Austin Oasis, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 901 South Austin Blvd, Chicago, Illinois 60644
- CMS Provider Number
- 145834
- Inspections on file
- 63
- Latest survey
- February 21, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Austin Oasis, The during CMS and state inspections, most recent first.
A resident with hypertension and other chronic conditions had physician orders for two oral antihypertensive medications. On one occasion, one of these blood pressure medications was not available, and the nurse on duty did not obtain it from backup supplies or notify the physician. Instead, the nurse documented on the MAR that the medication was given, despite acknowledging it was not administered and that she only reordered it. This conduct conflicted with facility policy requiring accurate medication administration and error reporting.
Surveyors observed boxes of food, including a box labeled pork, stored directly on the floor in the kitchen walk-in refrigerator, contrary to facility policy requiring all refrigerated food to be kept 6 inches above the floor. The Dietary Manager confirmed during interviews that food items are required to be elevated to prevent contamination and potential foodborne illness. Review of the written sanitation and food safety policy showed it specifies that refrigerated foods must be stored to ensure safety and that all food must be kept six inches off the floor. This deficiency had the potential to affect all residents receiving oral nutrition in the facility.
A staff member overseeing the smoking patio line became upset after a miscommunication about which floor’s residents were to go smoke and directed profanity and demeaning language toward residents in line. Cognitively intact residents reported that the staff member cursed, called them “kids,” and used terms such as “mother f***r” and “little boy,” while another resident described the staff member as rude and talking “crazy” all the time. These actions violated facility resident-rights policy requiring staff to treat residents with respect, kindness, and dignity and to maintain an environment that preserves resident dignity and supports a positive self-image.
A resident with hypertension, tachycardia, oxygen dependence, and severely impaired cognition was ordered Metoprolol Tartrate 25 mg tablets to be administered as a 18.75 mg dose twice daily. During a med pass, an LPN dispensed and gave a full 25 mg tablet instead of the ordered 0.75 tablet, later acknowledging she had not followed the physician’s order. Another LPN reported that she had routinely given this resident a whole tablet from the same container, believing it to be 18.75 mg, and upon review realized she had also been administering 25 mg instead of the prescribed dose. The DON confirmed the correct dose required splitting the 25 mg tablet into a half and a quarter to total 18.75 mg, and facility policies and job descriptions required nurses to administer medications exactly as ordered, including the correct dose.
A resident with a history of depression, substance dependence, and documented suicidal ideation was able to obtain and retain a razor after a community therapeutic leave and used it to scrape and cut her left forearm. During night rounds, a CNA found the resident actively scraping her arm with the razor, and the resident stated she wanted to go to the hospital to be with her boyfriend. The nurse supervisor confirmed the razor was brought in from outside and was different from the non-branded, curved-handle razors supplied by the facility. Hospital and wound documentation described a wide linear abrasion on the resident’s left forearm caused by a razor blade, demonstrating that the environment was not maintained free of hazardous materials for a resident at known risk of self-harm.
A resident with moderate cognitive impairment and a history of suspected abuse was physically attacked in a crowded elevator by another resident with severe cognitive and behavioral issues. The victim sustained a minor closed head injury and reported ongoing emotional distress and fear for her safety. Witnesses confirmed verbal threats and physical assault, and facility records indicated prior risk factors for abuse, but the facility failed to prevent the incident.
Multiple residents experienced ongoing issues with low water pressure, lack of hot water, and non-functioning toilets, particularly on upper floors. Surveyors confirmed that water temperatures in resident rooms and shower areas were consistently cold, and maintenance logs documented repeated complaints over several weeks. Staff reported being unable to provide proper showers, and residents described significant disruptions to their hygiene routines due to these persistent plumbing problems.
Surveyors found a brown bug, identified as likely a roach, crawling on the kitchen sink and observed the oven with dried brown substances and black particles inside. The Dietary Manager confirmed the oven's last deep cleaning was the previous week and stated that cleaning is usually done after each use. The DON expressed concern about pests in food preparation areas. Facility policies require sanitary food handling and pest control.
Two cognitively intact residents with complex medical histories were involved in a physical altercation in an elevator after a verbal dispute about elevator access. Both sustained minor injuries, including a bite that required antibiotic treatment. The facility failed to ensure residents were protected from abuse by others, as required by policy.
A resident was physically abused by another resident who slapped them, causing a fall and subsequent pain in the left elbow, back, and neck. The incident occurred during a medication line dispute, with the aggressor demanding immediate service and becoming violent. Despite the facility's policy to protect residents from abuse, the victim, who has a history of shoulder replacement surgery, experienced significant pain and emotional distress.
The facility failed to ensure proper kitchen hygiene and food labeling, affecting 175 residents. Staff did not cover facial hair as required, and a dietary aide did not perform hand hygiene between handling dirty and clean dishes. Additionally, several opened food items lacked proper labeling with preparation and use-by dates, contrary to facility policy.
The facility did not follow its linen handling policy, leading to loose soiled linens being found in the laundry chute without being bagged. This was confirmed by both a Laundry Aide and the DON/Infection Preventionist, who noted the potential for bacterial spread and contamination. The deficiency affected all 175 residents.
The facility failed to display posters informing residents of their rights under the [NAME] Consent Decree, affecting all [NAME] Class Members. During a survey, no signs were found in public areas, and staff were unaware of the facility's partnered agencies for community transition. The Social Service Director admitted the facility should have such flyers, but they were not located. The facility's PASRR policy lacks documentation on educating residents about their rights.
The facility failed to obtain physician orders for the code status of four residents and did not develop comprehensive care plans for two residents' advance directives. Despite having policies requiring documentation of code status, the facility did not ensure that these were included in the residents' medical records and care plans, affecting residents with varying cognitive abilities and medical conditions.
The facility failed to refer nine residents for required Level II PASARR evaluations, despite their mental health diagnoses necessitating such assessments. The oversight was due to a lack of follow-up screenings and access issues within the Maximus system, as acknowledged by the Director of Admissions.
A facility failed to conduct quarterly smoking assessments and develop individualized smoking care plans for independent smokers, including a resident with nicotine dependence who was observed lighting other residents' cigarettes. The facility's smoking safety policy lacked guidelines on assessment frequency, and the care plan policy was not followed for several independent smokers.
The facility failed to label open insulin vials and pens for four residents across two medication carts, as observed during an inventory. Insulins, including Basaglar Kwik Pen, Lantus, Humalog, and Insulin NPH Isophane and Regular Subcutaneous 70/30, were not labeled with the date they were opened. Additionally, an LPN borrowed iron supplement pills from another cart due to a lack of stock, contrary to facility policy. The DON confirmed that medications should not be shared between residents and must be labeled and administered according to orders.
The facility failed to adhere to menu specifications for pureed diets and did not provide adequate food portions as per recipes. Residents on pureed diets received mashed potatoes instead of pureed rice and pureed spinach instead of oriental vegetables. Additionally, ham portions were not uniform due to the lack of a slicer, leading to potential nutritional inadequacies.
The facility failed to prepare food in the correct consistency for residents on mechanical soft/ground and pureed diets. Observations revealed that Sweet and Sour Chicken was not ground for mechanical soft diets, and pureed ham was not smooth, posing potential choking hazards. The Dietary Manager and Registered Dietitian confirmed the inconsistencies, which were against the facility's documented guidelines for special diets.
The facility failed to provide double portions as prescribed in therapeutic diets for several residents. Observations revealed that only the rice was doubled, while the protein and vegetables remained at standard portions, contrary to the physician's orders. The Registered Dietitian confirmed that double portions should include all components of the meal, which was not followed, potentially leaving residents hungry.
The facility failed to educate and assess five residents for pneumococcal vaccinations, despite their eligibility and medical conditions. The facility's outdated policy did not align with CDC guidelines, and the Director of Nursing stated that education and consent were only given to certain residents, contrary to current recommendations.
The facility failed to serve meals simultaneously to residents sitting at the same table, affecting their dignity. During a dining session, a resident was observed watching their tablemate eat without having a meal tray, expressing hunger. Similarly, two other residents waited for their meals while their tablemates were already eating. The facility's policy requires meals to be served at the same time to all clients at a table, which was not followed, impacting the residents' dining experience.
