Asbury Gardens Nsg & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in North Aurora, Illinois.
- Location
- 212 Airport Road, North Aurora, Illinois 60542
- CMS Provider Number
- 146170
- Inspections on file
- 23
- Latest survey
- January 16, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Asbury Gardens Nsg & Rehab during CMS and state inspections, most recent first.
Two residents were left in a cool room with a nonfunctioning heating unit after one cognitively intact resident reported feeling cold and stated the heater had not worked for several days. Staff notified a maintenance assistant by phone, who assessed the unit, found it nonfunctional, left it unplugged, and did not enter a maintenance work order. The receptionist also failed to create a work order in the computer system, and the maintenance director was unaware of the issue until the survey, despite facility policy requiring maintenance of comfortable and safe temperature levels and properly operating heating units for resident comfort.
A dependent, cognitively impaired resident with severe dementia did not receive timely incontinence care as required by her care plan and facility policy. Surveyors observed the resident in bed with a strong foul urine odor persisting over an hour, a soiled urine-saturated brief, and dry urine-stained cloth pads beneath her. An RN acknowledged difficulty providing care due to the resident’s resistance and was unsure when incontinence care was last given, while a CNA reported last providing care several hours earlier. The DON later stated staff are expected to check for incontinence at least every two hours and that the resident should have received timely incontinence and hygiene care consistent with her assessed needs.
The facility failed to follow physician orders for CHF-related fluid management for three residents, including missing ordered daily weights and not applying prescribed compression stockings. One resident with CHF and bilateral lower extremity edema had orders and a care plan for daily weights with MD/NP notification for specific weight gains, yet several days lacked recorded weights. Another resident with chronic lower extremity edema related to CHF was repeatedly observed wearing regular socks and footwear instead of ordered compression stockings, despite being dependent on staff for their application. A third resident with CHF and generalized lower extremity edema also had orders and a care plan for daily weights with defined notification parameters, but multiple days showed no documented weights, contrary to facility policy on weight monitoring and fluid status assessment.
A resident with Parkinson’s disease, dementia, and moderate cognitive impairment stated he wanted unrestricted visits from his children, but staff followed a posted sign listing specific family members whose visitation was to be restricted per the POA. When a daughter arrived to visit, staff asked her name, informed her she was not allowed to see the resident based on the POA’s directive, and called the police when she refused to leave or provide ID; the police then told her she was trespassing. The Ombudsman reported that the POA was denying visitation and that there should not have been a barrier to the visit, while facility leadership acknowledged that the POA could not deny visitation and that the resident did want to see his daughter, yet the posted restriction and staff actions still prevented the visit.
A resident with hemiplegia and other complex medical conditions, who required substantial assistance for transfers, was moved from the toilet to a wheelchair by a CNA without the use of a gait belt as required by the care plan and facility policy. During the transfer, the resident's foot became caught, causing her contracted leg to strike the wheelchair frame and resulting in a laceration that required stitches. Staff interviews and documentation confirmed that proper transfer procedures were not followed.
The facility failed to assist residents with activities of daily living, including eating and personal hygiene. Several residents were observed with long facial hair and unkempt nails, and one resident's meal remained untouched until the DON intervened. The facility's policies on ADLs and nail care were not followed, leading to deficiencies in resident care.
The facility failed to properly puree maple glazed ham for eight residents on pureed diets. The cook blended pre-sliced ham with rind intact, resulting in a mixture with visible rind pieces, contrary to the required smooth, pudding-like consistency. This was identified by the Dining Director, highlighting a deviation from the facility's dietary policy.
A resident with medical conditions requiring assistance with hearing aid placement did not receive the necessary help from facility staff. Despite having a care plan indicating this need, the resident reported not receiving assistance and was observed without hearing aids, impacting her ability to hear. Staff members were either unaware of the resident's needs or had not been providing the required assistance, contrary to the care plan expectations.
A resident with spastic hemiplegia and contracture was not provided with a splint or positioning device to maintain ROM. Despite being moderately impaired and requiring assistance with ADLs, the resident was observed without necessary support. An OT recommended a hand roll and elbow orthosis, but these were not in place, highlighting a deficiency in care.
