effectively intervene to prevent the escalation of the conflict. The facility's policies on abuse prevention and residents' rights were not adequately enforced, as evidenced by the repeated incidents of verbal and physical abuse among residents. Staff interviews revealed that R3 had a history of antagonizing other residents, and R4 was known for being verbally abusive. Despite these known behaviors, the facility failed to implement effective measures to prevent abuse and protect residents, resulting in harm and distress.
Failure to Timely Address Resident's Fall and Head Injury
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice for a resident, identified as R7, who experienced a fall. The incident involved a lack of timely assessment, monitoring, and documentation following the fall. R7, who was cognitively intact and on anticoagulant medication for atrial fibrillation, fell from their bed and sustained a head injury. Despite the fall being reported by R7's roommate, there was a significant delay in the nurse's response, and the incident was not documented or communicated to the physician in a timely manner. The report highlights that the facility did not send R7 to the hospital immediately after the fall, despite the resident being on blood thinners and having a head injury, which could lead to serious complications such as a subdural hematoma. The Licensed Practical Nurse (LPN) on duty did not observe or document the bruise on R7's forehead initially, although later documentation contradicted this. The facility's staff, including the Restorative Director and the former Director of Nursing, acknowledged the need for immediate medical evaluation and monitoring, which was not conducted. The facility's policies on neurological assessment and change in resident's condition were not followed, as evidenced by the lack of 72-hour follow-up charting and neuro checks. The Nurse Practitioner was not informed of the fall until several days later, which delayed the necessary medical intervention. The report indicates a systemic failure in communication and adherence to protocols, resulting in R7 being sent to the hospital only after developing symptoms of a headache, where a subdural hematoma was diagnosed.
Failure to Monitor Diabetic Resident's Foot Care Leads to Severe Complications
Penalty
Summary
The facility failed to provide adequate foot care and monitoring for a diabetic resident, resulting in severe complications. The resident, who had a history of type 2 diabetes mellitus, diabetic peripheral angiopathy, and other comorbidities, required substantial assistance with activities of daily living, including bathing and dressing. Despite being cognitively intact, the resident was dependent on staff for foot care due to limited mobility and the use of a manual wheelchair. The facility's negligence in monitoring the resident's foot condition led to the development of a wound on the right big toe, which was discovered to be infested with maggots by the nurse practitioner during a routine assessment. The nurse practitioner observed redness and swelling in the resident's right lower leg and, upon removing the resident's sock, found multiple maggots crawling from a wound at the base of the big toe. This alarming discovery prompted immediate medical intervention, including the administration of antibiotics and pain management, and the resident was transferred to the hospital for further evaluation. The hospital diagnosed the resident with gangrene, necessitating the surgical amputation of the right big toe. The facility's failure to conduct routine foot examinations and adequately assess and report skin alterations contributed to the severity of the resident's condition. Interviews with facility staff revealed inconsistencies in the care provided to the resident. The CNA responsible for the resident's care on the day of the incident could not recall performing a skin check, and there was no documentation of a skin assessment or bath/shower on the resident's shower sheet for that period. The facility's policies on skin assessments and foot care were not adhered to, as evidenced by the lack of regular monitoring and documentation. The facility's failure to implement its policies and ensure proper care for the resident's diabetic condition resulted in a preventable and severe health outcome.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse to the Illinois Department of Public Health (IDPH) within the required two-hour timeframe. A resident reported that a nurse called them a 'crackhead' and threatened to transfer them to a different floor. The resident communicated this incident to social services and the facility administrator. However, the administrator did not consider the incident as an abuse allegation and did not report it to IDPH until the time of the survey, which was beyond the mandated reporting period. Interviews with the involved nurse and social services director revealed differing accounts of the incident. The nurse claimed that the resident misinterpreted a comment made during a conversation about another resident. The social services director confirmed that the resident reported the nurse's alleged verbal abuse. The facility's policy requires immediate reporting of any abuse allegations to the administrator and IDPH, but this protocol was not followed in this case, leading to the deficiency.