A facility failed to follow the five rights of medication administration when an LPN used another resident's insulin vial for a resident without proper labeling. The LPN admitted to using the wrong insulin due to the resident's supply running out and not wanting to retrieve insulin from the emergency box. The DON confirmed that all insulin vials should be labeled with open and expiration dates, and medications should not be shared between residents.
The facility failed to properly label, date, and store oxygen tubing and nebulizer masks for residents receiving oxygen therapy. Observations revealed unlabeled and undated oxygen tubing, nebulizer setups not stored in bags, and missing oxygen signage at room entrances. Residents with various diagnoses, including COPD and Heart Failure, were affected. The DON highlighted the need for staff to adhere to policies requiring equipment to be changed weekly and signage to be posted when oxygen is in use.
The facility failed to document COVID-19 vaccination status and education for three residents, leading to a deficiency. The EHRs of these residents lacked records of vaccine administration, refusal, or contraindication, as well as documentation of educational efforts. The DON confirmed that education was provided verbally, but not documented, violating CMS guidelines.
A resident in an LTC facility was physically attacked by her roommate, resulting in an abrasion under her eye and hospitalization. The attacker, who had a history of behavioral issues, became aggressive without provocation. Despite the facility's abuse prevention policy, the situation was not adequately addressed, leading to the incident.
A resident in a long-term care facility was injured after being pushed by another resident in an elevator, resulting in a fall and a fracture. The injured resident had a history of various medical conditions, while the aggressive resident had a history of physical aggression. The facility's staff recognized the incident as abuse, and it was reported to law enforcement and medical professionals.
A resident with multiple medical conditions was prescribed 800 mg of Ibuprofen for pain management but was only administered 600 mg by an LPN due to a lack of the correct dosage in stock. The LPN was unsure about administering the correct dosage using available tablets and incorrectly documented the administration of 800 mg. The facility's policies require adherence to physician orders, and the DON confirmed that altering medication dosage without a physician's directive is unacceptable.
The facility failed to maintain proper sanitation in the kitchen, with observations of poor cleaning practices and personal items improperly stored, potentially affecting all 177 residents on an oral diet. The Dietary Manager and a Dietary Aide acknowledged these issues, and the Housekeeping Director confirmed that kitchen staff are responsible for cleaning. Facility policies emphasize sanitation to prevent foodborne illnesses, yet significant cleaning deficiencies were noted.
The facility failed to maintain the dumpster area, resulting in broken lids and overflowing trash, potentially attracting rodents. The maintenance director is responsible for repairs but does not regularly check the area unless issues are reported. The housekeeping director was aware of the missing lids for two weeks. The facility's policies outline responsibilities for maintaining the dumpster area to prevent rodent attraction.
The facility's kitchen was found to have poor cleaning practices, leading to an infestation of flies and roaches. Despite pest control visits, the issue persisted, with structural issues like holes in walls contributing to the problem. Kitchen staff confirmed the daily presence of pests, and the responsibility for cleaning was unclear, as housekeeping was not involved.
The facility was found to have extensive wall and ceiling damage in residents' rooms across four floors, with issues such as wet plaster and black mold-like growth. The administrator acknowledged the damage, citing leaks from air conditioning units, showers, and toilets as causes. Despite ongoing repairs, the conditions persisted, indicating a failure to maintain a safe and sanitary environment as per the facility's preventative maintenance policy.
The facility's pest control program was ineffective, with roaches and mice observed in residents' rooms and common areas. Multiple residents reported frequent pest sightings, particularly at night. The administrator acknowledged the issue, despite having a pest control service and reporting system. The Resident Council President confirmed ongoing complaints about pests and additional facility issues.
The facility failed to properly label, date, and store food items in the refrigerator and freezer, and did not have a thermometer inside the freezer. Several food items were found without dates, and expired items were not discarded. The Dietary Manager acknowledged these issues, which could pose health risks to the 163 residents receiving an oral diet.
The facility failed to ensure proper disposal of garbage and refuse, with multiple instances of overfilled dumpsters and open lids observed. This non-compliance with the facility's waste management policy has the potential to affect all 163 residents.
The facility failed to maintain clean and sanitary bathrooms for five residents, improperly disposed of an incontinent brief for one resident, and did not ensure a window screen in another resident's room, leading to unsanitary and unsafe conditions.
The facility failed to ensure that the laundry chutes on the second and fourth floors were locked, posing a significant safety hazard to residents. On both floors, the chutes were found to be unlocked, and staff confirmed that they should be locked to prevent accidents. The Maintenance Director acknowledged the issue, and the Administrator was informed of the need for repairs.
The facility failed to have sufficient PRSCs to meet the psychosocial and mental health needs of residents. Observations and interviews revealed that residents were not receiving adequate support, with only one PRSC available in the morning shift and another resigning soon. The facility's documentation required a PRSC for every 30 participants, but the current staffing was insufficient to meet these needs.
The facility failed to label an opened multi-dose vial and discard an expired opened multi-dose vial, potentially affecting all 86 residents on the 4th and 5th floors. Observations revealed that Tuberculin PPD vials were either not labeled with the open date or were kept beyond the 30-day expiration period. The facility's policies and job descriptions support the requirement for labeling and discarding multi-use vials, but these were not followed.
The facility failed to provide appropriate PPE supplies for two residents with Enhanced Barrier Precautions and failed to display the correct Enhanced Barrier Precaution sign for one resident, affecting all residents reviewed for infection control on two floors. The discrepancy in communication and updating of the list of residents requiring Enhanced Barrier Precautions led to the absence of necessary PPE supplies in the rooms.
The facility failed to maintain the fourth-floor community shower room and the fifth-floor bathroom and day room in a sanitary and good repair condition. Issues included a partially covered toilet water tank, a shower stall with a blackish-brown substance, a non-functional bath-tub faucet, filthy clothes on the floor, a non-functional bathroom light bulb, chipped paint, and dusty ceiling vents. The Maintenance Director and Housekeeping Supervisor acknowledged these issues, but the facility's guidelines were not followed.
An LPN administered morning medications three hours late to four residents, affecting their treatment for conditions like diabetes and hypertension. The facility's policy requires medications to be given within a two-hour window, but there was no documentation of physician notification for the delays.
The facility failed to protect a resident from physical abuse, resulting in serious injuries. A resident was assaulted by another resident, leading to a left hip fracture and a right finger fracture. The incident occurred in a hallway, and staff responded immediately, transferring the injured resident to a trauma hospital for surgical repair. The aggressor had a history of inappropriate behavior and was cognitively intact, while the victim had moderate cognitive impairment and a complex medical history.
Failure to Administer Ordered Antihypertensive Medication and Inaccurate MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received ordered antihypertensive medication as prescribed. The resident is an alert female with diagnoses including COPD, bipolar disorder, hypertension, major depressive disorder, and reflux. Her POS dated 1/13/2026 ordered Amlodipine Besylate 5 mg by mouth in the morning for hypertension, and on 11/09/2025 she also started Lisinopril 5 mg by mouth in the morning for hypertension. The resident reported that she is on two blood pressure medications and stated that on 2/16/2026 she did not receive one of her blood pressure medications because the facility did not have it available, identifying V4 as the nurse on duty. V4 confirmed that one of the resident’s blood pressure medications was not available and stated that she reordered it but did not contact the physician. V4 acknowledged that she documented on the February MAR that the medication was given, even though it was not, and that she did not check the convenience box or follow any procedure beyond reordering the medication. She stated she was not informed of the procedure for when medication is out and was unable to recall which blood pressure medication was missing. The DON (V2) stated that when a medication is out, the nurse is expected to obtain it from the electronic medicine machine or emergency medication cart and notify the physician that the resident did not receive the medication. Review of the February 2026 MAR showed that V4 had marked the medication as administered on 2/16/2026, despite the resident’s report and V4’s admission that the medication was not available, which is inconsistent with the facility’s Medication Administration Policy requiring medications to be administered in accordance with physician orders and medication/treatment errors to be reported and documented.