The facility failed to follow their policy for transferring a resident with severe cognitive impairment and multiple diagnoses. CNAs transferred the resident without using the mechanical lift and without the required assistance of a second staff member, contrary to the care plan.
Failure to Maintain Functional Room Heating and Comfortable Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a comfortable environment by ensuring proper room heating for two residents sharing a room. One resident, who was cognitively intact per an MDS dated 12/08/2025, reported feeling cold and was observed wearing a shawl to keep warm. She stated that the room’s heating unit had not been working since 1/10/2026 and that she had reported this to staff on that date. She further reported that a maintenance assistant assessed the unit on 1/12/2026, determined it could not be fixed, left it unplugged, and did not return to reassess it. During the survey on 1/13/2026 at 10 AM, the room felt cool and the heating unit was unplugged. The cognitively intact resident’s roommate, who was documented as severely cognitively impaired and nonverbal on her MDS, was unable to be interviewed about the room temperature. Nursing staff notified the receptionist on 1/12/2026 at 3 PM that the heating unit was not working; the receptionist then notified the maintenance assistant by telephone but did not enter a work order into the computer system as required by the facility’s process. The maintenance assistant confirmed he assessed the unit, found it nonfunctional, left it unplugged, and did not complete a work order. The maintenance director stated he was unaware of the problem and confirmed there was no active maintenance order. Upon his assessment, the unit’s motor was not working and an outside vendor would be needed. He noted the room felt cool with a temperature around 71°F and acknowledged that residents’ rooms needed properly operating heating units so residents could adjust temperatures to their comfort level. The facility’s policy required maintaining comfortable and safe temperature levels within a specified range to minimize susceptibility to loss of body heat and to ensure resident comfort.
Failure to Provide Timely Incontinence Care to Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and assistance with activities of daily living to a dependent resident with severe dementia. On 1/13/2026 at 10:10 AM, the resident was observed in bed wearing a gown, severely confused and fidgeting, with a strong foul urine odor in the room and incontinence products on the bedside table. At 11:00 AM, the resident remained in bed with the same strong foul urine smell. The RN (V14) stated that providing incontinence care was difficult because the resident tended to resist due to severe dementia. Upon assessing the resident’s incontinence brief, V14 found it soiled with urine and emitting a strong foul odor. The resident had two cloth pads underneath her, with the top pad soiled by a dark yellow stain that V14 said was dry, and V14 was unsure when the resident last received incontinence care. At 11:20 AM, two CNAs (V12 and V13) stated they were going to provide incontinence care to the resident. V12 reported that she had last provided incontinence care around 8:00 AM and, upon assessing the soiled cloth pad, believed it had not been present previously and was now dry. The resident’s care plan documented cognitive impairment and a need for assistance with ADLs, including toileting, with interventions directing staff to provide total incontinence and hygiene care. The DON (V2) stated that nursing staff were expected to check residents for incontinence at least every two hours and as needed, and that this resident should have received timely incontinence care, including premedication with PRN antianxiety medication if necessary to allow staff to meet basic toileting needs. The facility’s incontinence care policy dated 05/2025 stated that all incontinent residents would receive appropriate treatment and services based on their comprehensive assessment.
Failure to Follow CHF Fluid Management Orders and Daily Weight Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for CHF-related fluid management, including daily weights and use of compression stockings, for three residents. One resident with CHF and bilateral lower extremity non-pitting edema reported that nursing staff were supposed to obtain daily weights but that this had not been done recently. The RN confirmed that this resident’s CHF management required a fluid restriction and daily weights with MD/NP notification for specified weight gains. The resident’s orders and care plan included daily weights with parameters for provider notification, yet the January 2026 weight record showed missing daily weights on multiple dates. The DON stated that staff were expected to follow CHF orders, including daily weights and application of edema compression stockings. Another resident with chronic lower extremity edema related to CHF was repeatedly observed on different days wearing regular ankle socks with shoes or slippers instead of compression stockings. An RN stated this resident required compression stockings for edema management, was dependent on staff to apply them, and that nurses were expected to follow the physician’s order to apply compression stockings in the morning and remove them at night. A third resident with CHF and generalized lower extremity edema had an active order and care plan for daily weights with MD/NP notification for specified weight gains, but the January 2026 weight record showed multiple days without recorded daily weights. The facility’s weight monitoring policy required assessment of weight and fluid status and development of individualized care plans based on professional standards, but the documented omissions in daily weights and failure to apply ordered compression stockings demonstrate that these orders and care plan interventions were not consistently implemented.