Failure to Coordinate Resident Appointments and Maintain Complete Medical Records
Penalty
Summary
The facility failed to ensure proper coordination of outside services and maintain a complete medical record for a resident, identified as R3, who was reviewed for appointments. The deficiency was identified through interviews and record reviews, revealing that R3 had multiple follow-up appointments recommended after hospitalizations, including with hepatology, primary care, and urology. However, there was a lack of clarity and coordination among the staff regarding these appointments. The primary nurse, V3, was unaware of whether R3 attended a past appointment or the purpose of future appointments. Similarly, the Transportation Coordinator, V14, and the Appointment Scheduler, V15, were not informed of R3's appointments, leading to a lack of transportation arrangements and incomplete appointment records. The Director of Nursing, V2, acknowledged the oversight and the absence of a facility appointment policy. The facility's Medical Record Policy mandates maintaining an organized, accurate, and complete record of each resident's care, which was not adhered to in R3's case. The surveyor's investigation revealed that the facility was unaware of some of R3's scheduled appointments until the time of the survey, indicating a breakdown in communication and record-keeping. This deficiency highlights the facility's failure to provide equal access to quality care and maintain the resident's health at the highest practical levels, as required by the Illinois Long-Term Care Ombudsman Program's Residents' Rights.
Inaccurate Medical Record Documentation for a Resident
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, leading to a discrepancy in the resident's documented diagnosis. The resident, identified as R1, reported that their medical records incorrectly listed a diagnosis of schizophrenia, which they did not have. The resident expressed concern about potential discrimination due to this incorrect diagnosis. Upon review, the resident's admission record documented a diagnosis of Schizoaffective Disorder, Bipolar Type, but there was no mention of schizophrenia in the psychiatric nurse practitioner's notes or in the hospital records. The psychiatric nurse practitioner confirmed that they did not diagnose the resident with schizophrenia and did not include it in their assessment. The Director of Nursing (DON) and the facility staff were unable to determine the origin of the schizophrenia diagnosis. The DON noted that the hospital intake forms and other medical records did not document schizophrenia. An interview with the nurse responsible for entering the diagnosis revealed uncertainty about the source of the information, suggesting it may have been a mistake. The facility's medical record policy emphasizes the importance of maintaining accurate and complete records, but in this case, the policy was not adhered to, resulting in incorrect documentation of the resident's medical condition.
Resident Injury Due to Inadequate Monitoring and Management of Aggressive Behavior
Penalty
Summary
The facility failed to protect a resident, identified as R5, from abuse, resulting in an incident where another resident, R4, ran over R5's foot with a wheelchair. This incident led to R5 experiencing significant pain and swelling in the foot, with a pain score of 7-9 out of 10. R5, who has a medical history including asthma and difficulty walking, reported that R4 ran over her foot intentionally after a disagreement at the nurse's station regarding smoking times. R5 had previously had a verbal altercation with R4, which was not adequately monitored by the staff. R4, who has a complex medical history including schizoaffective disorder, paraplegia, and other mental health issues, was known to exhibit manipulative and aggressive behaviors. On the day of the incident, R4 was observed by staff to be moving quickly in his wheelchair and ran over R5's foot while she was at the nurse's station. Despite the presence of staff, R4's behavior was not effectively managed, leading to the altercation. The staff's response included separating the residents and contacting medical professionals, but the incident had already resulted in injury to R5. The facility's initial report to the state agency was delayed, as it was sent the day after the incident occurred. The facility's abuse prevention program defines abuse as the willful infliction of injury, which aligns with the nature of the incident between R4 and R5. The facility's failure to prevent the altercation and protect R5 from harm highlights a deficiency in their ability to manage resident interactions and ensure a safe environment for all residents.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to provide a clean and sanitary home-like environment for its 221 residents, as observed during a survey. Numerous deficiencies were noted, including missing handrails, dirty and tattered chairs, and broken shower equipment. The surveyor observed these issues across multiple floors, including the dining rooms and shower rooms, which were found to be in disrepair and unsanitary conditions. The presence of debris, broken tiles, and stained ceiling tiles were common findings, indicating a lack of regular maintenance and cleaning. Several residents, including those with severe cognitive impairments, were directly affected by these conditions. For instance, a resident's room was found with peeling baseboards and a bathroom with a basin of cloudy water on the floor. Another resident's room had a shower curtain hanging off the rod and baseboards peeling off the wall. These observations were corroborated by staff interviews, where CNAs and maintenance personnel acknowledged the issues but indicated that maintenance requests were not consistently logged or addressed in a timely manner. The facility's maintenance and housekeeping protocols were found to be inadequate, as evidenced by the lack of documented maintenance requests and the poor condition of the environment. The facility's Preventative Maintenance Program and job descriptions for the Administrator, Maintenance Director, and Housekeeping Assistant outlined responsibilities for maintaining a clean and safe environment, yet these were not effectively implemented. The surveyor's findings were consistent with resident council meeting minutes, which also highlighted concerns about housekeeping and cleanliness.
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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