Improper Refrigerated Food Storage Directly on Walk-In Refrigerator Floor
Penalty
Summary
Surveyors identified a deficiency in food storage practices when, during an observation in the kitchen’s walk-in refrigerator with the Dietary Manager, they noted stacks of boxes of food items with at least one box labeled “pork/cerdo” stored directly on the floor. The Dietary Manager acknowledged during the observation that boxes of food items are required to be stored 6 inches above the floor to prevent food contamination. In a subsequent interview, the Dietary Manager reiterated that all food items should be stored 6 inches above the floor to prevent food contamination and potential foodborne illness. Record review of the facility’s “Sanitation and Food Safety Storage of Refrigerated Foods” policy, revised in 2017, documented that refrigerated food must be stored in a manner that ensures food safety and that food is to be stored six inches above the floor. This failure in following the facility’s policy occurred in a facility with a census of 180 residents, 179 of whom were taking oral nutrition and 1 resident listed as NPO (nothing per mouth).
Verbal Abuse and Demeaning Language Used Toward Residents in Smoking Area
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse by a staff member during a supervised smoking line. A psychiatric rehabilitation services coordinator (V4) was overseeing the smoking line when a miscommunication occurred between the front desk and V4 about which floor’s residents were to go down to smoke. Residents from the fifth floor, including R2 and R3, went to the first floor smoking area after the receptionist paged them. While residents were in line, V4 became upset and used profanity and demeaning language toward them, including statements such as being “sick of this s***,” calling them “f***** kids,” and asking “what are you doing mother f***r.” R2 reported that while he was talking with other residents about energy and people’s character, V4 told him, “Little boy, watch the f*** you are saying,” which he stated made him feel disrespected. Multiple cognitively intact residents corroborated that V4 was verbally aggressive and used derogatory language toward residents in the smoking line. R3 stated that V4 was verbally aggressive toward residents and used derogatory language toward everyone in line, including R2, and that she cursed when the wrong floor came down to smoke. R4, who was severely cognitively impaired, stated that V4 was rude and did not know how to talk to people and “talked crazy all the time.” The facility’s Resident Rights policy requires employees to treat all residents with respect, kindness, and dignity and to provide an environment that preserves dignity and supports a positive self-image. Staff, including the Social Services Director/Administrator-in-Training and the Administrator, acknowledged that calling residents children is demeaning and a dignity issue, and that staff are not expected to verbally abuse residents. The incident constituted a failure to uphold the resident’s right to be free from verbal abuse and to an environment that preserves dignity.
Incorrect Metoprolol Dosage Administered Contrary to Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to administer a prescribed medication at the correct dosage in accordance with the physician’s order, resident’s needs, and facility policy. During a medication pass observation, an LPN (V11) dispensed and administered one whole 25 mg tablet of Metoprolol Tartrate to a resident (R6), despite the medication container label directing that 0.75 of a 25 mg tablet (18.75 mg) be given every 12 hours. Shortly after administration, V11 confirmed she had given a full 25 mg tablet and acknowledged that the resident was supposed to receive 18.75 mg and that she did not follow the doctor’s order. The resident’s active order and MAR both documented Metoprolol Tartrate 25 mg tablets to be given as an 18.75 mg dose twice daily for hypertension. A second LPN (V12) reported that she regularly worked on the unit where the resident resided and, when assigned to this resident, she dispensed the medication from the same container and consistently administered one whole tablet, believing that the whole tablet was 18.75 mg. Upon re-checking the container, V12 recognized that she had been administering 25 mg instead of the ordered 18.75 mg and stated she had not followed the order. The DON (V2) clarified that the order required giving a half tablet plus a quarter tablet of the 25 mg Metoprolol to equal 18.75 mg, and that giving a whole 25 mg tablet did not follow the physician’s order. The resident’s records showed diagnoses including hypertension, tachycardia, oxygen dependence, and a severely impaired cognitive status (BIMS score of 5). Facility job descriptions for RNs and LPNs, as well as the medication administration policy, required medications to be prepared and administered as ordered by the physician, including the right dose, which was not done in this case.
Resident Returns From Community Pass With Razor and Self-Inflicts Forearm Abrasion
Penalty
Summary
The facility failed to ensure a resident’s environment was free from hazardous materials when a resident with a history of mental illness and suicidal ideation obtained and used a razor to harm herself. The resident’s diagnoses included cannabis dependence, alcohol dependence, alcoholic cirrhosis, and depression, and a recent petition for involuntary/judicial admission documented that she was reasonably expected, unless treated on an inpatient basis, to engage in conduct placing herself or others at risk of physical harm, and that she had exhibited suicidal ideation with an attempt to cut or slit her wrist. On admission to the hospital, records described a wide linear abrasion on the left forearm beginning at the base of the left thumb and extending to the mid forearm on the radial side, approximately 1.5 inches in width, caused by a razor blade. A wound inspection form from the same date documented a small cut wound and abrasion on the left wrist. During the survey, a CNA reported that while performing night rounds she observed the resident in her room scraping her arm with a razor. When questioned, the resident stated she wanted to go to the hospital to be with her boyfriend and that she had brought the razor into the facility after being out on a community pass. The CNA noted a long scratch with bleeding on the resident’s forearm. The nurse supervisor confirmed that the resident reported obtaining the razor outside the facility and returning with it after a community pass, and he showed a picture of the razor, which had a straight blue handle with a brand label. The central supply staff member stated that the razors purchased for the facility had a curved handle and no brand label and confirmed that the razor used by the resident was not one of the facility’s razors. The administrator’s email correspondence to the psychiatrist and ombudsman documented that the resident had brought razors into the facility and harmed herself, confirming that the resident had access to a hazardous item despite her known risk for self-harm.
Failure to Prevent Resident-on-Resident Physical Abuse in Elevator
Penalty
Summary
A resident with a history of epilepsy, cerebral infarction, and moderate cognitive impairment was physically attacked by another resident with severe cognitive impairment and multiple behavioral diagnoses while in a crowded elevator. The aggressor, a male resident with a history of behavioral and emotional disorders, struck the victim in the head multiple times with a cane following a verbal altercation. Witness statements confirm that verbal threats were made prior to the physical assault. The victim sustained a scratch on the head and was subsequently sent to the hospital, where she was diagnosed with a minor closed head injury and experienced ongoing emotional distress and anxiety related to the incident. The facility's records indicate that the victim had a care plan noting a history of suspected abuse and factors increasing her susceptibility to abuse or neglect. Despite this, the facility failed to prevent the assault, and the victim reported feeling unsafe and targeted by other residents following the incident. The aggressor was sent for psychiatric evaluation but returned to the facility before leaving against medical advice. The facility's abuse prevention policy states a commitment to protecting residents from abuse by anyone, but this policy was not effectively implemented in this case.
Failure to Provide Adequate Running and Hot Water
Penalty
Summary
The facility failed to provide adequate running water and hot water to its residents, affecting at least four individuals and potentially impacting all 181 residents. Multiple residents reported ongoing issues with low water pressure, lack of hot water, and non-functioning toilets, particularly on the upper floors. Observations by surveyors confirmed that water from faucets and showers was consistently cold, with measured temperatures ranging from 58 to 62 degrees Fahrenheit, and that toilets often would not flush due to insufficient water pressure. Residents described significant disruptions to their daily hygiene routines, with some unable to shower for extended periods and resorting to sponge baths or storing water in containers for basic washing. Staff interviews corroborated these accounts, noting that they were unable to provide proper showers and had to inform residents about the cold water, sometimes encouraging them to wash at the sink instead. Maintenance logs documented repeated complaints about cold water, low pressure, and non-flushing toilets over several weeks, with issues persisting across multiple floors. Facility leadership and maintenance staff acknowledged the ongoing plumbing problems, attributing them to issues with water valves and city water supply access. Despite awareness of the problem and communication with external plumbers and city officials, the facility continued to experience inadequate water service, as evidenced by maintenance records and direct observations by surveyors. The deficiency resulted in residents being unable to maintain personal hygiene and staff being unable to perform essential care tasks as expected.
