Astoria Place Living & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 6300 North California Avenue, Chicago, Illinois 60659
- CMS Provider Number
- 145634
- Inspections on file
- 29
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Astoria Place Living & Rehab during CMS and state inspections, most recent first.
Two residents at high risk for skin breakdown developed or experienced worsening unstageable pressure ulcers after staff failed to consistently implement and document pressure injury prevention and treatment measures. One resident with multiple comorbidities and impaired mobility progressed from incontinence-associated dermatitis to a large unstageable sacral ulcer, with delayed care plan updates, late initiation of a pressure-reducing mattress, and incomplete skin assessment documentation. Another resident admitted with a deep tissue injury and a very low Braden score later had sacral and mid-back wounds progress to unstageable status with malodor and slough, while staff claimed the resident refused a low air loss mattress but did not document any refusal or ensure orders were in place. Infection prevention staff and the ID NP were not informed of worsening wounds despite culture results showing MRSA and E. coli, and existing facility policies on Braden assessment, skin care, pressure redistribution mattresses, and Enhanced Barrier Precautions were not followed or properly documented.
A wound care dressing change for a resident was performed without proper infection control practices when the Wound Care Coordinator handled the treatment cart, surgical drape, personal items, and gauze with bare hands and delayed hand hygiene until after preparing several wound care supplies. The Infection Preventionist later described that facility expectations and policy require hand hygiene before and after contact with the treatment cart and wound care supplies, and the written infection control policy specifies that staff must perform hand hygiene before and after direct patient contact and after each situation requiring hand cleansing.
A resident with multiple psychiatric diagnoses alleged that a male CNA engaged in inappropriate sexual touching and attempted to kiss her during personal care. Several staff members became aware of the allegation at different times but did not immediately report it to the administrator or law enforcement as required by facility policy. The delay in reporting and failure to notify authorities constituted a breach of the facility's abuse prohibition policy.
A resident with multiple chronic conditions did not have required documentation for several scheduled medications in the MAR. Nursing staff failed to record administration or use appropriate codes for missed doses, as confirmed by the DON and ADON. Facility policy and RN job descriptions require accurate and timely documentation of medication administration.
A resident with multiple serious conditions did not receive scheduled pain medication as ordered due to delays in medication reordering, lack of timely communication with hospice, and failure to utilize available emergency medication stock. Staff provided PRN Morphine instead of the scheduled HYDROmorphone, and documentation errors occurred, resulting in the resident experiencing increased pain and agitation.
Multiple residents experienced inadequate pain management due to missed pain assessments, failure to obtain or follow physician orders, and delays in administering pain medication. One resident with severe arthritis and cervical radiculopathy reported ongoing, unrelieved pain and lack of regular assessment, while another with dementia and a bruised, swollen foot did not receive pain medication as prescribed, with staff failing to use language services to assess pain. A third resident had missing pain assessments and unavailable prescribed medication, and overall, staff training on pain management was insufficient.
The facility failed to ensure that medications were available, transcribed, and administered as ordered for four residents, including issues with unavailable pain patches, missing insulin doses, undocumented eye drop administration, and confusion over narcotic dosage forms. These deficiencies were confirmed through record review and staff and resident interviews.
A resident with a history of falls, poor trunk control, and high fall risk was left sitting upright and unattended in a geri-chair while two CNAs prepared for a transfer. One CNA left to get the mechanical lift, and the other was across the bed, leaving the resident unsupervised. The resident leaned forward, fell, and sustained a head laceration requiring hospitalization and stitches. Staff interviews and records confirmed that proper supervision and support were not maintained during the transfer process.
The facility failed to properly date, label, and discard prepared foods stored in the walk-in cooler, potentially affecting 154 residents receiving an oral diet. During a kitchen tour, unlabeled trays of prepared foods and improperly labeled items like grated parmesan cheese and pie crust were found. The Dietary Manager confirmed that all prepared foods should be labeled and dated, as per the facility's policy, which was not followed.
The facility failed to follow care plans for residents requiring oxygen therapy, resulting in deficiencies such as unlabeled nasal cannulas, improper storage of oxygen tubing, lack of required signage, and incorrect oxygen flow rates. The Director of Nursing confirmed these issues, which were contrary to the facility's policies and physician orders.