Failure to Honor Resident’s Right to Receive Family Visitors
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to receive visitors of his choosing. The resident, who had Parkinson’s disease, unspecified dementia, and moderate cognitive impairment, reported that he had a blended family with three daughters and a stepson who served as his POA. He stated there had been internal family conflict, that his stepson did not get along with his daughters, and that the stepson had blocked his daughters from phone contact and visiting. The resident clearly stated there should not be any restrictions on any of his children visiting him. Despite this, a sign was posted at the nurse’s station stating that, per the resident and his wife/POA’s request, specific daughters and their spouses, as well as another family member, were to have their visitation restricted and that police could be contacted if they refused to leave. A daughter reported that she drove several hours to visit her father and, upon arrival, was told by staff she was on a list of people not allowed to visit per the POA; staff then called the police, who informed her she was trespassing and could not be there. The Ombudsman stated that the POA was denying visitation, that the facility believed there was to be no contact, and that there should not have been a barrier to the visit. Facility staff, including the receptionist and an RN, described following the posted note by asking visitors for their names, denying the daughter access, and calling the police when she refused to leave or provide identification. The RN stated the note restricting visitation was put up after a prior disturbance involving the daughter and that the POA had said to restrict visitation for these individuals. The Administrator and Director of Operations both acknowledged that the POA could not deny visitation and that visitation ultimately depended on the resident’s wishes, which were that he wanted to see his daughter, yet the posted restriction and staff actions continued to deny the daughter’s visit based on the POA’s request.
Failure to Use Gait Belt During Transfer Results in Resident Injury
Penalty
Summary
A resident with a history of hemiplegia, hemiparesis following cerebral infarction, epilepsy, aphasia, and cellulitis of the right lower limb required substantial to maximal assistance for toileting hygiene and transfers, as documented in the care plan and Minimum Data Set. The care plan specifically directed staff to use a gait belt for all transfers. Despite these instructions, a CNA transferred the resident from the toilet to a wheelchair without using a gait belt, instead holding onto the resident's brief during the transfer. During the transfer, the CNA did not notice that the resident's right foot was caught near the wheelchair's leg rest area. As the resident attempted to sit, her right leg, which was contracted due to her medical condition, swung forward and struck the frame of the wheelchair. This resulted in a laceration to the resident's right lower leg, which required emergency medical attention and stitches. The incident was confirmed by interviews with the resident, the CNA involved, and other facility staff, all of whom acknowledged that a gait belt should have been used according to facility policy and the resident's care plan. The facility's policy mandates the use of gait belts for residents who cannot independently ambulate or transfer, and staff receive training on this policy during orientation and annually. The failure to follow this policy and the resident's care plan directly led to the resident sustaining a significant injury during a transfer. The event was documented in the facility's final report and corroborated by medical records from the emergency room.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for several residents, leading to deficiencies in personal hygiene and nutrition. One resident, identified as R50, who was cognitively intact and required assistance with eating and personal hygiene, was observed with long facial hair and unkempt fingernails. Despite being served a meal, the resident's food and drinks remained untouched until the Director of Nursing intervened to assist and cue the resident to eat. This lack of assistance was acknowledged by the Assistant Director of Nursing, who confirmed the resident's need for staff support in grooming and eating. Another resident, R51, who had multiple diagnoses including dementia and Parkinson's disease, also required maximum assistance with personal hygiene. Observations revealed that R51 had long facial hair and fingernails, despite expressing a desire for grooming. The Assistant Director of Nursing acknowledged the need for staff assistance in maintaining the resident's hygiene, which was not provided as per the care plan. Additional deficiencies were noted with residents R16 and R42. R16, who was severely cognitively impaired and dependent on staff for personal hygiene, was observed with long, unclean fingernails. Similarly, R42, who was admitted to hospice care and required substantial assistance with personal hygiene, was found with long nails and unkempt hair. The facility's policy on ADLs and nail care was not adhered to, as evidenced by the lack of documented nail care and grooming for these residents.