Pest Presence and Unsanitary Oven Conditions in Kitchen
Penalty
Summary
Surveyors observed a brown bug, identified by the Dietary Manager as likely a roach, crawling on the sink across from the oven in the kitchen. Additionally, the oven was found to have a brown dried substance on its doors and inside, along with black particles present within the oven. The Dietary Manager stated that the oven was last cleaned during a deep cleaning the previous Wednesday and that cleaning and sanitizing are typically performed after each use to help with pest control. The Director of Nursing expressed concern about the presence of pests in the kitchen, noting the risk of germs and bacteria in food preparation areas. The facility's census report documented 181 active residents at the time. Facility policies require food to be stored, prepared, and distributed under sanitary conditions and mandate pest control to prevent the spread of disease.
Failure to Protect Residents from Abuse During Altercation
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in an altercation between them in an elevator. One resident, with a history of psychosis, hallucinations, Parkinsonism, and anxiety disorder, and another resident, with diagnoses including diabetes, cerebral infarction, acute kidney failure, and opioid use, were both cognitively intact according to their BIMS scores. The incident began when one resident refused to allow another resident onto the elevator, leading to a verbal confrontation and subsequent physical altercation. Multiple accounts from those present provided conflicting descriptions of who initiated the physical contact, but it was confirmed that both residents sustained minor injuries during the event. A nurse assessed the residents after the altercation and noted that one had a bite mark on her hand, with broken skin, which required medical attention. An order for antibiotics was given to prevent infection due to the bite. The facility's policy affirms residents' rights to be free from abuse, including physical injury inflicted by non-accidental means. The incident demonstrated a failure to ensure residents were protected from abuse by others within the facility, as required by policy.
Resident Suffers Physical Abuse from Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse, as evidenced by an incident involving two residents. One resident, identified as R132, slapped another resident, R40, on the face, causing R40 to fall and sustain pain in the left elbow, back, and neck. The incident occurred while R40 was waiting in line for medication, and R132 approached the medication cart demanding immediate service. Despite the nurse's attempt to manage the situation, R132 became aggressive, leading to the physical altercation. R40, who is cognitively intact and requires supervision with walking, reported feeling scared and shaken after the incident. The resident described the pain as severe, with a pain level of 8, and noted that the pain was exacerbated by a previous shoulder replacement surgery. R40 was assessed by the nurse and given pain medication but declined to go to the hospital. The incident was witnessed by the nurse and another staff member, and both residents were separated following the altercation. The facility's Abuse Prevention Program policy affirms the residents' right to be free from abuse, including physical abuse, which is defined as the infliction of injury that requires medical attention. Despite this policy, the incident highlights a failure to protect R40 from physical abuse by another resident. The facility was aware of R132's history of aggressive behavior, yet the altercation still occurred, resulting in physical harm and emotional distress for R40.
Deficiencies in Kitchen Hygiene and Food Labeling
Penalty
Summary
The facility failed to ensure proper food safety and hygiene practices in the kitchen, which could potentially affect all 175 residents receiving food prepared there. Observations revealed that kitchen staff, including a dietary aide, were not wearing appropriate hair coverings. Specifically, staff members with facial hair, such as mustaches and beards, were not using beard guards or masks as required by the facility's policy. The Dietary Director initially stated that only hair on the head needed to be covered, but later acknowledged the policy required facial hair to be covered and instructed staff to use face masks until proper beard protectors could be ordered. Additionally, the facility did not adhere to proper hand hygiene protocols in the dishwashing area. A dietary aide was observed handling both dirty and clean dishes without performing hand hygiene between tasks. The facility's policy requires that if only one person is working in the dish room, they must change gloves and wash hands when transitioning from handling dirty to clean items. The Dietary Director confirmed the importance of this practice to prevent cross-contamination and potential illness among residents. The facility also failed to properly label and date food items in storage. Several opened food items in the prep and walk-in refrigerators were found without labels indicating the date they were opened or their use-by dates. This included items such as Italian dressing, thickened apple juice, shredded cheese, sliced cheese, and prepared chili-like material. The facility's policy mandates that all prepared and opened foods be labeled with preparation and discard dates to ensure food safety and quality. The lack of proper labeling could lead to the use of expired or unsafe food products, posing a risk to resident health.
Failure to Properly Bag Soiled Linens
Penalty
Summary
The facility failed to adhere to its linen handling policy, which requires soiled linens to be placed inside closed plastic bags before being dropped into the laundry chute. During an inspection, a surveyor observed loose soiled incontinence pads, towels, and bed sheets in the laundry chute, which were not bagged as per the facility's policy. The Laundry Aide confirmed that staff should bag dirty linens before placing them in the chute, acknowledging that it is unsanitary to do otherwise. The Director of Nursing/Infection Preventionist also stated that improperly bagged linens could spread bacteria and contaminate other areas, potentially affecting both staff and residents. The facility's policy emphasizes preventing the spread of microorganisms by ensuring soiled articles do not contact clean areas, yet this protocol was not followed, affecting all 175 residents in the facility.
Failure to Display [NAME] Consent Decree Posters
Penalty
Summary
The facility failed to display posters informing residents of their rights to explore or decline community transition under the [NAME] Consent Decree, as well as their right to be free from retaliation regardless of their decision. This deficiency was observed during a survey conducted on 03/04/2025, where no signs or posters related to the [NAME] Consent Decree were found in public and accessible locations throughout the facility, including the main entrance, dining rooms, and various floors. Staff members, including nurses and the Psychiatric Rehabilitation Services Coordinator, were unaware of the facility's partnered agencies for community transition and could not locate any relevant signage. The Social Service Director acknowledged that the facility should have flyers pertaining to the [NAME] Consent Decree and transition agency on every floor, but staff were unable to locate them when asked. The facility's Pre-Admission Screening and Resident Review (PASRR) policy, last revised in December 2023, documents the facility's role in submitting census data to the IDPH appointed company to comply with the [NAME] Consent Decree but does not include how the facility educates [NAME] Class Members about their rights. The facility did not provide any other policy related to the [NAME] Consent Decree, indicating a lack of compliance with the Illinois Administrative Code and the State Operations Manual Appendix PP requirements.
Failure to Document Advance Directives and Code Status
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding advance directives by not obtaining a physician's order for the code status of four residents. Specifically, residents R44, R63, R129, and R332 did not have documented physician orders for their code status, as required by the facility's policy. Additionally, the comprehensive care plans for residents R44 and R63 did not address their advance directives or code status. Interviews with the Social Service Director revealed that the facility's policy mandates that residents' code status should be ordered by a physician, documented on the residents' face sheets, and included in their care plans. Resident R44, who is cognitively intact, had a blank advance directive section on their face sheet and no physician order for code status in their order summary report. Similarly, resident R332, also cognitively intact, had no physician order for code status. Resident R63, with multiple diagnoses including dementia and heart failure, had no documented advance directives in their medical records. Resident R129, with a moderate cognitive impairment, had a POLST form indicating a wish for full treatment and CPR, but their order summary report did not include any order for advanced directives. These deficiencies highlight the facility's failure to ensure that residents' advance directives are properly documented and integrated into their care plans as per their policy.
Failure to Conduct Required PASARR Evaluations
Penalty
Summary
The facility failed to refer nine residents to the appropriate state-designated authority for a Level II Preadmission Screening and Resident Review (PASARR) evaluation. This deficiency was identified during a survey where nine residents were reviewed for PASARR compliance. The residents involved had various mental health diagnoses, including bipolar disorder, schizoaffective disorder, schizophrenia, and major depressive disorder, which necessitated a Level II PASARR evaluation to ensure appropriate care and services. For instance, Resident 22 was admitted with multiple mental health diagnoses, including major depressive disorder and bipolar disorder, but there was no documented follow-up screening after the initial PASARR Level II outcome. Similarly, Resident 59, who had severe mental health conditions requiring routine follow-up with a mental health professional, also lacked documented follow-up screening. Resident 70, diagnosed with paranoid schizophrenia, did not receive the necessary follow-up screening to address their psychiatric support needs. The facility's Director of Admissions, identified as V12, acknowledged the oversight in scheduling re-evaluations and the lack of access to request PASARR Level II screenings via the Maximus system. This resulted in several residents not being re-evaluated after their short-term PASARR approvals expired or after new mental health diagnoses were added. The facility's policy required compliance with federal and state standards for PASARR assessments, but the failure to adhere to these standards led to the deficiency identified in the survey.