The facility failed to properly label, store, and dispose of medications for six residents, including not dating opened inhalers and nasal sprays, not refrigerating unopened eye drop solutions, and not discarding expired medications. The DON confirmed that medications should be labeled and dated once opened to ensure proper disposal and effectiveness.
A facility failed to follow its infection control policy, leading to deficiencies in PPE use and linen handling. CNAs did not wear required PPE when entering a resident's room on Contact Isolation for ESBL, and soiled linen was improperly handled without hand hygiene. Incorrect signage and lack of a specific linen handling policy contributed to these issues, potentially affecting all residents on the floor.
A resident's urinary catheter bag was left uncovered and visible from the hallway, violating the facility's privacy and dignity policy. The DON acknowledged that catheter bags should be covered to prevent dignity issues. The resident required the catheter due to a neurogenic bladder, and the facility's policy mandates covering urine bags, which was not followed.
A facility failed to set a low air loss mattress correctly for a resident with a stage 4 pressure ulcer. The resident, at high risk for pressure ulcers, had a mattress set to 210 lbs instead of the correct 180 lbs. The wound care team confirmed the importance of setting the mattress to the resident's weight to aid in wound healing, as per facility policy.
A resident with cognitive impairment and high fall risk was found on the floor with their head on a wheelchair leg rest. The LPN documented the incident as a behavior slide instead of a fall, contrary to the facility's policy. The DON later acknowledged the incident should have been treated as a fall, highlighting the need for staff training on differentiating between falls and behavior slides.
A resident with multiple diagnoses, including hyperthyroidism, was found with medication left at the bedside, contrary to facility policy. The RN identified the pill as possibly a thyroid medication, and the DON confirmed that medications should not be left unless there is an order and assessment for self-administration, which was absent. The resident's cognition was moderately impaired, highlighting the deficiency in medication administration procedures.
A resident with severe cognitive impairment was physically and verbally abused by their roommate in an LTC facility. The incident, involving a skin tear and derogatory language, was witnessed by a CNA and another resident. Despite staff intervention and reporting to health authorities, the facility failed to prevent the abuse, highlighting a deficiency in resident protection.
Failure to Prevent and Manage Pressure Ulcers and Document Skin Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer care, prevent new ulcers, and adequately document skin monitoring for multiple residents, resulting in new unstageable pressure ulcers. One resident (R1) had multiple comorbidities including diabetes, anemia, hypertension, hyperlipidemia, schizoaffective disorder, bilateral hearing loss, and impaired mobility. R1 initially had incontinence-associated dermatitis (IAD) to the left buttock documented on 12/9/25, with treatment ordered but no mention of an air mattress intervention on the skin alteration evaluation. By 12/16/25, R1 had developed a new unstageable pressure ulcer from the sacrum to buttock, documented by the wound NP and in subsequent wound assessments as largely covered with slough. The care plan for risk of pressure ulcer development, including the need for assistance with repositioning and transfers and the use of pressure-reducing devices, was not updated until 12/31/25, approximately 24 days after the sacral pressure ulcer was first documented. There were discrepancies between the MDS documentation and wound assessment dates regarding when the wound was first observed, and the air mattress was not ordered until 12/16, one week after identification of a skin impairment. R1’s skin monitoring documentation was incomplete and lacked detail. The Shower/Bathing & Skin Monitoring records between 12/1/25 and 12/17/25 showed multiple entries marked “yes” for bathing but did not describe skin condition, and the facility was unable to provide documentation of skin integrity observation details when requested by surveyors. On 12/16/25, records showed that R1 received a shower or bath, but there was no documentation by CNAs, nurses, or the wound care nurse of alterations in skin integrity that day, despite the presence of a new unstageable sacral pressure ulcer documented in wound care records. Staff interviews indicated that CNAs reported performing daily skin assessments and documenting skin impairments in the electronic record, but the surveyors verified that the follow-up question report for skin assessment and showers did not document R1’s skin integrity. The DON and Wound Care Coordinator acknowledged that air mattresses are used for residents with wounds or at risk for skin breakdown and that refusals of care should be care planned, but there was no documentation of refusal related to pressure-relieving surfaces for R1. A second resident (R3) was admitted with an intact deep tissue injury (DTI) to the sacrum and intact skin