Improper Preparation of Pureed Diets
Penalty
Summary
The facility failed to properly prepare pureed maple glazed ham for eight residents on pureed diets, as observed during a meal preparation on November 13, 2024. The cook, identified as V9, was responsible for preparing the meal and was observed placing pre-sliced ham with rind intact into a blender, adding glaze for flavor, and pureeing the mixture. Despite blending the ham for about two minutes, the resulting product contained small pieces of rind that were visible and not fully pureed, posing a risk to residents who require a smooth, pudding-like consistency for safe consumption. The issue was identified when the Dining Director, V10, was informed that the pureed ham was unsafe due to the presence of rind pieces. The facility's 'Diet Type Report' confirmed that the eight residents were on pureed diets, and the facility's policy for pureed diets specified that the texture should be smooth, similar to mashed potatoes or pudding. The failure to achieve the required consistency for the pureed ham indicates a deviation from the facility's policy and the dietary needs of the residents.
Failure to Assist Resident with Hearing Aid Placement
Penalty
Summary
The facility failed to provide necessary assistance with hearing aid placement for a resident, identified as R31, who required such assistance. R31, a female resident with medical conditions including Carpal Tunnel Syndrome, Torticollis, Neuropathy, and Poly-osteoarthritis, was admitted to the facility with a care plan indicating a need for assistance with personal care, including the placement of hearing aids. Despite this documented need, R31 reported that staff did not assist her with her hearing aids, leading her to stop asking for help. During a resident council interview, R31 was observed without her hearing aids and expressed difficulty hearing, confirming that she had not received assistance from staff. Further investigation revealed that the staff, including a registered nurse (V15) and a certified nursing assistant (V16), were either unaware of R31's need for hearing aids or had not been assisting her with them. V15 acknowledged seeing R31 with hearing aids occasionally but stated that R31 had never requested assistance. V16 admitted to not helping R31 with her hearing aids and noted it had been a while since she had seen R31 wearing them. The Assistant Director of Nursing (V3) confirmed that residents requiring assistance with hearing aids should have such orders in their care plans and expected staff to follow these plans. Despite this expectation, R31 remained without her hearing aids throughout the day, highlighting a lapse in care and adherence to the resident's care plan by the facility staff.
Failure to Provide Splint for Resident with Contracture
Penalty
Summary
The facility failed to assess and provide appropriate care for a resident, identified as R38, to maintain and/or improve range of motion (ROM). R38 was admitted with multiple diagnoses, including spastic hemiplegia affecting the left dominant side, mild dementia, and contracture of the left hand muscle. The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment and functional limitations in ROM on one side of both upper and lower extremities, requiring maximum to total assistance with activities of daily living (ADLs). Despite these needs, observations on two separate occasions revealed that R38 had left hand weakness and contracture without any splint or positioning device in place. The Assistant Director of Nursing (V3) acknowledged the contracture and was prompted to have the therapy department screen R38. The Occupational Therapist (V11) conducted a screening and confirmed the presence of contractures in the left hand and elbow, which were partially stretchable. V11 recommended the use of a left hand roll and a left elbow orthosis to prevent further contracture, stiffness, deformity, and skin breakdown. However, these recommendations were not implemented prior to the surveyor's observations, indicating a deficiency in the facility's care for maintaining and improving the resident's ROM.
Failure to Follow Transfer Policy
Penalty
Summary
The facility failed to follow their policy to transfer a resident according to the resident's care plan. The resident, who had multiple diagnoses including Parkinson's disease, heart failure, dementia, anxiety, and falls, required extensive assistance from two facility staff for transfers between surfaces as per their care plan. However, on multiple occasions, CNAs transferred the resident without using the mechanical lift and without the assistance of a second staff member. One CNA admitted to transferring the resident manually by himself, while another CNA used the mechanical lift but did so alone, contrary to the care plan requirements. The Director of Nursing confirmed that the CNAs should have used the mechanical lift with two staff members present for the transfers. The facility documentation corroborated the CNAs' admissions, showing that they did not follow the prescribed transfer procedures. This failure to adhere to the care plan and facility policy resulted in improper nursing care for the resident, who had severe cognitive impairment and was non-ambulatory, requiring total staff assistance for transfers.
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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