Failure to Conduct Smoking Assessments and Care Plans for Independent Smokers
Penalty
Summary
The facility failed to complete a quarterly smoking assessment for a resident, identified as R1, and did not have individualized smoking care plans for independent smokers. R1, who has a diagnosis of nicotine dependence and is cognitively intact, was observed assisting other residents by lighting their cigarettes in the smoking patio. Despite R1's involvement in smoking activities, the facility did not provide a recent Smoking Risk Review Assessment for R1, nor did they have a comprehensive care plan addressing R1's nicotine dependence or smoking habits. The facility's Director of Nursing acknowledged that Smoking Risk Review Assessments should be conducted quarterly, yet R1 and other independent smokers did not have updated assessments or care plans. The facility's smoking safety policy lacked specific guidelines on the frequency of these assessments. Additionally, the facility's care plan policy mandates comprehensive assessments and individualized care plans for all residents, but this was not adhered to for the independent smokers, including R1, R8, R44, R85, R129, and R168.
Failure to Label Insulin and Medication Borrowing
Penalty
Summary
The facility failed to properly label open insulin vials and pens for four residents across two medication carts. During an inventory of the second-floor south medication cart, it was observed that several insulin pens and vials, including Basaglar Kwik Pen, Lantus, Humalog, and Insulin NPH Isophane and Regular Subcutaneous 70/30, were not labeled with the date they were opened. This oversight was confirmed by the Licensed Practical Nurse (LPN) and the Assistant Director of Nursing (ADON), who acknowledged that all medications should be in their original bottles with appropriate labels and that insulins should be dated when opened. Additionally, the report highlights an incident where an LPN borrowed iron supplement pills from another medication cart due to a lack of stock on their own cart. The Director of Nursing (DON) stated that medications supplied to one resident should not be administered to another, and the facility has an emergency insulin box for such situations. The facility's policy mandates that multi-use medications must be dated when opened and administered according to the physician's order, ensuring the right resident, medication, dosage, route, and time.
Deficiency in Menu Adherence and Portion Control
Penalty
Summary
The facility failed to prepare food items listed on the menu for pureed diets and did not prepare adequate food portions as documented on the recipe. During an observation of the lunch tray line, it was noted that residents on pureed diets were served mashed potatoes instead of pureed rice and pureed spinach instead of pureed oriental vegetables, which were not part of the regular menu. The Dietary Manager confirmed that the pureed diets should have received the same food as the regular diets but in pureed form, emphasizing the importance of menu variety and dignity for residents. Additionally, the facility did not provide uniform portions of ham as required by the recipe. The cook had to hand-cut the ham due to the lack of a slicer, resulting in non-uniform slices that did not meet the 3-ounce portion size specified in the recipe. The Registered Dietitian expressed concern that not following the menus and recipes could lead to residents not receiving the correct nutrition, potentially making their diet nutritionally inadequate and leading to weight loss over time.
Inadequate Food Preparation for Special Diets
Penalty
Summary
The facility failed to prepare food in the appropriate consistency for residents on mechanical soft/ground and pureed diets. During an observation, it was noted that the Sweet and Sour Chicken served to residents on mechanical soft/ground diets contained large chunks of chicken instead of being ground, as required. The Dietary Manager confirmed that the chicken should have been ground to prevent potential choking hazards. Additionally, during the preparation of pureed ham, the blender used was ineffective, resulting in a final product that was not smooth and contained large particles, which required chewing. This inconsistency in food preparation was acknowledged by the Registered Dietitian, who emphasized the importance of proper food consistency to prevent choking in residents with chewing or swallowing difficulties. The facility's documentation, including job descriptions, diet spreadsheets, recipes, and policies, indicated that food should be prepared to meet individual dietary needs, with specific instructions for ground and pureed consistencies. However, the facility did not adhere to these guidelines, as evidenced by the improper preparation of meals for residents on special diets. The failure to provide food in the correct form poses a risk to residents who require modified diets due to chewing or swallowing issues.
Failure to Provide Prescribed Double Portions in Therapeutic Diets
Penalty
Summary
The facility failed to provide double portions as part of the therapeutic diet prescribed by the physician for 19 residents. During an observation of the tray line, it was noted that the cook, identified as V19, was portioning food onto residents' trays for lunch. V19 stated that the serving size for regular diets included a 6-ounce ladle of Sweet & Sour Chicken, a #8 scoop (4-ounces) of rice, and a 4-ounce ladle of Stir Fry Oriental Vegetables. However, for residents with orders for double portions, only the rice was doubled to 8 ounces, while the protein and vegetables remained at the standard portion size. This practice was inconsistent with the prescribed therapeutic diet orders. The Registered Dietitian, V23, confirmed that a double portion order is considered a therapeutic diet if ordered by a physician, often to promote weight gain or due to food preferences. V23 stated that a double portion should mean doubling everything on the plate, including the protein, starch, and vegetables. The failure to provide double portions as ordered was acknowledged by V23, who noted that this might be why residents were still hungry and requesting more food after meals. The facility's policy documents also indicated that double portions should be served as double servings of food on the plate, which was not adhered to in this instance.
Failure to Provide Pneumococcal Vaccination Education and Assessment
Penalty
Summary
The facility failed to provide education on the benefits and potential side effects of pneumococcal vaccinations to eligible residents or their representatives. Additionally, the facility did not assess the eligibility of five residents for pneumococcal vaccinations, nor did it offer the vaccinations to them. These residents, who were cognitively intact and had various medical conditions such as diabetes, chronic obstructive pulmonary disease, and heart failure, had no documentation in their electronic health records indicating that they were assessed for vaccination eligibility or provided with the necessary education. The facility's policy on pneumococcal immunization was outdated and did not align with the current CDC Adult Vaccination Schedule. The policy only recommended a second dose of the vaccine for individuals over 65 who received their first dose before turning 65, without considering the updated guidance on PCV15, PCV20, or PCV21. The Director of Nursing/Infection Preventionist indicated that the corporate nurse was responsible for updating these policies, and that education and consent for pneumococcal vaccination were only provided to residents over a certain age or those who were immunocompromised, which was not in line with current CDC recommendations.
Failure to Serve Meals Simultaneously Affects Resident Dignity
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity during meal service by not serving meals to all residents sitting at the same table simultaneously. This deficiency was observed during a dining session where residents were left waiting for their meals while others at the same table were already eating. Specifically, Resident 43 was observed watching their tablemate eat without having a meal tray in front of them, and expressed hunger. Similarly, Residents 27 and 125 were observed waiting for their meals while their tablemates were already eating, and they also expressed their desire to be served at the same time as their tablemates. The facility's policy titled 'The Dining Experience' states that meals should be served at approximately the same time to all clients sitting at a table, which was not adhered to in this instance. The Registered Dietitian confirmed that residents sitting at the same table should receive their meals simultaneously to avoid dignity issues. The residents involved had various medical conditions, including chronic obstructive pulmonary disease, diabetes, and schizoaffective disorder, with varying levels of cognitive impairment as indicated by their BIMS scores. The failure to serve meals simultaneously affected the dignity and dining experience of the residents involved.
Medication Administration Deficiency
Penalty
Summary
The facility failed to adhere to the five rights of medication administration for a resident, identified as R151, during a survey. On March 4, 2025, a Licensed Practical Nurse (LPN), referred to as V5, was observed administering insulin to R151 using a vial labeled with another resident's name, R59. The insulin vial was not marked with an open or expiration date, which is against the facility's policy. V5 admitted to using R59's insulin because R151 had run out and the LPN did not want to retrieve insulin from the emergency box due to feeling unwell. This action was contrary to the facility's policy, which prohibits borrowing medication from another resident and mandates proper labeling of multi-use vials. The Director of Nursing (DON), identified as V2, confirmed that all insulin vials and pens should be labeled with the date opened and a discontinue date to ensure effectiveness and prevent potential harm. The facility's medication administration policy clearly states that medications supplied to one resident should not be administered to another, and all medications must be properly labeled. The failure to follow these protocols could lead to adverse reactions and ineffectiveness of the medication, posing a risk to resident safety.