to the mid-back, with a Braden score of 8 indicating high risk for skin breakdown and intact cognition. Early wound assessments documented a sacral DTI present on admission and a new mid-back DTI with intact epithelium and evidence of deeper tissue injury. By 01/06/26, wound assessments showed that both the sacral and mid-back wounds had progressed to unstageable pressure injuries with malodorous odor post-cleansing, increased size, and 100% slough at the mid-back site. Progress notes identified R3 as high risk for pressure sore development and ordered a low air loss mattress and offloading/repositioning interventions; however, the Wound Care Coordinator stated that although she believed there was a standing order for air mattresses and claimed R3 refused an air mattress, she had no documentation of such refusal and did not place an order. The wound care nurse similarly stated that R3 refused the low air loss mattress but admitted she did not document the refusal. Review of progress notes and care plans showed only one entry of R3 refusing wound care and no documentation of refusal of an air mattress or other care, despite staff statements that refusals should be documented and care planned. The facility also failed to consistently implement and document infection prevention measures related to worsening wounds. R3’s wounds later cultured MRSA and E. coli, and staff interviews indicated that the wounds showed signs of infection and had an odor. The Infection Preventionist stated that residents with wounds should be placed on Enhanced Barrier Precautions (EBP), which are to be care planned, and that she was never informed that R3’s wounds were worsening or showing signs of infection. She indicated that, had she been informed, she would have contacted the Infectious Disease NP to consider empiric antibiotics. The Infectious Disease NP confirmed she had not been notified of R3’s worsening wounds after 11/19/25. Surveyors also found that the facility did not have specific policies titled “Pressure Wound Care” and “Pressure Wound Prevention,” and that existing skin care and Braden Scale policies, which required prompt identification, documentation, use of pressure redistribution mattresses, and implementation of interventions per Braden score, were not followed for R1 and R3. These combined failures in prevention, timely intervention, documentation, and communication led to the development and worsening of unstageable pressure ulcers in both residents. The facility’s documentation systems and staff practices did not align with their written policies on skin care, Braden risk assessment, and use of pressure redistribution surfaces. For R1, there was a delay in ordering an air mattress and updating the care plan despite documented high risk and the presence of skin impairment, as well as missing or nonspecific documentation of skin assessments around the time the unstageable sacral ulcer developed. For R3, despite high risk status, admission with a DTI, and subsequent progression to unstageable wounds, there was no documented order or consistent implementation of a low air loss mattress at the time staff claimed it was offered and refused, and no documented refusals of this intervention. Additionally, staff acknowledged that they did not routinely review care plans, even though they relied on them to know resident interventions. These actions and omissions collectively constitute the deficiency in failing to provide appropriate pressure ulcer care, prevent new ulcers, and document skin monitoring as required.
Failure to Perform Proper Hand Hygiene During Wound Care Procedure
Penalty
Summary
The deficiency involves a failure to follow infection prevention and control practices during a wound care dressing change for one resident reviewed for wound care. During an observation of a wound care procedure, the Wound Care Coordinator prepared wound care supplies without performing hand washing or hand sanitizing, while opening and touching the treatment cart drawers. The Wound Care Coordinator opened a surgical drape and touched it with bare hands, touched her glasses, and then used the same hand to type on her laptop while reading the wound care order. She then opened another drawer and removed a stack of gauze with bare hands before using hand sanitizer and removing additional supplies from the cart. In an interview conducted shortly after the observation, the Wound Care Coordinator acknowledged that she should practice handwashing and infection control practices before, between, and after wound care, and verified that she used hand sanitizer only after opening the surgical drape and preparing other wound care supplies. The Infection Preventionist stated that for a clean wound care procedure, the nurse should wash hands, gather equipment, wash hands again, don PPE, and then complete the wound care, and further explained that the outside of the wound care treatment cart is considered dirty and that hand hygiene should be performed after touching the outside of the cart and before handling wound care dressing supplies. The facility’s infection control policy requires hand hygiene before and after direct patient contact and after each situation that necessitates hand hygiene, using alcohol-based hand rubs or hand washing for 20 seconds.
Failure to Immediately Report Alleged Sexual Abuse and Notify Law Enforcement
Penalty
Summary
The facility failed to implement its abuse prohibition policy by not immediately reporting an allegation of staff-to-resident sexual abuse to the abuse coordinator and by failing to notify local law enforcement of a suspected crime. A resident with a history of mood disorder, schizoaffective disorder, bipolar disorder, major depressive disorder, and generalized anxiety disorder was admitted for therapy following knee surgery. On the evening of admission, the resident alleged that a male CNA performed inappropriate and non-consensual touching during personal care, including touching her genital area and breast, and attempting to kiss her. The resident reported these actions to a nurse the following morning and also communicated the incident to her social worker via text messages. Multiple staff members became aware of the resident's allegations at different times, but failed to follow the facility's abuse policy requiring immediate reporting to the administrator and law enforcement. The night shift nurse, morning nurse, and wound care nurse each received information about the alleged abuse, but did not promptly report it as required. Some staff expressed disbelief in the resident's account due to her psychiatric history, and others admitted not knowing the reporting requirements or failing to act due to the time of day or personal judgment. The administrator was eventually informed by the wound care nurse, but this was not immediate, and the facility did not report the incident to police, citing the resident's refusal, despite policy requiring such reporting. The facility's abuse policy, consistent with federal guidelines and the Social Security Act, mandates immediate reporting of all allegations or suspicions of abuse to the administrator and law enforcement, especially in cases of sexual abuse. The policy specifically defines sexual abuse to include unwanted touching of the breast or perineal area and requires notification of law enforcement within a specified timeframe. The failure to adhere to these procedures resulted in a delay in both internal and external reporting of the alleged abuse, contrary to established protocols.
Failure to Document Medication Administration in MAR
Penalty
Summary
The facility failed to ensure that a resident's medications were properly documented as administered according to physician orders. During a review of medication administration records (MARs) for one resident with multiple diagnoses, including Dementia, Asthma, Bipolar Disorder, Chronic Diastolic Heart Failure, and Major Depressive Disorder, surveyors found missing entries of nurses' signatures, initials, or codes for several scheduled medications. Specifically, on a certain date and time, there were no documented entries for the administration of Levothyroxine Sodium, Pantoprazole Sodium, and Advair Diskus, all of which were ordered to be given in the morning. The absence of documentation was confirmed by both the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), who stated that nurses are responsible for administering medications and documenting their administration in the electronic MAR. Codes are available for situations such as resident refusal or absence, but blank spaces indicate that the medication was not administered. Facility policy requires that after medication is administered, the MAR must be signed to confirm administration. The Registered Nurse job description also mandates completion of medical records documenting care provided, in accordance with nursing policies and confidentiality standards. The failure to document medication administration as required was observed during the survey and confirmed through staff interviews and policy review.
Failure to Provide Scheduled Pain Medication Due to Medication Availability and Communication Lapses
Penalty
Summary
A deficiency occurred when a resident with multiple complex diagnoses, including multiple sclerosis, palliative care needs, colon cancer, and a cervical vertebra fracture, did not receive pain management in accordance with their comprehensive care plan and physician orders. The resident was prescribed scheduled HYDROmorphone HCl (Dilaudid) and PRN Morphine Sulfate for pain and difficulty breathing. The care plan required administration of medications as ordered and monitoring for effectiveness and side effects. However, there were instances where the scheduled Dilaudid was not available, and the resident missed doses, which led to increased pain and agitation as reported by the resident. Staff interviews revealed that nurses did not consistently reorder pain medications in a timely manner, waiting until supplies were low before notifying hospice or the pharmacy. On one occasion, the resident was not given the scheduled Dilaudid because it was not available, and the nurse did not check the emergency medication box for an alternative supply, despite it being stocked with Dilaudid. Instead, the resident was offered PRN Morphine, which he accepted, but this was not in accordance with the scheduled pain management plan. Documentation errors also occurred, with a nurse mistakenly recording administration of Dilaudid when it was not given. The facility's own policies required assessment and management of pain in all situations where pain was possible, and residents' rights included the provision of safe and appropriate care. Despite these policies, the resident experienced lapses in pain management due to medication availability issues, lack of timely communication with hospice, and failure to utilize available emergency medication stock. These actions and inactions resulted in the resident not receiving pain management as planned and ordered.
Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for multiple residents, as evidenced by a lack of pain assessments, failure to obtain and follow physician orders, and delays in administering pain medication. One resident with a history of cervical radiculopathy and rheumatoid arthritis reported experiencing severe, unrelieved pain and stated that staff did not assess her pain regularly or provide her with prescribed pain medication, despite her repeated requests. The resident's care plan indicated a need for pain monitoring and medication administration, but there were no pain medications listed in her physician orders, and staff did not document or assess her pain as required. Another resident with dementia and palliative care needs was observed in apparent pain, with physical signs such as grimacing and guarding a bruised, swollen foot. Despite having orders for pain assessments and medications, staff failed to document pain assessments on multiple shifts and did not administer pain medication as prescribed. Communication barriers were not adequately addressed, and staff did not use available language services to assess the resident's pain level. Pain medication was not given according to the prescribed pain scale, and there were significant delays in administration. A third resident with a history of hip dislocation and sciatica also experienced lapses in pain management, with missing pain assessments on several days and a prescribed lidocaine patch marked as unavailable. Facility records and staff interviews confirmed that residents often waited a long time for pain medication, and staff training on pain management was insufficient, as evidenced by limited participation in in-service sessions. Facility policies required regular pain assessments and prompt administration of pain medication, but these were not consistently followed.
Failure to Ensure Accurate Medication Administration and Documentation
Penalty
Summary
The facility failed to ensure proper medication administration and documentation for four residents, resulting in multiple deficiencies. For one resident with a history of hip dislocation and pain, the prescribed 4% Lidocaine patch was not available on a documented date, and the Medication Administration Record (MAR) was marked as unavailable. Staff interviews confirmed that the facility sometimes had to purchase patches from a drug store due to supply issues, but the patch was not always on hand. Another resident with diabetes did not consistently receive prescribed Glargine insulin, as evidenced by a blank entry on the MAR and the resident's report of inconsistent administration and poor blood sugar control. A third resident, with diagnoses including cataracts and neuropathy, did not have a prescribed Lidocaine patch transcribed onto the MAR, and administration of prescribed Latanoprost eye drops was not documented on the MAR. The resident reported not receiving the eye drops and being told by staff that the medication was not available. For a fourth resident with dementia and palliative care needs, there was confusion regarding the form and dosage of Hydromorphone, with staff unsure whether the medication should be administered as a tablet or liquid, and the physician order specifying a tablet but the dosage written in milliliters. Facility policy requires that all medications and treatments be administered and documented as ordered, but these requirements were not met in these cases.
Failure to Provide Adequate Supervision During Transfer Results in Resident Fall and Injury
Penalty
Summary
The facility failed to ensure the safety of a resident with a history of falls, poor trunk control, and high risk for injury during a transfer from a geri-chair to bed. Two CNAs were preparing to transfer the resident, who was dependent on staff for transfers and required a reclining wheelchair for proper positioning. One CNA left to retrieve the mechanical lift while the other stood on the opposite side of the bed, leaving the resident sitting upright and unattended in the chair. The resident, who was not reclined and had poor trunk support, leaned forward and fell from the chair, resulting in a laceration to the forehead that required hospitalization and stitches. Interviews with staff confirmed that the resident was left without close supervision during the transfer process, despite care plan instructions and facility policy requiring two staff to assist and maintain support for residents with poor trunk control. The incident report and hospital summary documented the fall and resulting injury. Staff acknowledged that being within arm's reach and maintaining physical support was necessary for this resident's safety, and that the resident's chair was not reclined at the time of the fall, increasing the risk of leaning forward and falling.
Deficiency in Food Labeling and Storage Practices
Penalty
Summary
The facility failed to ensure that prepared foods stored in the walk-in cooler were properly dated, labeled, and discarded by the use-by date. During an initial kitchen tour, a surveyor observed a food cart with trays of prepared foods such as ham sandwiches, vanilla pudding, chocolate pudding, cups of fruits, and pitchers of lemonade, none of which were labeled with preparation dates. Additionally, a plastic cover on the food cart lacked a label. An opened bag of grated parmesan cheese was found with a label indicating a prepared date of 11/9/24 and a use-by date of 11/16/24, but no manufacturer's expiration date was noted. A tray of pie crust inside a clear bag was also found without a label. The Dietary Manager stated that all prepared foods should be labeled and dated, and they are considered good for seven days after opening, after which they should be discarded. The facility's Receiving policy requires all food items to be appropriately labeled and dated either through manufacturer packaging or staff notation. The facility's roster indicated 156 residents, with two residents who are NPO (Nothing by Mouth), potentially affecting 154 residents receiving an oral diet.