Deficiencies in Oxygen Therapy Management
Penalty
Summary
The facility failed to ensure proper labeling, dating, and storage of oxygen tubing and nebulizer masks for residents receiving oxygen therapy. During observations, it was noted that the oxygen tubing for several residents was not labeled or dated, and nebulizer setups were not stored in bags to prevent contamination. Additionally, there was a lack of oxygen signage at the entrances of rooms where residents were receiving oxygen therapy, which is a requirement to alert staff and visitors of the oxygen use. One resident, diagnosed with Generalized Anxiety Disorder, Heart Failure, and Chronic Obstructive Pulmonary Disease (COPD), was observed with oxygen tubing that was not labeled or dated, and a nebulizer setup that was not stored in a bag. Another resident with Dementia, Heart Failure, and Obstructive Pulmonary Disease was found with unlabeled oxygen tubing, and the flow rate of the oxygen was not consistent with the physician's orders. A third resident, with multiple diagnoses including Seasonal Allergic Rhinitis, Cardiomyopathy, and COPD with Acute Exacerbation, had their nasal cannula on the floor and the nebulizer setup not stored properly. The Director of Nursing (DON) stated that the expectation is for nursing staff to check oxygen saturation, ensure oxygen tubing and nebulizers are dated, and store them in bags when not in use. The facility's policy requires oxygen equipment to be changed and dated weekly and as needed, and for oxygen signage to be posted when oxygen is in use. These deficiencies in following the facility's policies and procedures for oxygen therapy and equipment management were observed during the survey.
Deficiency in COVID-19 Vaccination Documentation and Education
Penalty
Summary
The facility failed to properly document COVID-19 vaccination information and education for three residents, leading to a deficiency in compliance with health regulations. Specifically, the electronic health records (EHR) of three residents, identified as R61, R156, and R332, were reviewed and found lacking in documentation regarding their COVID-19 vaccination status and the education provided about the vaccine's benefits and potential risks. R61 and R156 had documentation indicating they refused the vaccine, but there was no record of education being provided. For R332, there was no documentation of whether the vaccine was administered, refused, or contraindicated, nor was there any record of educational efforts. Additionally, no COVID-19 consent forms were found in the EHRs of these residents. The Director of Nursing/Infection Preventionist (V2) confirmed that there was no documentation of education being provided to the residents, as it was conducted verbally. The residents involved were cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 15, indicating they were capable of understanding the information. The lack of documentation is a violation of the Department of Health & Human Services Centers for Medicare & Medicaid Services guidelines, which require that residents' medical records include documentation of education about the COVID-19 vaccine and the residents' decisions regarding vaccination. This deficiency was identified during a survey conducted on March 5th and 6th, 2025.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, resulting in a serious incident involving two residents. On January 27, 2025, a resident (R2) physically attacked another resident (R1) in their shared room. R2, who had a history of behavioral symptoms related to severe mental illness, became verbally and physically aggressive towards R1 without provocation. R1 sustained an abrasion under the left eye and was transferred to the hospital for evaluation and treatment. The facility's final investigation report documented that R2 refused to be interviewed and left the facility against medical advice. The incident was reported to the facility administrator by a nurse who witnessed the commotion and intervened to separate the residents. The nurse observed R2 throwing R1 into the hallway and immediately took action to protect R1 by escorting her to the nurse's station. The facility notified both residents' representatives, the physician, and the police about the incident. Despite these actions, R2 managed to leave the facility before the police arrived, and R1 was sent to the hospital for safety precautions and treatment of her injuries. The facility's abuse prevention program policy, dated 2011, emphasizes the right of residents to be free from abuse and neglect. However, the facility failed to identify and mitigate the risk of potential mistreatment, as evidenced by R2's escalating behavior and verbal threats prior to the physical attack. The registered nurse had been informed by R2 of her dissatisfaction with the roommate situation and her intent to cause harm, yet the situation was not adequately addressed to prevent the subsequent assault on R1.
Resident Injury Due to Physical Abuse in Elevator
Penalty
Summary
The facility failed to protect a resident from physical abuse, resulting in an unwitnessed fall and injury. The incident involved two residents in an elevator, where one resident was pushed by another, leading to a fall and a fracture of the left tibial plateau. The injured resident was subsequently sent to a local hospital for evaluation and treatment. The facility's preliminary incident investigation confirmed that the resident was pushed, causing the fall. The resident who was pushed had a medical history that included a displaced fracture of the left tibia, type 2 diabetes mellitus, muscle weakness, paranoid schizophrenia, and depression. The resident was able to communicate in English as a second language and recalled the incident, stating that they were pushed by another resident in the elevator. The resident who pushed had a history of hemiplegia, hemiparesis, aphasia, and restlessness, and was known to be verbally and physically aggressive. The facility's abuse prevention policy affirms the right of residents to be free from abuse, including physical abuse. Despite this policy, the incident occurred, and the facility's staff, including the administrator and the director of nursing, acknowledged the event as a form of abuse. The incident was reported to local law enforcement and the residents' physicians, and the aggressive resident was sent for a psychiatric evaluation.
Failure to Administer Correct Medication Dosage
Penalty
Summary
The facility failed to administer the correct dosage of a prescribed medication to a resident, identified as R3, according to the physician's order. R3, who has a medical history including chronic obstructive pulmonary disease, bipolar disorder, anemia, progressive vascular leukoencephalopathy, and anogenital herpes viral infection, was prescribed 800 mg of Ibuprofen every eight hours as needed for pain. However, on the observed date, R3 was administered only 600 mg by an LPN, who used three 200 mg tablets from the facility's house stock instead of the prescribed 800 mg. The LPN was unsure about administering four tablets to make up the 800 mg dose, as the medication usually comes in a single 800 mg tablet, which had not been refilled since November 30th. The deficiency was further highlighted when the LPN signed out that 800 mg had been administered, despite only giving 600 mg. The Director of Nursing (DON) confirmed that medications should be administered according to the physician's order and that it is unacceptable for a nurse to alter the dosage without a physician's directive. The facility's policies on medication administration and physician orders emphasize the importance of adhering to the prescribed dosage. The Nurse Practitioner also confirmed that changing medication dosage without a physician's order is inappropriate. The facility's failure to ensure the correct dosage was administered as per the physician's order constitutes a deficiency in care provided to R3.
Sanitation and Personal Item Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain proper sanitation in the kitchen, which could potentially lead to food-borne illnesses affecting all 177 residents receiving an oral diet. During a tour of the kitchen, the surveyor and the Dietary Manager observed poor cleaning practices, including food and trash on the floor, soiled floors, stagnant water, and dirty walls. Additionally, a staff coat was found hanging on a food rack in the dry storage area, which the Dietary Manager acknowledged should not be there. The facility's policy requires non-refrigerated foods and other dry goods to be stored in a clean, dry area free from contaminants. Further observations revealed personal food items belonging to a Dietary Aide stored improperly in the kitchen, which the aide admitted was due to a lack of time to put it away. The Housekeeping Director confirmed that the kitchen staff, not the housekeeping department, is responsible for cleaning the kitchen. The facility's policies emphasize the importance of maintaining sanitation to prevent foodborne illnesses and cross-contamination, yet the Service Inspection Report highlighted significant cleaning deficiencies in the kitchen, including stagnant water and broken tiles, which could attract pests.