Oxygen Therapy Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to the care plans for several residents requiring oxygen therapy, leading to deficiencies in the administration and management of oxygen. For instance, a resident with chronic respiratory failure was observed receiving oxygen via a nasal cannula that was not labeled, and the resident could not recall when it was last changed, contrary to the facility's policy requiring weekly changes and labeling. The Director of Nursing confirmed that the nasal cannula should be changed weekly or as needed and labeled accordingly. Another resident was observed with oxygen tubing improperly stored, hanging on an oxygen tank, which contradicts the facility's policy that requires oxygen tubing to be stored properly to prevent contamination. Additionally, a resident receiving oxygen therapy did not have the required oxygen signage posted by the room entrance, which is necessary to alert staff and visitors of oxygen use. The Director of Nursing acknowledged that signage should be posted as a warning. Furthermore, discrepancies were noted in the oxygen flow rates administered to two residents. One resident's oxygen was set at 4 liters per minute, while the physician's order specified 2-3 liters per minute. Similarly, another resident's oxygen was set at 4 liters per minute, contrary to the physician's order of 2-3 liters per minute. The Director of Nursing stated that nurses are responsible for ensuring that oxygen settings align with physician orders, which was not followed in these cases.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to properly manage the labeling, storage, and disposal of medications for six residents across three medication carts. Specifically, the facility did not date opened multi-dose respiratory inhalers and nasal sprays, did not store unopened multi-dose eye drop solutions correctly, and did not discard expired multi-dose medications. During an inspection, it was found that a resident's Latanoprost ophthalmic solution was not refrigerated as required, and another resident's opened Latanoprost solution was not discarded after the recommended six weeks. Additionally, several inhalers and nasal sprays were found without open dates, making it difficult to determine their expiration. The Director of Nursing confirmed that medications should be labeled and dated once opened to ensure proper disposal and maintain their effectiveness. The facility's policy mandates compliance with federal regulations regarding medication storage, labeling, and disposal, including following pharmacy recommendations for discarding medications after opening. The failure to adhere to these guidelines could potentially affect the potency and safety of the medications administered to residents.
Infection Control Deficiencies in PPE Use and Linen Handling
Penalty
Summary
The facility failed to adhere to its infection prevention and control policy, resulting in multiple deficiencies. Certified Nursing Assistants (CNAs) V12 and V13 did not don the appropriate personal protective equipment (PPE) when entering a resident's room who was on Contact Isolation precautions due to an ESBL infection in a wound. Despite the requirement to wear gowns and gloves, both CNAs only performed hand hygiene when entering the room to deliver a meal tray, which was contrary to the facility's policy and the Centers for Disease Control (CDC) guidelines. Additionally, there was a failure in the proper handling of soiled linen. CNA V12 was observed carrying soiled linen with bare hands down the hallway, which had visible stains, and did not place it in a plastic bag immediately after removal from the bed. V12 admitted to not washing hands after handling the soiled linen and before entering the clean supply room, acknowledging the lapse in following infection control procedures. This action was against the facility's expectations for handling soiled linen to prevent cross-contamination. The facility's Infection Preventionist Nurse, V4, confirmed that the incorrect signage was posted outside the resident's room, which contributed to the misunderstanding of the required precautions. The Director of Nursing, V2, stated that there was no specific policy for handling linen, which further highlights the gaps in the facility's infection control practices. These deficiencies have the potential to affect all residents on the residential floor, as they increase the risk of spreading infections.
Failure to Ensure Privacy and Dignity for Resident with Urinary Catheter
Penalty
Summary
The facility failed to provide privacy and promote dignity for a resident using a urinary catheter. During an observation, the resident's urinary catheter bag was found hanging on the side of the bed, half-filled with urine and visible from the hallway, without a protective cover. The resident explained that the catheter was necessary due to a wound. The Director of Nursing confirmed that the catheter bag should not face the door and should be covered to maintain privacy, as per the facility's policy. The physician's orders indicated the use of an indwelling catheter for a neurogenic bladder, ordered on a previous date. The facility's policy on privacy and dignity mandates that urine bags be covered with privacy bags, which was not adhered to in this instance.
Incorrect Low Air Loss Mattress Setting for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a low air loss mattress device was set to the correct weight setting for a resident with a stage 4 pressure ulcer. The resident, who was admitted with multiple sclerosis and a high risk of developing pressure ulcers, had a physician's order for a low air loss mattress. The resident's care plan included checking the mattress's functionality every shift and as needed. Despite this, the mattress was observed to be set incorrectly at 210 lbs, while the resident's recorded weight was 180 lbs. The wound care coordinator and treatment nurse confirmed that the mattress should be set according to the resident's current weight to effectively offload pressure and promote wound healing. The facility's policy on specialized mattresses emphasizes the importance of using these devices to control moisture, heat, and friction for residents with severe pressure sores. The incorrect setting of the mattress could compromise its intended function, potentially affecting the resident's wound healing process.
Failure to Distinguish Between Behavior Slide and Fall
Penalty
Summary
The facility failed to properly distinguish between a behavior slide and a fall for a resident, R119, who was at high risk for falls due to cognitive deficits, poor balance, and limited mobility. R119's clinical record indicated a history of cerebral infarction with hemiplegia, coronary angioplasty, and other medical conditions, along with moderate cognitive impairment. The care plan noted R119's behavior of sliding onto the floor when experiencing abdominal discomfort, but this behavior was not consistently documented or treated according to the facility's fall occurrence policy. During an observation, a surveyor found R119 on the floor with his head resting on a wheelchair's leg rest. The Licensed Practical Nurse (LPN), V8, did not witness the incident but assumed it was a behavior slide rather than a fall, as instructed by the Director of Nursing (DON). The incident was documented as a behavior slide without a neurological assessment or proper documentation of the head's position on the wheelchair leg. The facility's policy required that any fall, witnessed or not, should be documented and treated as a fall, with an incident report and appropriate assessments. The Restorative Director and the DON acknowledged that R119 was a high fall risk and that the behavior slide should have been treated as a fall if the resident was found off the floor mat. The facility's inability to provide a 24-hour sitter for R119, who required constant supervision, was also noted. The DON admitted that the incident should have been documented as a fall, and the staff needed further training to differentiate between a fall and a behavior slide. The original behavior care plan was missing, and the updated care plan was only entered after the surveyor's request.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure proper medication administration for a resident, identified as R113, by leaving medication at the bedside. R113 was admitted with multiple diagnoses, including hemiplegia, hypertension, and hyperthyroidism, and was observed sitting on the side of the bed with a white round pill inside a medication cup on the bedside table. The resident was unaware of what the medication was, and the Registered Nurse (RN) identified it as potentially being a thyroid medication from the previous shift. The RN acknowledged that medication should not be left at the bedside unless there is an order and assessment for self-administration, which was not present in R113's records. The Director of Nursing (DON) confirmed that nurses are expected to administer medications as ordered and ensure residents take them before leaving the room. The facility's policies on medication pass and storage emphasize adherence to federal and state regulations and securing medications in a locked storage area. However, R113's physician order summary did not include permission for self-administration, and no assessment for self-administration was found in the electronic health record. Additionally, the Minimum Data Set (MDS) indicated that R113's cognition was moderately impaired, further underscoring the inappropriateness of leaving medication at the bedside.
Failure to Protect Resident from Abuse by Roommate
Penalty
Summary
The facility failed to protect a resident, identified as R1, from abuse by their roommate, R2. R1, who was admitted under hospice care, has severe cognitive impairment and requires substantial assistance with activities of daily living. An incident occurred where R2, who also has severe cognitive impairment and a history of aggressive behavior, physically and verbally assaulted R1. R2 grabbed R1's arm, causing a skin tear, and verbally abused R1 over a disagreement about the television. The incident was witnessed by a Certified Nursing Assistant (CNA) and another resident, R3, who reported seeing R2 shaking R1 by the arm and yelling derogatory terms. The CNA intervened and separated the two residents, but the altercation had already resulted in a skin tear on R1's arm. The wound was assessed by a wound care nurse, who confirmed the presence of a skin tear with minimal bleeding. The facility's staff, including the Assistant Director of Nursing and the Nursing Supervisor, were involved in managing the situation. They documented the incident and took steps to ensure R1's safety by removing R2 from the room. The facility's administrator, who is also the Abuse Coordinator, acknowledged the incident as abuse and reported it to the Illinois Department of Health. Despite these actions, the initial failure to prevent the abuse constitutes a deficiency in the facility's obligation to protect residents from harm.
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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