Improper Garbage Disposal and Maintenance
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as evidenced by the observation of a dumpster with broken lids and overflowing trash. This issue was identified during a tour of the dumpster area by a surveyor and a dietary aide. The dietary aide mentioned that the garbage pickup occurs every other day and that the dumpster should have been emptied on the day of observation. The aide also indicated that the maintenance director is responsible for repairing the dumpster lids, which were broken, potentially attracting rodents to the facility. Further interviews revealed that the maintenance director acknowledged responsibility for repairing or replacing broken dumpster lids but stated that they do not regularly check the dumpster area unless an issue is reported. The housekeeping director confirmed that the housekeeping staff is responsible for maintaining the cleanliness of the dumpster area and was aware of the missing lids for about two weeks. The facility's pest control policy and job descriptions for the environmental services/housekeeping director and maintenance director outline responsibilities for maintaining the dumpster area in good repair to prevent rodent attraction.
Ineffective Pest Control and Poor Kitchen Sanitation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in an infestation of insects in the kitchen area. During a survey, the kitchen was observed to have poor cleaning practices, with food and trash on the floor, stagnant water, and soiled walls. Flies, including fruit flies and gnats, were seen in the food preparation area and the pots and pans area. The Dietary Manager acknowledged the presence of flies and roaches in the kitchen and mentioned that pest control had visited two weeks prior, but the issue persisted. Interviews with various kitchen staff, including dietary aides and cooks, confirmed the daily presence of roaches and flies in the kitchen. The Maintenance Director, responsible for coordinating pest control visits, stated that pest control should address pest issues during their visits. However, there was uncertainty about whether the pest control company had effectively treated the kitchen for flies. The Maintenance Director was aware of structural issues, such as holes in the walls, which could allow pests to enter, but these had not been repaired. The facility's documentation highlighted ongoing cleaning issues in the kitchen, with reports noting poor cleaning in the dish room and main kitchen area, stagnant water, broken tiles, and missing grout. The facility's policies and job descriptions emphasized the importance of maintaining cleanliness and sanitation to prevent pest infestations. However, the responsibility for cleaning the kitchen was unclear, with the housekeeping department not involved, leaving it to the kitchen staff. Despite these policies, the facility's pest control program was ineffective, leading to the observed deficiencies.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents and staff on four of the five resident floors. During a tour of the facility, extensive wall damage was observed in multiple residents' rooms, including damage at the wall/floor junctions and ceiling plaster damage. Some rooms had wet and collapsing plaster with black mold-like growth, indicating long-standing water damage issues. Residents reported that these conditions had persisted for a significant period. The facility's administrator acknowledged awareness of the wall damage, attributing it to leaking air conditioner units, showers, and toilets. Despite having a maintenance crew working on repairs, including replacing air conditioning units and recaulking showers, the issues remained unresolved at the time of the survey. The facility's preventative maintenance policy outlines regular inspections to ensure equipment and furnishings are in good repair, but the observed conditions suggest a failure to adhere to these guidelines.
Ineffective Pest Control Program in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of insects and rodents on five of the six floors. Observations during a facility tour revealed live and dead roaches in multiple residents' rooms, including R9, R12, R15, R18, and R22. Mouse droppings were also found in several rooms, such as R12 and R15. Residents, including R12, R15, R18, R16, R17, and R3, reported frequent sightings of roaches and mice, particularly at night. The dietary area in the basement was also affected, with roaches observed under the dishwasher and sink countertops, and mouse droppings found in the dry food storage room. The laundry service soiled linen storage room also had a live roach present. The facility's administrator, V1, acknowledged the issue, stating that despite having a pest control service and a reporting system in place, the reports did not reflect the sightings of roaches and mice. The Resident Council President, R23, confirmed that residents have been complaining about the pest problem and additional issues such as wall damage and leaks. The facility's pest control policy aims to prevent or control insects and rodents from spreading disease, with the responsibility assigned to the Administrator and Environmental Services.
Deficiencies in Food Labeling, Storage, and Temperature Monitoring
Penalty
Summary
The facility failed to ensure proper labeling, dating, and storage of food items in the refrigerator and freezer, as well as the presence of a thermometer inside the freezer. During an inspection, the surveyor observed several food items in the walk-in refrigerator and freezer that were not labeled with dates indicating when they were stored. Specifically, a box of chicken base cups had an unreadable date, and various other items such as pizza puffs, chicken breast patties, and turkeys were not labeled with storage dates. Additionally, expired food items, including a bag of frozen seasoned mashed potatoes and a box of Thick and Easy Shaped Pureed frozen foods, were found in the freezer. The facility's Dietary Manager (V8) acknowledged these issues and stated that it is the responsibility of the kitchen staff to label and monitor food items to prevent residents from getting sick due to expired or improperly stored food. Furthermore, the surveyor noted the absence of a thermometer inside the freezer, which V8 confirmed should be present to ensure accurate temperature monitoring in case the external thermometer fails. A thermometer was later observed inside the freezer with an acceptable temperature reading. The facility's policies on food storage, food preparation, and food safety guidelines were reviewed and found to require proper labeling, dating, and monitoring of expiration dates for all food items. The policies also mandated the use of refrigerator/freezer thermometers to check temperatures. The Dietary Manager admitted that the oversight in labeling and monitoring food items, as well as the absence of a thermometer inside the freezer, could lead to potential health risks for the 163 residents receiving an oral diet. The facility's failure to adhere to these policies resulted in the observed deficiencies during the survey.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed during a survey. On multiple occasions, the outside dumpsters were found overfilled with trash bags, causing the lids to remain open. Specifically, on one occasion, a red dumpster was overfilled, and another dumpster had its middle lid open. Additionally, a plastic trash bag containing charcoals was found sitting on the ground next to the dumpster. The Dietary Manager acknowledged the issue, stating that the garbage disposal company empties the dumpsters daily, but staff had overfilled them over the weekend. The Dietary Manager also confirmed that open dumpster lids could attract rodents. Further observations revealed that the issue persisted, with two white trash bags overfilling a dumpster, causing its lid to remain open. The Maintenance Director stated that staff conduct rounds to check the dumpsters, ensuring they are not overfilled and that the lids are closed. However, the facility's policy on waste management, which mandates that plastic liners be tied and placed inside the dumpster with the lids kept closed, was not adhered to. This failure has the potential to affect all 163 residents residing in the facility.
Failure to Maintain Cleanliness and Safety in Resident Areas
Penalty
Summary
The facility failed to ensure that five residents had clean and sanitary bathrooms. Observations revealed human feces on the walls of the bathrooms used by these residents. Interviews with residents confirmed the unsanitary conditions, with one resident expressing that the bathroom is always messy and another stating that the feces in the bathroom was not theirs and was gross. The facility's housekeeping staff acknowledged the issue and stated that it was their responsibility to clean the bathrooms, but the problem persisted over multiple days of observation. The facility's policies and job descriptions clearly outline the responsibility of housekeeping staff to maintain cleanliness, but these were not adhered to in this instance. Additionally, the facility failed to ensure that an incontinent brief was properly disposed of for one resident. A soiled brief was left on the floor of the resident's room, emitting a foul smell. The resident reported that a CNA had left the brief on the floor and did not return to dispose of it properly. The LPN and CNA involved acknowledged that this was not acceptable practice and not in line with the facility's policies on incontinence care and infection control. The facility's policies emphasize the importance of maintaining a clean environment and proper disposal of biohazardous waste, but these were not followed in this case. Furthermore, the facility failed to ensure that one resident had a screen in their bedroom window. The absence of a window screen allowed flies to enter the resident's room, which was observed on multiple occasions. The Maintenance Director confirmed that all resident windows should have screens to prevent insects from entering and acknowledged that it was their responsibility to ensure this. The facility's job descriptions for maintenance staff outline the responsibility to maintain the building in a safe and comfortable manner, but this was not upheld in this instance.
Unlocked Laundry Chutes Pose Safety Hazard
Penalty
Summary
The facility failed to ensure that the laundry chutes on the second and fourth floors were locked, posing a significant safety hazard to residents. On the fourth floor, the laundry chute was observed to be unlocked, and a CNA confirmed that it should be locked to prevent residents from falling and injuring themselves. The Maintenance Director acknowledged that the chute could not lock due to a broken latch and cylinder, which required replacement. Similarly, on the second floor, the laundry chute was also found to be unlocked, and a CNA confirmed that it should normally be locked but was unable to secure it at the time of observation. The facility's policy on supervision and safety emphasizes the importance of maintaining an environment free from hazards and ensuring resident safety through ongoing employee training. Despite this policy, the unlocked laundry chutes on both floors presented a clear risk to the residents. The Administrator was informed of the issue and acknowledged the need for maintenance to address the problem to prevent potential accidents. The facility census at the time included 40 residents on the second floor and 44 residents on the fourth floor, all of whom were potentially affected by this safety lapse.
Insufficient Psychiatric Rehabilitation Services Coordinators
Penalty
Summary
The facility failed to have sufficient Psychiatric Rehabilitation Services Coordinators (PRSC) to meet the individualized psychosocial and mental health needs of residents. The facility census was 163 residents, with 49 residents diagnosed with Severe Mental Illness (SMI). Observations revealed that residents were not receiving adequate psychosocial support, as evidenced by residents sitting with flat affect and stating they had not spoken with any Counselor or PRSC in a while. Interviews with nursing staff confirmed the absence of social services staff on the floor. Only one PRSC was available in the morning shift, responsible for 84 residents, while another PRSC, who was resigning soon, was responsible for 79 residents in the afternoon shift. The facility's Social Services Director acknowledged the shortage and mentioned efforts to hire more PRSCs, but the current staffing was insufficient to meet the residents' needs. The facility's documentation indicated that a PRSC should provide a stable therapeutic relationship, coordinate psychiatric rehabilitation services, monitor residents' compliance with treatment plans, and provide active listening and behavioral intervention. Additionally, the facility's administrative code required a PRSC for every 30 participants. The deficiency was highlighted by the lack of sufficient PRSCs to provide the necessary psychosocial services to the residents, as mandated by the facility's policies and administrative code.
Failure to Label and Discard Expired Multi-Dose Vials
Penalty
Summary
The facility failed to label an opened multi-dose vial and discard an expired opened multi-dose vial, which has the potential to affect all 86 residents on the 4th and 5th floors. During an observation of medication storage on the 4th floor, a house stock vial of Tuberculin PPD was found opened without a label indicating when it was opened. The label on the tuberculin states that it should be discarded 30 days after opening. An LPN confirmed that the purpose of labeling the Tuberculin PPD is to ensure it is discarded after 30 days to maintain test accuracy. Similarly, on the 5th floor, another house stock vial of Tuberculin PPD was found with an open date that was more than 30 days old. The LPN on duty acknowledged that the vial was expired and stated that it would be reported to the DON and discarded immediately. The DON confirmed that Tuberculin PPD vials should be dated once opened and discarded after 30 days. The facility's policies and job descriptions support the requirement for labeling and discarding multi-use vials. The Medication Administration Policy and the MEDICATION PASS: PROCESS AND PROCEDURE both state that multi-use vials and house stock liquids must be dated when opened. The Resident Rights policy emphasizes providing an environment that preserves dignity and contributes to a positive self-image. The LPN and Director/Assistant Director of Nursing job descriptions include ensuring an adequate supply of house stock medications and making rounds to ensure acceptable standards are met. Despite these policies, the facility failed to adhere to the labeling and discarding requirements, potentially affecting the accuracy of medical tests for the residents.
Failure to Provide PPE and Correct Signage for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to provide appropriate Personal Protective Equipment (PPE) supplies for two residents with Enhanced Barrier Precautions and failed to display the correct Enhanced Barrier Precaution sign for one resident. This deficiency affected all 37 residents on the third floor and all 42 residents on the fifth floor reviewed for infection control. Specifically, the surveyor observed that rooms of residents requiring Enhanced Barrier Precautions did not have PPE supplies available for staff use, and one resident's room had an incorrect droplet precaution sign instead of the required Enhanced Barrier Precaution sign. The Director of Nursing (DON) acknowledged that every Enhanced Barrier Precaution room should have PPE supplies for staff use and explained that the Central Supply staff is responsible for ordering and stocking PPE. However, there was a discrepancy in the communication and updating of the list of residents requiring Enhanced Barrier Precautions, leading to the absence of necessary PPE supplies in the rooms. The Central Supply staff confirmed that they did not receive the updated list in a timely manner, resulting in the missing PPE supplies for the affected residents. The residents involved had various medical conditions that increased their risk of infection, such as the presence of urinary catheters, chronic wounds, and cognitive impairments. The facility's infection control policy emphasized the importance of PPE in preventing the transmission of infections, but the failure to provide and maintain the necessary supplies and signage compromised the safety and care of the residents. The facility's policies and procedures were not effectively implemented, leading to the observed deficiencies in infection control practices.
Facility Maintenance and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain the community shower room on the fourth floor and the bathroom and day room on the fifth floor in a sanitary and good repair condition. Observations revealed that the fourth-floor community shower room had a partially covered toilet water tank with brown stains, a shower stall with a blackish-brown substance on the wall tiles, a non-functional bath-tub faucet, filthy clothes on the floor, and a large rod on the floor. Additionally, the clean utility room had a bag of clothes on the floor. The fourth-floor Maintenance Log Sheet did not show any reports of these issues. The Maintenance Director acknowledged the issues but only suggested power-washing the mold and using grout. The Housekeeping Supervisor confirmed that housekeepers are responsible for cleaning the shower rooms, but the facility's guidelines were not followed in this case. On the fifth floor, the bathroom shared by two residents had a non-functional light bulb, which had been broken for a long time according to one of the residents. Despite daily rounds by the Maintenance Director to inspect lighting fixtures, the issue persisted over multiple days. Additionally, the fourth-floor dayroom had chipped paint on the walls and ceiling vents coated with a black substance, which the Maintenance Director identified as dust that should be cleaned by housekeeping. The Maintenance Director also noted that the entire building needed painting. The facility's job descriptions for both the Housekeeper and Maintenance Director outline responsibilities for maintaining cleanliness and safety, which were not adhered to in these instances.
Medication Administration Delays
Penalty
Summary
The facility failed to administer scheduled medications within the prescribed time frame, affecting four residents. On the day of the survey, an LPN was observed administering morning medications at noon, which were scheduled for 9:00 am. The LPN, who was called in to work unexpectedly, started their shift at 9:02 am and was responsible for 23 residents. This delay in medication administration was observed for residents with various medical conditions, including cerebral infarction, diabetes, hypertension, and depression. Resident 1 received medications for cerebral infarction, diabetes, hypertension, and depression three hours late. Resident 3, who has type 2 diabetes, peripheral vascular disease, and hypertension, also received their medications late. Similarly, Resident 2, with diagnoses including cerebral infarction and epilepsy, and Resident 4, with congestive heart failure and chronic obstructive pulmonary disease, experienced delays in receiving their prescribed medications. The facility's policy requires medications to be administered within a two-hour window, and staff are expected to notify a physician if medications are not given on time. However, there was no documentation indicating that the physician was notified of the late administration for any of the affected residents. The Director of Nursing and the Administrator both confirmed the expectation for medications to be administered within the designated time frame. Resident council meeting minutes from earlier in the year also noted concerns about the timeliness of medication administration.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from physical abuse, resulting in a serious incident involving two residents. Resident R3 was physically assaulted by Resident R8, leading to R3 sustaining a left hip fracture and a right finger fracture. The incident occurred in the hallway near the entryway to the stairs, where R8 punched and pushed R3, causing R3 to fall. Staff responded immediately, and R3 was transferred to a trauma hospital for surgical repair of the injuries. R3's medical history includes seizures, schizoaffective disorder, major depressive disorder, and paranoid schizophrenia, among other conditions. R3 was found to have moderate cognitive impairment based on the Minimum Data Set (MDS) scores. R8, who was cognitively intact, had a history of aggressive and inappropriate behavior, including roaming into peers' personal spaces. R8 was discharged from the facility in 2022 and was not available for an interview. The facility's Director of Nursing and Administrator acknowledged the incident and emphasized the importance of monitoring residents to prevent such occurrences. The facility's policy on abuse prevention affirms the right of residents to be free from abuse and outlines measures to protect residents from mistreatment by anyone, including other residents.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
